Deanne Tabb PharmD MT ASCP Infectious Disease Pharmacy specialist Clinical Microbiologist Midtown Medical Center Columbus Georgia Disclosure I do not have nor does any immediate family member have actual or potential conflict of interest within the last twelve ID: 731513
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Slide1
Antimicrobial Stewardship Beyond the Hospital SettingSlide2
Deanne Tabb PharmD, MT (ASCP)
Infectious Disease Pharmacy specialist
Clinical Microbiologist
Midtown Medical Center, Columbus, GeorgiaSlide3
Disclosure
I do not have (nor does any immediate family member have) actual or potential conflict of interest, within the last twelve
months; a
vested interest in or affiliation with any corporate organization offering
financial support or grant monies
for this continuing education
activity; or
any affiliation with an organization whose philosophy could potentially bias my presentation.Slide4
Objectives
Evaluate the need for antibiotic stewardship beyond the acute care hospital setting
Outline core elements of antimicrobial stewardship in community and long term care facilities
Describe development and application of an antibiogram for various patient care settings
Provide specific examples of antimicrobial interventions following emergency room dischargeSlide5
Significance and Relevance
Antibiotics are among the most commonly prescribed drugs used in human
medicine
50
% are not needed or not optimally
prescribed
Annual
impact of antibiotic resistant infections2 million illnesses23,000 deaths8 million additional hospital days$20-35 billion excess direct healthcare costsUp to $35 billion societal costs
PCAST
Report to the President on Combating Antibiotic Resistance
. Slide6
Annual Antibiotic Use
http://www.cnbc.com/2014/01/16/antibiotic-resistance-economist-proposes-superbug-solution.htmlSlide7
What is Antimicrobial Stewardship?
Using the right antibiotic at the right time at the right dose for the right duration
Primary goal
Optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance
The White House.
National
Action Plan for Combating Antibiotic-Resistant Bacteria
.IDSA and the SHEA guidelines for developing an institutional program to enhance antimicrobial stewardship. Slide8
Timeline of Recent Events
CDC Federal
Engagement in Antimicrobial Resistance.Slide9
Assessment of domestic antibiotic resistance threats
C. difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
MDR Acinetobacter
DR Campylobacter
ESBLs
VRE
MRSA
MDR
Pseudomonas aeruginosa
Strep pneumonia
Fluconazole-resistant
Candida
MDR & XDR TB
VRSA
Erythromycin-resistant Streptococcus Group A
Clindamycin-resistant Streptococcus Group B
CDC Antibiotic Resistance Threats in the United States, 2013
.Slide10
Slow emergence of resistant bacteria and prevent spread
Strengthen National One-Health surveillance efforts to combat resistance
Advance development and use of rapid and innovative diagnostic tests for identification and characterization of resistant bacteria
Accelerate basic and applied research and development of new antibiotics, other therapeutics, and vaccines
Improve international collaboration and capacities for antibiotic-resistance prevention, surveillance, control, and antibiotic research and development
The White
House.
National Action Plan for Combating Antibiotic-Resistant Bacteria.Slide11
5 year roadmap to guide the Nation in rising to the challenge
Outlines steps for implementing the National Strategy and addresses PCAST recommendations
Organized around 5 goals with objectives (Year 1, 3, 5)
Primary goal: guide activities by the federal government as well as actions by public health,
healthcare
, and veterinary partners to address this urgent drug-resistant threat
The White
House. National Action Plan for Combating Antibiotic-Resistant Bacteria.Slide12
National Targets by 2020
Target
CDC
Recognized Urgent Threats
50%
Incidence of overall C. diff infection
60%
Hospital acquired CRE infections
<2%
Prevalence of ceftriaxone-resistant
Neisseria gonorrhoeae
Target
CDC Recognized
Serious Threats
35%
Hospital acquired
MDR
Pseudomonas
species
infections
≥50%
Overall MRSA BSI
25%
MDR
non-
typhoidal
Salmonella infections
15%
Number of MDR TB infections
≥25%
Rate of antibiotic-resistant
invasive pneumococcal disease <5
yo
≥25%Rate of antibiotic-resistant invasive pneumococcal disease >65 yo
The White
House.
National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide13
By 2020 significant outcomes of Goal 1
Improve antibiotic stewardship across all healthcare settings
Reduce inappropriate antibiotic use by 50% in outpatient settings
Establish state antibiotic resistance prevention programs in all 50 states to monitor regionally important MDR organisms and provide feedback and technical assistance
Eliminate medically-important antibiotics for growth promotion in food producing animals
Requirement of veterinary oversight for use of medically-important antibiotics in the feed or water for food-producing animals
The White
House. National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide14
Goal 1: Objectives & Milestones
Strengthen antibiotic stewardship in outpatient and long-term care settings by developing, expanding, and monitoring progress
Within
1 Year
P
ropose regulations to
implement
antibiotic stewardship programs in ambulatory surgery centers, dialysis clinics, and other inpatient facilitiesNational Healthcare Safety Network (NHSN) will begin tracking the number of facilities with stewardship policies and programsThe White House. National Action Plan for Combating Antibiotic-Resistant Bacteria.Antibiotic Stewardship HICPAC Update and Discussion July 2015.Slide15
Goal 1: Objectives & Milestones
Improve antibiotic stewardship across all healthcare settings
Within
3 Years
Centers for Medicare & Medicaid Services (CMS) will issue new Conditions of Participation (COP) Interpretive Guidelines
t
o advance compliance with recommendations in CDC’s Core Elements
All long-term acute care hospitals, post-acute care facilities, ambulatory surgery centers and dialysis centers governed by CMS COP will be required to implement antibiotic stewardship programsTraining webinars for CMS surveyors will be updated to include information on antibiotic utilization in nursing homesCDC and others will issue guidance on AS and best practices for ambulatory surgery centers, dialysis centers, nursing homes, long term care facilities, doctor’s offices, and other outpatient settings, pharmacies, Emergency departments and correctional facilities.
The White
House.
National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide16
Goal 1: Objectives & Milestones
Improve antibiotic stewardship across all healthcare settings
Within 5
Years
Department of defense will support stewardship programs and interventions critical for maintaining quality health care throughout the military healthcare system
CDC will work with select hospital systems to expand antibiotic use reporting and stewardship implementation, and will partner with nursing organizations to develop and implement stewardship programs and interventions in a set of nursing homes
All states will establish or enhance antibiotic stewardship activities in healthcare delivery settings
The White House. National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide17
Goal 1: Objectives & Milestones
Strengthen
educational programs that inform physicians and public about good antibiotic stewardship.
Within 1 Year
CDC & VA will apply lessons learned from pilot project to provide clinical decision support
Within
3
YearsCDC & CMS will propose expanded quality measures for antibiotic prescribingCMS will expand the Physician Quality Reporting System (PQRS) to include quality measures to discourage inappropriate antibiotic use to treat non-bacterial infectionsThe White House. National Action Plan for Combating Antibiotic-Resistant Bacteria
.Slide18
Goal 1.1.2 and 1.1.3 Objectives & Milestones
Expand collaborative efforts by groups of healthcare facilities that focus on preventing the spread of antibiotic-resistant bacteria
Within 1 Year
DOD Multidrug-Resistant Organism Repository & Surveillance Network (MRSN) will expand its detection and reporting capabilities to include high-risk drug resistant pathogens
Implement annual reporting of antibiotic use in outpatient settings
Within
1 Year
CDC will report outpatient prescribing rates and use this data to target and prioritize intervention efforts (number of prescriptions per population)CDC will establish a benchmark for reduction in antibiotic useWithin 3 Years
CDC
will issue yearly reports on progress in meeting the national target of 50% reduction in inappropriate use in outpatient settings
The White
House.
National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide19
Goal 2: Objectives & Milestones
Enhance
reporting
infrastructure and
provide incentives for reporting
Within 1 Year
CDC will develop an implementation plan for regional laboratories that considers all aspects of operation, including specimen transport, testing, reporting and data-sharing
Within 3 yearsCDC will charge at least 5 public labs with rapid detection of outbreaks caused by MDR pathogens Provide incentives for timely reporting of antibiotic-resistance and antibiotic use in all healthcare settingsWithin 1 YearIt has been proposed for NHSN data reporting to add to an institution’s meaningful use
The White
House.
National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide20
Goals continued
Goal 3
: Advance development and use of rapid and innovative diagnostic tests
T
o distinguish between bacterial and viral infections
D
etermine antibiotic-resistance profiles
Goal 4: Accelerate research to develop new antibiotics, other therapeutics, vaccines, and diagnosticsGoal 5: Improve international collaboration and capacities for prevention, surveillance and antibiotic research and developmentThe White House.
National Action Plan for Combating Antibiotic-Resistant
Bacteria
.Slide21
Core elements of
Performance in Nursing Homes
CDC Core Elements of
Antibiotic
Stewardship
for Nursing Homes.
The
Joint Commission. Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC, and OBS.Slide22
Core Elements
Formal, written statement in support of improving antibiotic use
Include stewardship related duties in position descriptions for the medical director, clinical nurse leads, and consultant pharmacist
Communicate expectations about antibiotic use, monitor and inforce AS policies
Create a culture which promotes stewardship
CDC Core Elements of Antibiotic Stewardship for Nursing Homes
The
Joint Commission.
Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC,
and OBS
.
Empower director to set standards for antibiotic prescribing
Empower the director of nursing to set the practice standards for assessing, monitoring and communicating changes in a resident’s condition by front-line nursing staff
Engage consultant pharmacist in supporting and reporting antibiotic use dataSlide23
Core Elements
Infection preventionist review antibiotic resistance patterns, collect and analyze infection surveillance data which can be used for stewardship purposes
Laboratory support for MDR organism alerts, education on technology and creation of annual antibiogram
CDC Core Elements of Antibiotic Stewardship for Nursing Homes
The
Joint
Commission.
Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC, and OBS.
Incorporate consultant pharmacist trained in ID or antibiotic stewardship
Collaborate with antibiotic stewardship program leads at the hospitals within your
referral network
Develop relationships with ID consultants interested in supporting your facilities
stewardship effortsSlide24
Core
Elements
Policies
Documentation of dose (route), duration (start/end date, planned days of therapy), indication (including rational/treatment site) for every antibiotic
Develop treatment recommendations based on guidelines and local susceptibility
Establish best practices for use of microbiology testing
Review antibiotic agents available on site
Broad interventionsDevelop and implement algorithms for assessment of residents suspected of having an infectionDevelop an antibiogramAntibiotic time out: clinicians to review antibiotics at 48-72 hours
Reduce prolonged antibiotic treatment courses for common infections
CDC Core Elements of Antibiotic Stewardship for Nursing Homes
The
Joint
Commission.
Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC,
and OBS
.Slide25
Example of Empiric Antibiotic
GuidelineSlide26
Internal
AST
WebsiteSlide27
Core
Elements
Diagnosis and infection specific interventions
Reduce antibiotic use in asymptomatic bacteriuria
Reduce antibiotic prophylaxis for prevention of UTI
Optimize management of nursing home-associated pneumonia
Optimize use of superficial cultures for management of chronic wounds
CDC Core Elements of Hospital Antibiotic Stewardship Programs
.
The
Joint
Commission.
Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC,
and OBS.Slide28
Core
Elements
Process Measures
Completeness of clinical assessment documentation at the time of antibiotic prescription
Completeness of antibiotic prescribing documentation
Antibiotic selection is consistent with recommended agents for specific indications
Measures of Antibiotic Use
Point prevalence of antibiotic useTrack new antibiotic startsAntibiotic days of therapy (DOT/1000 resident-days)
Antibiotic Outcome Measures
By counts of antibiotic(s) administered to patients per
day = Days
of therapy (DOT)
/per 1000 patient days
CDC Core Elements of Hospital Antibiotic Stewardship Programs
.
The
Joint
Commission.
Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC,
and OBS.Slide29
Days
of therapy (DOT)
/per 1000 patient
days
CDC Core Elements of Hospital Antibiotic Stewardship Programs
.
The
Joint Commission. Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC, and OBS; Antimicrobial Stewardship Toolkit. Slide30
Post-
Meditech
implementation with CPOE Mandatory ID indication selection: (n=169)
81% of all ID indications were included with CPOE orders
An additional 7% of indications were included in the progress note
I
ndication were unclear in the remaining 12% of antibiotic orders Slide31
Pre/Post-Meditech
implementation with CPOE Mandatory ID indication
selection
% Defined antibiotic indication Slide32
Criteria for UseSlide33
Pre Intervention September: 96.9%
Pre Intervention October: 89.5%
Overall % Patients Met Criteria for Use (includes those not met that had Pharmacy intervention proposed & accepted)
Goal
> 98%
Recommendation
Monitoring/ analysis frequency
Monthly Pharmacy Review
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Percentage
Overall % Patients met criteria for use
100.0%
100.0%
98.9%
100.0%
99.1%
100.0%
99.4%
99.1%
99.0%
97.6%
100.0%
#N/A
Numerator
# Patients met criteria including those not met that had pharmacy intervention proposed & accepted
75
91
92
103
110
119
173
109
98
121
4
Denominator
# Patients on use restricted antimicrobials
75
91
93
103
111
119
174
110
99
124
4
Benchmark
Baseline (Mar-Apr 2010)
82%
82%
82%
82%
82%
82%
82%
82%
82%
82%
82%
82%
Goal
Hospital Goal
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%Slide34
Slide35
10 Month Linezolid Use
History of VRE with sepsis/confirmed VRE infection
45
Vancomycin failure
33
Confirmed MRSA pneumonia
17
Vancomycin allergy
15
Vancomycin renal intolerance
12
Loss of IV access (short term use)
10
Daptomycin failure
2Slide36
TJC EP 5 – Core Elements
Share facility-specific reports on antibiotic use with prescribers
Distribute current antibiogram to prescribers
Direct, personalized communication to prescribers about how they can improve their antibiotic prescribing
CDC Core Elements of Hospital Antibiotic Stewardship Programs
.
The
Joint Commission. Proposed Standard for Antimicrobial Stewardship in AHC, CAH, HAP, NCC, and OBS.
Provide education to clinicians and
staff
on improving antibiotic prescribing
Informal +
formalSlide37
Centers for Disease Control and Prevention (CDC): Perspective on Antimicrobial Stewardship
Benefits of Antibiotic Stewardship:
Helps streamline therapy and improve patient outcomes
Helps set duration of therapy
Improves handoff communication
Reduces the emergence of multi-drug resistant pathogens and
C.
difficile
colitis
Reduces adverse drug reactions
Antibiotic resistance is a major public health problem. We now have organisms resistant to all readily available antibiotics. Some would argue that we are in the post-antibiotic era. Antibiotics are a shared resource.
Principles of Antimicrobial Stewardship:
Obtain Quality Cultures
Before antibiotics initiated (if possible)
Utilize Respiratory Therapy to obtain sputum samples
Avoid surface cultures
Establish source control if applicable
Indications
are written with
all antibiotic orders
Stream line to narrow spectrum antibiotics following culture results
Set antibiotic durations of therapy
at time of prescribing or immediately following clinical response
For more information refer to the stewardship website on OASIS (Medical access) or contact
the Infectious
Disease
Pharmacist
Quality Measures Identified:
Multidisciplinary process to review antimicrobial utilization and local susceptibility patterns
Systems to prompt appropriate use of antimicrobial agents
Antibiotic orders include indication for use
Clinician review of need/selection of antibiotics at 72 hours
IV to PO programSlide38
Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data; Approved Guidelines
2014 (M39-A4)Slide39
In vitro
SusceptibilitySlide40
Antibiogram
Introduction, scope and definitions
Information system design
Data analysis
Data presentation
Use of cumulative antimicrobial susceptibility reports
Limitation of data, data analysis and data presentationSlide41
Selection Criteria
Patient location
Specific ward, clinic, inpatient, outpatient, intensive care unit
Clinical service
Specimen type
Certain organism subgroups
Special populationsSlide42Slide43
Pediatric 2016Slide44
Year
Percent
MRSA
Staphylococcus
aureus Isolates
Pediatric PatientsSlide45
Staphylococcus
aureus Isolates
Pediatric Patients
Percent Susceptibility
Year
TMP/SXT
______
Clindamycin
______
CD MRSA susceptibility = 98 %
CD MSSA susceptibility = 89 %Slide46
Pediatric Empiric GuidelinesSlide47
Interventions Following ETC DischargeSlide48
Interventions Post Discharge
MDR community-acquired infections are on the rise, and inappropriate empiric therapies can lead
to:
Rehospitalizations
I
ncreased
hospital
costsIncreased morbidity and mortalityDecreased quality of lifeSlide49
Emergency Department Cultures
M
id level practitioners or ED physicians
Notification occurs via message, fax or call
C
ulture is then reviewed for
antibiotic changes
Barriers/solutionED patient turnover is highED physicians do not have the time to review culturesPharmacy programs could give ED physicians more time with current patients, reduce readmissions, and improve outcomesSlide50
Readmissions after 96 hours
Methods
:
ED of Carolinas Medical Center NE
Retroactive
chart review one year before a pharmacist-managed
process was introduced compared to new processPrimary Outcome: Frequency and reason of readmission within 96 hours Subjects: ED patients with positive culturesResults Common reasons for readmission were treatment failure, patient noncompliance, allergy to medication, and adverse drug reactions
ED Physician
Led
Pharmacist Managed
Cultures Reported
2278
2361
Antimicrobial
Modifications
12%
15%
Readmitted within 96 hours
of Discharge
15%
7%Slide51
Time to Culture Follow up, Patient or PCP notification, and Appropriateness of Therapy
Methods
:
University of Rochester Medical Center
P
re-implementation data November – January 2008
P
ost-implementation November – January 2009Primary Outcome: Time to positive culture follow up, notification, and appropriateness of empiric or final antimicrobial therapy Subjects: Patients discharged from the ED with positive culturesResultsThere was no difference in appropriate therapies
ED
Physician Led
Pharmacist Managed
Positive
Cultures Reviewed
104
73
Time
to Culture Review
3 days (1 – 15)
2 days (0 – 4)
Required
Notification
74 (71.2%)
36 (49.3%)
Time to patient/PCP notification
3 days (1 – 9)2 days (0 – 4)Slide52
Empiric Therapy Assessment following Culture Results
Methods
:
6 week retrospective ED Physician Assistant culture assessment versus 15 week pharmacist managed AS program
Primary Outcome
:
Compliance with contacting patient and/or PCP if positive for STD or empiric therapy was inappropriate
Subjects: ED discharged patients with positive results ResultsCurrent PracticeED Pharmacist Managed ASPContacted vs Not Contacted10/22
(45.5%)
72/73 (98.7%)Slide53
MMC Experience
ID
Indications
(N
= 505 patients)Slide54
SSTI MicroorganismsSlide55
SSTI Antibiotics
Clindamycin
35
Ampicillin
1
Bactrim
16
Levofloxacin1Cephalexin10
Doxycycline
1
Ciprofloxacin
5
Vancomycin
1
Augmentin
3
Amoxicillin
2Slide56
SSTI
Empiric GuidelinesSlide57
SSTI PathwaySlide58
UTI PathogensSlide59
UTI AntibioticsSlide60
Empiric Antibiotic GuidelinesSlide61
Post-Lecture Test
True-False question
Antimicrobial stewardship only affects acute care hospitals
2. Which of the following are proposed core elements of antimicrobial stewardship?
Leadership commitment/Accountability
Drug expertise
Action/Tracking/Reporting
EducationAll the above are included in core elements of performance3. Which of the following represent examples of antibiogram reporting or application?Stratified in vitro sensitivity data of urinary isolates in the EDEmpiric guidelines for skin soft tissue infection
Development of a skin soft
tissue pathway for use in the ED
All of the aboveSlide62
Questions?Slide63
Deanne Tabb PharmD, MT (ASCP)
d
eanne.tabb@crhs.net
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