Antimicrobial Stewardship & Joint Commission Requirements: - PowerPoint Presentation

Slide1

Antimicrobial Stewardship & Joint Commission Requirements:An Opportunity for Pharmacy Leadership

Holly Maples,

Pharm.D

.

Associate Professor,

Dept

of Pharmacy Practiced

Jeff & Kathy Lewis Sanders Endowed Chair in Pediatrics

UAMS College of Pharmacy

Director, Antimicrobial Stewardship

Director, Pediatric ID and Antimicrobial Stewardship Fellowship

Arkansas Children’s HospitalSlide2

Conflict of InterestDr. Maples has no conflict of interest to report pertaining to this talk.

This talk is

NOT

Slide3

ObjectivesDescribe

the eight elements of performance in the New Antimicrobial Stewardship Standard

Identify

specific antimicrobial stewardship strategies utilizing clinical pharmacists within your institution

Discuss

educational opportunities to enhance pharmacists skills in antimicrobial management

Describe

antimicrobial usage measurements

Identify

quality improvement opportunities within your institution and how to get it accomplishedSlide4

Antibiotic overuse

Leads to avoidable costs and toxicities

Disruption of the host

microbiome

Is the most important contributor to

antibiotic resistance

The White House has called for hospitals and healthcare systems to implement stewardship programs by 2020.

Reduce inappropriate

abx use by 50% in OP settingsReduce inappropriate abx use by 20% in IP settingsSlide5

CDC 2013 Report: Antibiotic Resistance Threats in the United States.Slide6

New Antimicrobial Stewardship Standard

Effective January 1, 2017

Hospitals have an antimicrobial stewardship program based on current scientific literature.Slide7

Elements of Performance (1)Leaders establish antimicrobial stewardship as an organizational priority

Accountability documents

Budget plans

Infection prevention plans

Performance improvement plans

Strategic plans

Using the EMR to collect antimicrobial stewardship dataSlide8

Elements of Performance (2)The hospital educates staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire or granting of initial privileges and periodically thereafter, based on organizational need.Slide9

Elements of Performance (3)The hospital educates patients, and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics.

Education tool that can be used

CDC’s Get Smart document, “Viruses or Bacteria-What’s got you sick?” at

http://www.cdc.gov/getsmart/community/downloads/getsmart-chart.pdf

.Slide10

Elements of Performance (4)The hospital has an ASP multidisciplinary team that includes the following members, when available in the setting:

ID physician

Infection

preventionist

Pharmacist(s)

Practioner

Note 1

: Part-time or consultant staff are acceptable as members of the ASP multidisciplinary team

Note 2: Telehealth staff are acceptable as members of the ASP multidisciplinary teamSlide11

Elements of Performance (5)

The hospital’s ASP includes the following core elements (documentation required)

Leadership commitment

: Dedicating necessary human, financial, and IT resources

Accountability

: Appointing a single leader responsible for program outcomes.

Drug Expertise

: Appointing a single pharmacist leader responsible for working to improve antibiotic use

Action: Implementing recommended actions, such as systemic evaluation of ongoing treatment need, after a set period of initial treatment. (example, antibiotic time out after 48 hours)Tracking: Monitoring the antimicrobial stewardship program, which may include information on antibiotic prescribing and resistance patterns.Reporting: Regularly reporting information on the antimicrobial stewardship program, which may include information on abx use and resistance, to doctors, nurses, and relevant staffEducation: Educating practitioners, staff, and patients on the ASP, which may include information about resistance and optimal prescribing.Slide12

Elements of Performance (5)Core elements were cited from the CDC’s Core Elements of Hospital Antimicrobial Stewardship Programs (

http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

)

Joint Commission recommends that organizations use this document when designing their antimicrobial stewardship program.Slide13

Elements of Performance (6)

The hospital’s ASP uses organization-approved multidisciplinary protocols (example, policies and procedures) (documentation required)

Antimicrobial Formulary Restrictions

Assessment of Appropriateness of

Abx

for CAP

Assessment of Appropriateness of

Abx

for SSTI’sAssessment of Appropriateness of Abx for UTI’sCare of the Patient with C. diffGuidelines for Antimicrobial Use in AdultsGuidelines for Antimicrobial Use in PediatricsPlan for IV to PO conversionPreauthorization requirement for specific antimicrobialsUse of prophylactic antibioticsSlide14

Elements of Performance (7)The hospital collects, analyzes, and reports data on its ASP. (documentation required)

Note

: Examples of topics to collect and analyze data on may include evaluation of the ASP, antimicrobial prescribing patterns, and antimicrobial resistance patternsSlide15

Elements of Performance (8)The hospital takes action on improvement opportunities identified in its antimicrobial stewardship program. (documentation required)Slide16

New Stewardship Guidelines

Barlam

TF et al. CID 2016 April 13 (

Epub

ahead of print)Slide17

Key Points- Guideline Interventions

Combination of preauthorization

and

prospective review of antibiotics have shown to be most effective.

Barlam

TF et al. CID 2016 April 13 (

Epub

ahead of print

)Slide18

ACH Example: Pre-authorization of MeropenemSlide19

ACH Cefepime UsageSlide20

Key Points- Guideline Interventions

Combination of preauthorization

and

prospective review of antibiotics have shown to be most effective.

Stewardship programs should be led by physicians and pharmacists on equal levels.

Barlam

TF et al. CID 2016 April 13 (

Epub

ahead of print)Slide21

Key to Success: Multidisciplinary Involvement

Program Coordinators

ID physician

ID Pharm.D.

Clinical Pharmacy Specialists

Decentralized Pharmacy Specialists

Microbiology Lab

Medical Information Systems

Infection Control

Hospital Epidemiologist

Hospital Administrator

Infectious Disease Division

P & T Committee

Adapted from: Fishman NO. In: Principles and Practice of Infectious Diseases. 4

th

ed. 1995:539-46.Slide22

Education Opportunities for Pharmacists

ID Fellowships

ID Residency

Board Certification in IDCertificates MAD-ID (Making a Difference in Infectious Diseases)

SIDP (Society of Infectious Diseases Pharmacists)

Workshops

IDSA (Infectious Diseases Society of America)

SHEA (Society of Healthcare Epidemiology of America)Slide23

Key Points- Guideline Interventions

Combination of preauthorization

and

prospective review of antibiotics have shown to be most effective.

Stewardship programs should be led by physicians and pharmacists on equal levels.

Interventions should be focused at institution level.

Barlam

TF et al. CID 2016 April

13 (Epub ahead of print) Slide24
Slide25

ACH Top 20 AntibioticsSlide26

Key Points- Guideline Interventions

Combination of preauthorization

and

prospective review of antibiotics have shown to be most effective.

Stewardship programs should be led by physicians and pharmacists on equal levels.

Interventions should be focused at institution level.

Direct input from stewardship team will improve prescriber led review of appropriateness of Antibiotic regimens.

Barlam

TF et al. CID 2016 April 13 (Epub ahead of print)Slide27

5 D’s of Antimicrobial StewardshipSlide28

5 D’s of Antimicrobial Stewardship

Ensuring a diagnosis or indication is established to direct antibiotic therapy

Consistency amongst prescribers in diagnosis

Rapid DiagnosticsSlide29

Variation in Antibiotic Prescribing Across a Pediatric Primary Care Network

Jeffrey Gerber,

Priya

Prasad, Russell

Localio

et al.

J

Ped

Infect Dis 2015;4(4):297-304Abx are the most common Rx drug given to childrenOutpatient ARTI’s account for the majority of these Rx’s

Inappropriate

Abx

prescribing for viral infections has decreased over time while broad spectrum

Abx

usage has increased.

AAP

supports treatment of most ARTI’s with narrow spectrum antibiotics

Current studies lack detailed, patient specific clinical data, including: comorbid conditions, drug allergies, and prior

abx

use along with the ability to compare prescribing across practitioners and practice groups.Slide30

Purpose

Compare management of common pediatric infections across practices to generate

benchmarking data and

help to define high-impact targets for intervention

Time/Place:

Jan 1-Dec 31 2009

pediatric

healthcare network that included 29 primary care pediatric practice sites staffed by 222 pediatric

practitioners

who share a comprehensive EHR.

Outcome Measures

Abx

prescriptions

Broad-spectrum prescriptions

Encounter diagnosis based on ICD-9 codeSlide31

Data AnalysisTotal of 102,102 prescriptions evaluated

59,259 narrow spectrum

42,843 broad spectrum

9597 had an abx allergy

3611 prior

abx

29,635 broad spectrum prescriptions evaluated

Between the 29 clinics a

significant difference was found between the clinics for abx usage for sick visits:All Abx (Range of 18-36%; P<.001)Broad spectrum Abx (Range of 15 -57%; P<.001)All Abx for otitis media (Range 8-20%; P<.

001)

Broad spectrum

Abx

for otitis media (

Range 18-60%; P<.

001)

Others (sinusitis, streptococcal pharyngitis, pneumonia)

Just not UTI

….why?Slide32

Conclusions

Wide variation in diagnosis and management

behaviors

, despite adjustment through exclusion and regression for patient clinical and demographic factors.

Stewardship interventions can now target specific practices, providers, and conditionsSlide33

5 D’s of Antimicrobial Stewardship

Empiric choice

Antibiogram

De-escalate

Narrowest spectrum

Allergies

Are they real?

Duplicate therapy

Know MOAKnow coverageSlide34

Predictors of Increased Mortality with Bloodstream Infections

Lodise TP et al. found for patients with Pseudomonas bloodstream infections they had an

↑ 30 day mortality if therapy delayed for > 52 hours by 44%.

Tumbarello

M et al. found for patients with an ESBL producing

Enterobacteriacea

a 3-fold increase in mortality compared to an initial adequately treated group.

21 Day mortality rate of 59.5% compared to 18.5%

Lodise TP et al.

Antimicrob

Agents

Chemother

2007;51:3510-15

Tumbarello

M et al.

Antimicrob

Agents

Chemother

2007;51:1987-94Slide35

CVICU Gram Negative Antibiogram 2014-2015Slide36

NICU Gram Negative

Antibiogram

2013-2014

Percentage of Susceptible IsolatesSlide37

Total Antibiotic NICU DataSlide38

Broad Spectrum

FY08

FY09

FY10

FY11

FY12

FY13

FY14

FY15

Cefepime

32.35

28.75

28.83

36.17

44.21

42.93

50.91

52.96

Ciprofloxacin

2.12

2.83

2.57

2.01

2.48

2.55

2.81

1.28

Daptomycin

1.36

0.71

0.28

0.87

1.36

1.64

1.31

1.65

Levofloxacin

7.35

11.86

6.16

4.87

2.78

3.03

2.37

2.17

Linezolid

8.38

1.97

3.86

1.89

2.10

0.60

1.58

0.52

Meropenem

51.09

47.61

44.90

47.51

31.83

20.66

13.02

7.02

Pip/

Tazo

28.88

27.96

27.52

30.11

27.50

30.16

41.96

31.71

Ticar

/

Clav

15.24

12.73

14.90

3.50

0.83

0.20

2.84

2.06

Vancomycin

141.48

140.48

133.47

101.14

96.73

76.28

88.72

70.51

Hospital Census

86,001

83,662

87,053

80,474

79,455

81,105

79,654

83,452 Slide39

ACH NICU Antibiotic Usage

Broad Spectrum includes:

Vanc

,

Dapto

, Linezolid,

Mero

,

Cefepime, Pip/tazo, Ticar/clav, Levo, CiproSlide40

De-escalation

Once culture results are finalized, unnecessary antibiotics are discontinued and or narrowed to a smaller spectrum so as to minimize selective pressure.Slide41

Impact of Incorrect Antibiotic Allergy

Penicillin is the most common allergy, reported in 5-10% of all

patients

Only 2-

15% of patients with reported penicillin allergies actually have a positive reaction to penicillin skin

testing

Non-immunologically mediated adverse drug reactions make up more than 80% of all adverse drug reactions

The rate of positive skin testing in patients with reported penicillin allergy have been decreasing over the past 20 years

Trubiano J, Phillips E. Curr Opin Infect Dis 2013.

Rimawi RH, Cook PP, Gooch M, et al. J Hosp Med 2013.

Macy E, Schatz M, Lin C, Poon K-Y. Perm J 2009.

Macy E, Ngor E. J Allergy Clin Immunol Practice 2013.

Charneski

L, Deshpande G, Smith SW.

Pharmacotherapy

2011.

Unger NR, Gauthier TP, Cheung LW. Pharmacotherapy 2013.

Lee CE, Zembower TR, Fotis MA, et al. Arch Intern Med 2000

.Slide42

Implications of Antibiotic Allergies

When treated for infections, patients with reported penicillin allergies often receive broader

spectrum (fluoroquinolone, 3

rd

/4

th

-generation cephalosporin, clindamycin, aminoglycloside),

suboptimal, and even more toxic agents than patients without reported penicillin

allergies.Reported penicillin allergy has been associated with increased antibiotic resistance, cost, length of hospital stay, and mortality

Lee CE, Zembower TR, Fotis MA, et al. Ann Intern Med 2000.

Unger

NR, Gauthier TP, Cheung

LW.

Pharmacotherapy

2013

.Slide43

Consequences of avoiding β-lactams in patients with β

-lactam allergies

Meghan

Jeffres

,

Prasanna

Narayanan, Jerrica Shuster et al.

J Allergy

Clin Immunol 2016;137:1148-53.Slide44

Cross-sensitivity

Adapted from:

Trubiano

J, Phillips E.

Curr

Opin

Infect Dis 2013; 26: 526-537.Slide45

Antimicrobial Combinations:

Synergy: Gram Positive (MRSA)

Vancomycin plus

Gentamicin

Rifampin

Treatment: Gram Negative (Pseudomonas)

Utilization of 2 gram negative antibiotics that work by different MOA

3 main MOA

Cell wall break down (beta lactams)Inhibition of protein synthesis (Aminoglycosides)Inhibition of DNA gyrase (fluoroquinolones)To Prevent the Emergence of Resistance

Liu C et al. Clin Infect Dis 2011;52:1-38.

Kanj SS et al. Mayo Clin Proc 2011;86:250-9.Slide46

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial

Daniella Meeker, Jeffrey Linder, Craig Fox et al.

JAMA 2016;315:562-70.

Despite published clinical guidelines and decades of efforts to change prescribing patterns…antibiotic overuse still persists

.

Interventions that have been tried but with minimal reductions in prescription rates for ARTI’s include education, computerized clinical decision support, and financial incentivesSlide47

Purpose

To apply

behavioral science

to design

3

interventions to reduce the rate of unnecessary antibiotic prescribing for ARTI’s

Interventions

:

Suggested alternativesAccountable justification – “

abx

justification note”

Peer comparison – email to peersSlide48

Results (no evidence of diagnosis shifting)

Antibiotic Prescribing

Control:

(educational module or observation alone)

Mean

abx

prescribing rates decreased from 24.1% at intervention start to 13.1% at month 18.

Suggested alternatives:

Mean abx prescribing rates decreased from

22.1

% at intervention start to 6

.1

% at month 18

. (P=0.66)

Accountable justification:

Mean

abx

prescribing rates decreased from

23.2%

at intervention start to

5.2%

at month 18

. (P <.001

Peer Comparison:

Mean

abx

prescribing rates decreased from

19.9%

at intervention start to

3.7%

at month 18

. (P <.001)Slide49

Results

Safety

The rate of return visits for possible bacterial infections within 30 days following visit for ARTI where

abxs

were NOT prescribed (both

abx

inappropriate and potentially appropriate) among the control group was

0.43%.

Only one intervention group had a statistically significantly higher rate of return visits and that was in the accountable justification plus peer comparison group

was

1.41%

.

33 Cases were reviewed

12-

abx

unlikely to have been helpful if prescribed at index visit (cold symptoms with clear chest and no fever at return visit

8- uncertainty (

pt

returned with diagnosis of pneumonia, but no chest radiograph was obtained at the index or return visit

13-

abxs

might have been helpfulSlide50

5 D’s of Antimicrobial Stewardship

Location

MIC

Age/renal function

Weight (obesity)

Other Disease states

Drug Interactions

Fluids

PressorsSlide51

Meaning of a Number: MICSlide52

5 D’s of Antimicrobial Stewardship

Positive cx

vs

negative

What research is current LOT based on?Slide53

Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections

Christine Schuler, Joshua Courter, Shannon

Conneely

et al.

Pediatrics 2016;137(2):e20151223

SSTI’s accounts for the 8

th

most common cause of hospitalization at children’s hospitals.

Increasing incidence due to MRSAIDSA guidelines for management of SSTIs suggest 5 days of abx therapy is effective in cases of nonpurulent cellulitisSlide54

Purpose/Methods

To decrease duration of

abxs

prescribed in children hospitalized for

uSSTIs

Cincinnati Children’s Hospital Medical Center

Fiscal year 2013

4 Interventions

Physician awareness of IDSA guidelines2- 15 min didactic sessions to resident and attendingAccess to best practicesLanyard cardsModification of Electronic Order SetsDefault moved from 14 days to 7 dayID and review of abx plans before dischargeSlide55

Results

641 admissions (90% hospital medicine, 10% community pediatrics)

Increase from 23% to 74% of patients discharged with short courses

Most common

abx

Clinda

- 88%

TMP/SMX- 8%

Cephalexin- 4%Readmissions (no sig differences from prior to study)26 (4%) were readmitted11 for recurrence16 for treatment failureSlide56

Short vs Prolonged Courses of Antibiotic Therapy for Children with Uncomplicated Gram-negative bacteraemia

Park SH et al. J

Antimicrob

Chemother

2014;69:779-85.

Objectives:

Compare clinical outcomes of patients with uncomplicated GN bacteremia receiving short (7-10 days) versus prolonged (>10 days) duration of antibiotic therapy.

Method: Retrospective cohort study between 2002 and 2012. Estimated bacteremic relapse among children who received short vs prolonged antibiotic therapy.Slide57

Results170 matched pairsDuration of therapy in short and prolonged were 10 days and 14 days, respectively

30 day mortality was similar

Prolonged therapy did not reduce the relapse risk

Possible association with an increased risk found for

candidemia

in prolonged treatment.Slide58

5 D’s of Antimicrobial Stewardship

IV to PO

GAP in current stewardship research/intervention between hospital and community for PO Rx’s.

Ensuring consistency with what was prescribed inpatient.Slide59

SummaryASP standard goes into effect per the Joint Commission in January….Are you ready?

Leaders must be identified...are you the one?

If you are the one....empower those around you to help with the cause...this is a huge undertaking.

If you are not the one....there are many things you can do to help.

This is a TEAM effort...all healthcare providers are needed....and pharmacy can take the initiative...we have the drug expertise!!!Slide60

What prevents the intravenous to oral antibiotic switch? A qualitative study of hospital doctor’s accounts of what influences their clinical practice.

Broom J et al. J

Antimicrob

Chemother

2016;71:2295-99.Slide61

QuestionWhich of the following is the narrowest spectrum antibiotic?

Linezolid

Levofloxacin

Cefepime

NafcillinSlide62

Questions