Core Elements of Outpatient Antibiotic - PowerPoint Presentation

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Core Elements of Outpatient Antibiotic Stewardship:Implementing Antibiotic Stewardship Into Your Outpatient Practice

Office of Antibiotic StewardshipDivision of Healthcare Quality PromotionNational Center for Emerging and Zoonotic Infectious DiseasesCenters for Disease Control and PreventionJanuary 17, 2017

Guillermo V. Sanchez, PA-C, MPH

Sarah Kabbani, MD,

MScSlide2

ObjectivesIdentify four core elements of antibiotic stewardship across outpatient settings, and strategies to implement them

Review multidrug resistant organisms in hemodialysis patientsSummarize data on antibiotic use and appropriateness in hemodialysis patientsDiscuss challenges and opportunities for antibiotic stewardship in hemodialysis units Slide3

Introduction to Outpatient Antibiotic Stewardship Slide4

What is Antibiotic Stewardship?Antibiotic stewardship is the effort to:Measure antibiotic prescribing

Improve antibiotic prescribing so that antibiotics are only prescribed and used when needed Minimize misdiagnoses or delayed diagnoses leading to underuse of antibiotics

Ensure that the right drug, dose, and duration are selected when an antibiotic is needed

It’s about patient safety and delivering high-quality healthcare.Slide5

Why Antibiotic Stewardship in Outpatient Settings?High levels of antibiotic useMajority of human antibiotic use occurs in outpatients

30% of outpatient antibiotic prescriptions are unnecessary50% of antibiotics for acute respiratory conditions are unnecessaryIt’s a matter of patient safetySide effects from antibiotics lead to an estimated 143,000 emergency department visits per yearAntibiotic treatment is the most important risk factor for Clostridium difficile infectionInappropriate antibiotic use is primary modifiable driver of antibiotic resistance

Shehab N, et al. Clin Infect Dis 2008;47:735–43. Gonzales R et al. Clin Infect Dis 2001;33:757–62.

Suda et al. J Antimicrob Chemother 2013; 68: 715–718

; Fleming-Dutra

KE et al. JAMA 2016;315:1864–73

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_Report_2014__3_.pdf

.

https://www.folkhalsomyndigheten.se/pagefiles/20281/Swedres-Svarm-2014-14027.pdf

.Slide6

CDC’s Core Elements of Antibiotic Stewardship for Hospitals and Nursing HomesSlide7

Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1-12. https://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e Slide8

Initial Steps for Outpatient Antibiotic StewardshipSlide9

Diagnoses Leading to Antibiotics — United States, 2010–11

Fleming-Dutra et al. JAMA 2016;315(17): 1864-1873. The Pew Charitable Trusts. May 2016.Slide10

Initial Steps for Outpatient Antibiotic StewardshipSlide11

Initial Steps for Outpatient Antibiotic StewardshipSlide12

Core Elements of Outpatient Antibiotic Stewardship and Interventions to Improve PrescribingSlide13

The Core Elements of Outpatient Antibiotic StewardshipCommitment: demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety

Action for policy and practice: implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as neededTracking and Reporting: monitor antibiotic prescribing practices and offer regular feedback to clinicians or have clinicians assess their own antibiotic useEducation and Expertise: Provide educational resources to clinicians and patients on antibiotic prescribing and ensure access to needed expertise on antibiotic prescribing

https://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.html

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Checklist for the Core Elements of Outpatient Antibiotic StewardshipSlide15

CommitmentDemonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety by doing

at least one of the following:

Key Actions

Write and display

public commitments in support of antibiotic stewardship

Identify a single leader to direct antibiotic stewardship activities within a facility

Include stewardship-related duties in position descriptions or job evaluation criteria

Communicate with all clinic staff to set patient expectationsSlide16

Public Commitment PostersSimple intervention: poster-placed in exam rooms with

clinician picture and commitment to use antibiotics appropriately Randomized-controlled trialPrinciple of behavioral science: desire to be consistent with previous commitments“Behavioral nudge” to make the right choice“As your doctors, we promise to treat your illness in the best way possible. We are also dedicated to avoid prescribing antibiotics when they are likely do to more harm than good.”Adjusted absolute

reduction in inappropriate antibiotic prescribing: -20% compared to controls, p=0.02

Meeker et al.

JAMA Intern Med

. 2014;174(3):425-31.Slide17

Put a Commitment Poster in Your Clinic!

CDC worked with the authors of the study to create a poster template for downloadWill be coming in SpanishAdd your picture and signature Place in your examination roomsAvailable at:

https://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/index.html

Add your picture and signature here

Meeker et al.

JAMA Intern Med

. 2014;174(3):425-31.Slide18

ActionImplement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed

Key Actions

Use evidence-based diagnostic criteria and treatment recommendations

Use delayed prescribing practices or watchful waiting, when appropriate

Provide c

ommunications skills training for clinicians

Require explicit written justification in the medical record for nonrecommended antibiotic prescribing

Provide support for clinical decisions

Use call centers, nurse hotlines, or pharmacist consultations as triage systems to prevent unnecessary visitsSlide19

Effect of Behavioral Interventions on Inappropriate Antibiotic PrescribingMeeker, Linder, et al.

JAMA 2016;315(6): 562-570. Cluster randomized trial—47 primary care practices (248 clinicians)Behavioral science principle: Clinicians want to preserve their reputation Outcome: Prescribing rates for visits with inappropriate antibiotics for acute respiratory infections

Three specific EHR interventions Suggested alternatives (menu of symptomatic treatment choices)

Accountable

Justification (antibiotic justification note)

Peer

ComparisonSlide20

Peer Comparison“You are a Top Performer”You are in the top 10% of clinicians. You wrote 0 prescriptions out of 21 acute respiratory infection cases that did not warrant antibiotics. 

“You are not a Top Performer”Your inappropriate antibiotic prescribing rate is 15%. Top performers' rate is 0%. You wrote 3 prescriptions out of 20 acute respiratory infection cases that did not warrant antibiotics.Slide content courtesy of Dr. Jeff LinderSlide21

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing

Meeker, Linder, et al. JAMA 2016;315(6): 562-570. Slide22

Effect of an Audit and Feedback on Broad-Spectrum Antibiotic Prescribing

Gerber. JAMA 2013; 309(22): 2345-2352. Gerber. JAMA 2014 Dec 17;312(23): 2569-70.Slide23

Tracking and ReportingMonitor antibiotic prescribing practices and offer regular feedback to clinicians or have clinicians assess their own antibiotic prescribing practices themselves

Key Actions

Self-evaluate antibiotic prescribing practices.

(This intervention only applies to solo practitioners or practices with fewer than 5 clinicians as long as all clinicians participate.)

Participate in continuing medical education and quality improvement activities to track and improve antibiotic prescribing.

(This intervention only applies if all clinicians in the practice participate in the activity.)

Implement at least one antibiotic prescribing tracking and reporting system.

Assess and share performance on quality measures and established reduction goals addressing appropriate antibiotic prescribing from health care plans and payers.Slide24

What Should You Track and Report in Your Outpatient Facility?Decisions should be made in each practice or facility based on your opportunities for improvement

Options:Antibiotic prescribing for one or more high-priority conditions (e.g. acute bronchitis)Percentage of all visits leading to antibiotic prescriptionsAt the level of a health care systemComplications of antibiotic use (e.g. adverse

drug events, C. difficile infections)

Antibiotic

resistance trends among common outpatient bacterial

pathogensSlide25

Tracking and Reporting with Peer ComparisonsEffective feedback interventions often include peer performance comparisons

Comparing clinician’s antibiotic selection patterns for respiratory conditions to colleagues’ performance1Led to increased use of guideline recommended agentsComparing clinician’s percentage of inappropriate antibiotic prescribing for acute respiratory conditions to “top-performers” in their practice 2Led to decreased inappropriate antibiotic prescribing for acute respiratory infections that should not be treated with antibiotics (e.g. colds and acute bronchitis)

Notifying clinicians that they prescribe more antibiotics than 80% of their peers, based on the percentage all visits leading to antibiotic prescriptions3Led to decreased overall antibiotic prescribing and cost-savings

1. Gerber.

JAMA

2013; 309(22): 2345-2352. 2. Meeker et al.

JAMA

2016;315(6): 562-570. 3. Hallsworth et al.

Lancet

2016; 387(10029): 1743-1752.

Slide26

Slide courtesy of Jeff Gerber

Gerber.

JAMA

2013;

309

(22): 2345-2352. Slide27

Education and Expertise

Provide educational resources to clinicians and patients on antibiotic prescribing and ensure access to needed expertise on optimizing antibiotic prescribing.

Education targeting patients

Education targeting clinicians

Use effective communications strategies to educate patients about when antibiotics are and are not needed

Educate about the potential harms of antibiotic treatment

Provide patient education materials

Provide face-to-face educational training (academic detailing)

Provide continuing education activities for clinicians

Ensure timely access to persons with expertiseSlide28

Communication Training as an Antibiotic Stewardship InterventionClinicians cite patient demand for antibiotics as a reason they prescribe inappropriately1

Clinicians are more likely to prescribe antibiotics when they think that the patient wants them2Patients can be satisfied without antibiotics, even if they expect them, with effective communication3,4Enhanced communication training reduces antibiotic prescribing for respiratory infections in all ages while maintaining patient satisfactionCommunication goals

Understanding the patient’s expectationsExplaining why antibiotics will/will not helpProviding symptomatic recommendations

Discussing when to return if the patient is not better

Effect

appears to be sustainable over

time

5,6

1. Sanchez, EID; 2014; 20(12);2041-7. 2. Mangione-Smith

Pediatrics

1999;103(4):711-8. 3. Mangione-Smith Ann Family Med 2015; 13(3)

221-7. 4

. Mangione-Smith Arch

Pediatr

Adolesc Med 2001;155:800-6. 5. Cals et al. Ann Family Med 2013;11(2)157-64. 6. Little et al. Lancet 2013:382(9899)1175-82.Slide29

www.cdc.gov/getsmartSlide30

Important partners in outpatient antibiotic stewardshipState and local health departments

Health care professional societiesCommunity pharmacies and pharmacistsLocal microbiology laboratories

Health plans and payersAcute

care hospitals

Long-term

care facilitiesSlide31

SummaryAntibiotic stewardship is one of the most important strategies to combat antibiotic resistance and keep our patients safeThe Core Elements of Outpatient Stewardship

provides a framework for improving outpatient antibiotic prescribing The Core Elements of Outpatient Stewardship include the following:CommitmentAction for Policy and Practice

Tracking and ReportingEducation and ExpertiseWe can all be antibiotic stewards!Slide32

Multidrug Resistant Organisms in HemodialysisSlide33

Multidrug Resistant Organisms in HemodialysisAntimicrobial resistant infections are associated with increased mortality, morbidity, length of hospitalization, and cost of healthcare

1Antimicrobial resistance rates are high among hemodialysis patients2,3Antibiotic exposure is one of the main risk factors for the emergence and spread of multidrug resistant organisms

1Cosgrove, et al ,

The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs.

2006

2

MMWR 2007,

Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients-United States.

2005

3

Snyder

et al,

Novel antimicrobial-resistant bacteria among patients requiring chronic hemodialysis.

2015Slide34

Multidrug Resistant Organisms in Hemodialysis

Invasive methicillin-resistant S. aureus (MRSA) infection rate 45.2 cases/1,000 population in hemodialysis patients (x100 than the general population)1MRSA colonization

6.2% (95% CI 4.2-8.5%)2x11 more likely to develop MRSA infection than non-colonized

hemodialysis patients

V

ancomycin

resistant

Enterococcus

(VRE) colonization

6.2%

(95% CI 2.8-10.8

%)3X21 more likely to develop VRE infection than non-colonized

hemodialysis patients

VRE colonization 3x higher in those who received antibiotics (5x if vancomycin

)

Multidrug resistant gram-negative bacteria colonization 16%4Antibiotic exposure was the only independent risk factor for multidrug resistant gram-negative bacteria acquisition1MMWR 2007, Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients--United States. 2005.2Zacharioudakis et al, Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients. 20143Zacharioudakis et al, Vancomycin-resistant enterococci colonization among dialysis patients: a meta-analysis of prevalence, risk factors, and significance, 2014

4

Pop-Vicas

, Multidrug-resistant gram-negative bacteria among patients who require chronic hemodialysis. 2008Slide35

Multidrug Resistant Organisms in Hemodialysis

Hemodialysis patients contribute to the spread of multidrug resistant organisms:In the hospital settingHemodialysis patients are admitted to the hospital on average twice a year

for an average of 12 days, and 36% are readmitted within 30 days1In the outpatient

setting

Transmission of

methicillin-resistant

S. aureus

(MRSA) among dialysis patients, healthcare worker and family members

2

1

U.S. Renal Data System. USRDS 2009 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. 2009

2

Lu

et al, Methicillin-resistant Staphylococcus aureus carriage, infection and transmission in dialysis patients, healthcare workers and their family members. 2008Slide36

Antibiotic Use in HemodialysisSlide37

Antibiotic Use in Hemodialysis-United States Renal Data System Database, 1995-2007

1995-2005, patients receiving at least one IV antibiotic dose in outpatient HD units increased from 31%44%, decreased slightly

since then (41.3% 2007)

Vancomycin> cefazolin> aminoglycosides>3

rd

generation cephalosporin

https://www.usrds.org/2009/pres/06U_asn09_antibiotic_use.pdfSlide38

Antibiotic Use in Hemodialysis32

hemodialysis units reporting to NHSN in 20061Antibiotic starts/100 patient-months: 1.8 (fistula)-25.4 (temporary central line)73% were vancomycin

2 hemodialysis units in 2008-2011, 32.9 antibiotic doses

per 100

patient-months

2

One in

three

patients received at least one antibiotic dose per year

68% were vancomycin

1

Kelvens

et al,

Dialysis Surveillance Report: National Healthcare Safety Network (NHSN)-data summary for 2006.

20082Snyder et al, Antimicrobial Use in Outpatient Hemodialysis Units. 2013Slide39

Antibiotic Appropriateness in Hemodialysis80% of vancomycin doses prescribed

for hospitalized hemodialysis patients were appropriate1Inappropriate indication: negative culture for β-lactam resistant organism88% of vancomycin courses for hemodialysis

patients were initially appropriate, decreased to 63% based on culture and susceptibility results2

Blood

cultures

were not consistently drawn

when a

suspected

blood stream infection is

treated with vancomycin

75% of inappropriate

continuations were for a susceptible organism without β-lactam allergy

1

Green

et al,

Vancomycin prescribing practices in hospitalized chronic hemodialysis patients. 2000 2Zvonar, Assessment of vancomycin use in chronic haemodialysis patients: room for improvement, 2008Slide40

Antibiotic Appropriateness in Hemodialysis276 (29.8%

) of antibiotic doses were classified as inappropriate1Vancomycin and 3rd-4th generation cephalosporins were most commonly inappropriately

prescribedFirst dose is often appropriate, subsequent doses accounted for 69% of all inappropriate therapy

1

Snyder

et al,

Antimicrobial Use in Outpatient Hemodialysis Units.

2013

2

Snyder

et al,

Factors associated with the receipt of antimicrobials among hemodialysis patients.

2016

58%

of patients receiving antibiotics received ≥ 1 inappropriately indicated dose

2

Independent risk factors:

tunneled

catheter, unit B, longer duration of

hemodialysisSlide41

β-lactam Therapy is Superior for Methicillin-susceptible S. aureus

Hemodialysis patients treated with vancomycin for methicillin-susceptible S. aureus had a higher rate of treatment failure (death or recurrent infection) compared to those treated with cefazolin131.2% vs. 13%; P=0.02, vancomycin was independtly associated with treatment failure on multivariable analysis

Cefazolin use in hemodialysis patients with methicillin-susceptible S. aureus bacteremia was associated with

38% lower risk

of hospitalization or death compared to vancomycin

2

1

Stryjewski

,

Use of vancomycin or first-generation

cephalosporins

for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. 2007

2

Chan

et al, Prevalence and outcomes of antimicrobial treatment for Staphylococcus aureus bacteremia in outpatients with ESRD. 2012Slide42

Measuring Antibiotic Use and Appropriateness-SummaryAntibiotics are commonly prescribed in hemodialysis patientsVancomycin is the most commonly prescribed antibiotic

Limited studies that define appropriateness of antibiotic therapyLimited generalizability, may be driven by outliers and variation in individual practiceIdentified that there is an amount of inappropriate use and an opportunity for improvement Empiric treatment is mostly

appropriateImprovements can be made in de-escalation of therapy, specifically using β-lactams for susceptible organismsSlide43

Antibiotic Stewardship in HemodialysisSlide44

Antibiotic Stewardship in HemodialysisA set of commitments and actions designed to optimize

the treatment of infections while reducing the adverse events associated with antibiotic useAntibiotic stewardship target conditions in hemodialysis:De-escalation, specifically cefazolin for methicillin-sensitive organismsSurgical prophylaxis

Antibiotic stewardship in dialysis may not decrease

overall use

but can

improve appropriateness

Decline in vancomycin will be offset by an increase in

cefazolin

>400,000 dialysis patients, even incremental improvements will lead to a meaningful

differenceSlide45

Antibiotic Stewardship in Hemodialysis-ChallengesDialysis patients are

high risk and medically complexLow threshold for initiating antibiotic therapyAdministering antibiotics in dialysis patients is convenient, especially vancomycinSeveral clinicians can prescribe antibiotics Availability of microbiology resultsTransitions of care, hemodialysis patients are frequently hospitalized

Indication and duration of antibiotic therapy, and microbiology results may not be communicated clearly with hemodialysis unit providers

No CMS metrics related to antibiotic administration

Malani

et al, Optimizing antimicrobial use in hemodialysis: time to take a hard look in the mirror, 2013

Cunha et al, Implementing an antimicrobial stewardship program in out-patient dialysis units, 2016

D’Agata, Antimicrobial use and stewardship programs among dialysis centers, 2013Slide46

Antibiotic Stewardship in Hemodialysis-Opportunities1

Extended team approach for antibiotic stewardship implementation used in the acute care setting is not feasible in hemodialysis units. D’Agata recently identified that:2Leadership support is critical in the success of an antibiotic stewardship program

Clinical managers of a dialysis unit can act as “champions” that lead antibiotic stewardship implementation Tracking antibiotic use will allow providers to assess their prescribing practices and identify opportunities for improvement

1. D’Agata

, Antimicrobial use and stewardship programs among dialysis centers,

2013

2. Personal communicationSlide47

Antibiotic Stewardship in Hemodialysis-OpportunitiesPractices that can improve antibiotic prescribing in dialysis patients:Improve

documentation of antibiotic ordersOptimize procedures for obtaining and following up on culture resultsDevelop clinical guidelines and pathways for common infectionsProvide educational resources on antibiotic stewardship to clinicians and staff in hemodialysis units

Cunha et al, Implementing an antimicrobial stewardship program in out-patient dialysis units, 2016

Malani

et al, Optimizing antimicrobial use in hemodialysis: time to take a hard look in the mirror, 2013

D’Agata, Antimicrobial use and stewardship

prrogams

among dialysis centers,

2013Slide48

Questions?Do you think that antibiotic use can be improved in hemodialysis patients?What are target conditions where antibiotic use can be improved?

What actions can be done to improve antibiotic use? Slide49

Questions?Slide50

www.cdc.gov/getsmartGetSmart@cdc.gov

Acknowledgements:

Rebecca

Roberts, Lauri Hicks

Jonathan A. Finkelstein, Jeffrey S. Gerber, Adam L. Hersh, David Y. Hyun, Jeffrey A. Linder, Larissa S. May, Daniel Merenstein, Katie J. Suda, Rachel Zetts, Kelly O’Neill, Austyn Dukes, Rachel Robb, Meredith

Reagan, Erica D’Agata