Promoting Judicious Antibiotic Use in the Community - PowerPoint Presentation

Slide1

Promoting Judicious Antibiotic Use in the CommunitySlide2

Overview

Discuss antibiotic resistance in the United States

Summarize recent national policy developments

Describe

the Get Smart: Know When Antibiotics Work program

Discuss perceptions/misperceptions contributing to

inappropriate antibiotic prescribing

Review what school nurses can do to educate parents and students about antibiotic resistance

Review free “Get Smart” educational materials available for school nurse outreachSlide3

Antibiotic Resistance:

A Growing Threat

Higher costs

P

oor

health outcomesMore toxic treatment Slide4

There’s More to the story

> 1/2 of outpatient antibiotic prescribing is

unnecessary/inappropriate

Antibiotics

are responsible for almost 1 out of every 5 visits to emergency departments for drug-related adverse

events (142,000 visits annually).Antibiotics are the most common cause of drug-related emergency department visits for children.Shehab, et al. Clin Infect Dis. 2008 Sep 15;47(6):735-43Slide5

Unintended Consequences Of Antibiotics

Clostridium Difficile Infections (CDI)

Wendt

, J. M., et al. (2014).

Pediatrics 133(4): 651-658. Khanna, S., et al. (2012). Am J Gastroenterol 107(1): 89-95. 77% of pediatric CDI cases and 41% of adult CDI cases are Community-AcquiredSlide6

Antibiotic P

rescriptions

per 1000 P

ersons

of

A

ll

A

ges By State

,

2010

Hicks LA et al. N Engl J Med 2013;368:1461-1462

Lowest prescribing rate (529/1000)

Highest prescribing rate (1237/1000)Slide7

More

than

80% of patients diagnosed as having acute

sinusitis are prescribed an antibiotic

Nearly 50% of patients diagnosed

as having acute sinusitis received either a macrolide or a quinolone, Fewer than 20% received amoxicillin, the recommended first-line treatment (at the time)Ahovuo-Saloranta, A., et al. (2014). Cochrane Database Syst Rev 2: CD000243.Fairlie et al. (2012). Arch Intern Med. 172(19):1513-1514.Acute Bacterial Rhinosinusitis“Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels”-2014 Cochrane Review, “Antibiotics for Acute Sinusitis in Adults”Slide8

Acute Bacterial Rhinosinusitis

Diagnose bacterial sinusitis based on

symptoms that are:

Severe

(>3-4 days

) such as fever ≥39°C (102°F) and purulent nasal discharge or facial pain;Persistent (>10 days) without improvement, such as nasal discharge or daytime cough; orWorsening (3-4 days) such as worsening or new onset fever, daytime cough, or nasal discharge after initial improvement of a viral upper respiratory infections (URI) lasting 5-6 days. “The prevalence of a bacterial infection during acute rhinosinusitis is estimated to be 2%–10%, … viral causes account for 90%–98%”-2012 IDSA Guidelines for Acute Bacterial RhinosinusitisChow, A. W., et al. (2012). Clin Infect Dis 54(8): e72-e112.Slide9

Acute Bacterial

Rhinosinusitis

In patients who meet diagnostic criteria:

Routine sinus radiographs are not

recommended

Follow the American Academy of Pediatrics 2013 Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 YearsAntibiotic selection:Amoxicillin/clavulanate is the recommended first-line therapyFor penicillin-allergic patients, doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) are recommended as alternative agentsChow, A. W., et al. (2012). Clin Infect Dis 54(8): e72-e112.Wald, E.R., et al. (2013) Pediatrics 132 (1): e262-e280.Macrolides such as azithromycin are not recommended

due to high levels of

Streptococcus

pneumoniae

antibiotic resistance (~30%)Slide10

AAP Clinical Practice Guideline

Adds clinical presentation “worsening course”

Option to treat immediately or observe children with persistent symptoms for 3 days before treating

Imaging not necessary for uncomplicated acute bacterial sinusitis

Amoxicillin w/or w/out clavulanate is first-line of acute bacterial sinusitis

Wald, E.R., et al. (2013) Pediatrics 132 (1): e262-e280.Slide11

Group A Streptococcal Pharyngitis

The

Centor

criteria (no cough, cervical lymphadenopathy,

tonsillar

exudate, fever)It is a screening tool to determine who should receive a RADTPresence of all criteria has a positive predictive value of only 40-60%Antibiotic treatment is NOT recommended for patients with negative RADT resultsAmoxicillin and penicillin V remain first-line therapy for confirmed Group A streptococcal (GAS) casesGAS resistance to macrolides is increasingly common“Clinical features alone do not reliably discriminate between GAS and viral pharyngitis…”

-2012 IDSA Guidelines for GAS Pharyngitis

Shulman, S. T., et al. (2012).

Clin

Infect Dis 55(10): 1279-1282

.

Roggen

, I., et al. (2013).

BMJ

Open 3(4).Slide12

Barnett, M. L. and J. A. Linder (2014).

JAMA

Intern Med

174

(1): 138-140.

GAS prevalence in adults

Group A Streptococcal PharyngitisSlide13

Aggregate

antibiogram

surveillance of outpatient urinary

E. coli

, United StatesFigure. Cumulative changes in E. coli

antibiotic resistance, 2000-2010

Sanchez GV, et al. (2012).

Antimicrob

Agents Chemother. Apr;56(4):2181-3.Slide14

Acute Uncomplicated Cystitis

Increased

use of 2

nd

-line broad-spectrum agents leads to

resistance and difficult-to-treat infectionsNitrofurantoin

,

fosfomycin

, and TMP/SMX

remain 1st-line therapy

Nitrofurantoin

retains good antimicrobial activity against

E. coli

, including multidrug resistant strains

Nitrites and leukocyte esterase are the most accurate indicators of acute uncomplicated cystitis “[Ciprofloxacin has] a propensity for collateral damage and… should be considered [an] alternative antimicrobial for acute cystitis” -2011 IDSA Guidelines for UTIs

Gupta, K., et al. (2011

).

Clin

Infect Dis 52(5): e103-120

.

Colgan

R, Williams

M

(2011).

Am

Fam

Physician.

84(7

):771-6.Slide15

Methicillin-resistant

Staphylococcus aureus

(MRSA)

Formerly seen in acute/long-term care settings, now sometimes seen in children, student athletes

Usually starts as skin infection

Look for bumps on skin that are sore, swollen, red, leakingAdvise parents to contact healthcare providerSlide16

Drivers of

Inappropriate Antibiotic Use

Patient perspective

Want symptoms resolved quickly

Want clear explanations, even when there is no “cure”May harbor misconceptions about when antibiotics workCycle of expectations – previous experiences influence current behaviors Clinician perspectivePerceived patient expectations Concern for misdiagnoses and potential negative consequencesTime pressureCycle of broad-spectrum prescribing – concern for resistance leads to broad-spectrum useWant to score well on patient evaluation surveysBarden at al. Clin Pediatr 1998 Nov;37(11):665-71Finkelstein et al. Clin Pediatr 2013 Oct 17.Sanchez, G. V., et al. (2014). "Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States." Emerg Infect Dis 20(12): 2041-2047.Both are increasingly concerned with antibiotic overuse and resistanceSlide17

Patient satisfaction drives

antibiotic overuse

:

“We as doctors are business people. We’re no different than running a shoe store. If somebody comes in and wants black

shoes, you don’t sell them white shoes. And if you do, they get upset. …patients in general don’t understand that concept of not taking [an antibiotic] if you don’t need it… [and] if you don’t give it to them, they don’t come back to you.”

Sanchez, G

. V., et al. (2014). "Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States."

Emerg

Infect Dis

20(12): 2041-2047

.

Insight From In-Depth Interviews with

Primary Care ProvidersSlide18

Children And Antibiotic Resistance In The Headlines

Vaz

, et. al.

Pediatrics

, Volume 136, number 2, August 2015

Parents with Medicaid insurance were more likely to misunderstand appropriate antibiotic use than parents with private commercial insuranceSlide19

MMWR July 24,2015

Antibiotic Use-Knowledge & Attitude

Among Consumers and Health Care Providers

Hispanic consumers more likely to believe antibiotics help them get better from a cold more quickly (48% vs. 25%)

Providers reported 54% of all patients

expect antibiotics for cough/cold, but 26% of all consumers (41% Hispanics) expected thisSlide20

Vaz

LE et al.

Pediatrics. 2015;136:pp

. 221 -231Slide21

Parental trust in sources of information for prevention of coughs, colds, and flu, 2013.

Louise Elaine Vaz et al. Pediatrics 2015;136:221-231

©2015 by American Academy of PediatricsSlide22

Percentage correctly answering knowledge questions in 2000 versus 2013 among Medicaid-insured and commercially insured parents (weighted responses in select Massachusetts communities).

Louise Elaine Vaz et al. Pediatrics 2015;136:221-231

©2015 by American Academy of PediatricsSlide23

Percentage endorsing statements suggesting an expectation for antibiotics in 2000 versus 2013 among Medicaid-insured and commercially insured parents (weighted responses in select Massachusetts communities).

Louise Elaine Vaz et al. Pediatrics 2015;136:221-231

©2015 by American Academy of PediatricsSlide24

A National Strategy for Combating Antibiotic Resistant Bacteria

Presidential Committee of Advisors for Science and Technology (PCAST) Report on Antibiotic Resistance

National Strategy Goal #1

: Slow the Development of Resistant Bacteria and Prevent the Spread of Resistant

Infection

March 2015: White House announces National Action Plan for Combating Antibiotic ResistanceJune 2015: White House Forum with key human and animal health constituencies

"

National Strategy for Combating Antibiotic Resistant Bacteria." Retrieved

September 18,

2014, from

http://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf

. Slide25

Actions to address the threat of

antibiotic resistanceSlide26

Improving Antibiotic Use in the Community

Goals

Decrease unnecessary

antibiotic

use

in the communityReduce the spread of antibiotic resistanceObjectivesPromote appropriate antibiotic prescribing Decrease consumer demand for antibioticsPromote adherence to prescribed therapies FocusCommon infections in ambulatory care settings, especially acute respiratory tract infectionsSlide27

New York “Get Smart” Campaign

NYSDOH analyzed 2013 Medicaid claims data to determine NY counties where there is a high rate of avoidable antibiotic prescribing

Based on analysis, NYSDOH sent “Dear Provider” letters to all potential antibiotics prescribers in 11 targeted countiesSlide28

Map of 11 Targeted NYS CountiesSlide29

New York “Get Smart” Campaign

A follow-up mailing sent educational materials

Providers were asked to become “champions” for antibiotic stewardship in their own facilities/communitiesSlide30

NY “Get Smart” Campaign:

Future Outreach

Collaboration with health care insurers/health plans/medical schools on disseminating message

Looking at high rate of community C. difficile in Monroe County and what “Get Smart” interventions might be appropriate

Enlisting antibiotic stewardship “champions” among school nurses/prescribers/county medical societies/hospital outpatient settingsSlide31

What Can School Nurses Do?

Do

Not

try to “diagnose” a child’s

illness - Outside scope of practiceDo

initiate a conversation with the parent when they pick up an ill childDo suggest that the parent speak to their pediatrician/family practitioner about the child’s symptomsDo pre-educate parents before they see the healthcare provider. Explain that antibiotics might not always be “the answer” and have no effect on most viral infectionsSlide32

School Nurses Can Share

“Get Smart” Materials

www.schoolhealthservicesny.com/a-zindex.cfm?subpage=370Slide33

Get Smart General Patient Communication

Educational ToolsSlide34

Brochures for Parents

http://

www.cdc.gov/getsmart/community/materials-references/print-materials/parents-young-children/snort-sniffle-sneeze-color-b.pdfSlide35

Spanish Language Materials

http://

www.cdc.gov/getsmart/community/sp/materials/index.htmlSlide36

“Get Smart” Posters, Flyers, Fact Sheets

http://

www.cdc.gov/getsmart/community/materials-references/index.htmlSlide37

Safe drug disposalSlide38

http://www2.erie.gov/health/index.php?q=needle-disposal-amp-accessSlide39

http://www2.erie.gov/health/sites/www2.erie.gov.health/files/uploads/2015%20ESAP%20onepage%20All%20Sites3%2011%202015.pdfSlide40

http://nydropboxes.org/Slide41

http://nydropboxes.org/

Slide42

http://nydropboxes.org/Slide43

www.dec.ny.gov/chemical/45189.htmlSlide44

Summary

Antibiotic resistance is a serious threat to public health

Get Smart: Know When Antibiotics Work promotes judicious antibiotic prescribing among outpatients

Antibiotics are most commonly prescribed inappropriately for respiratory infections

Educating parents and prescribers can support appropriate prescribing and useSlide45

Call to Action- You Are Part of the Solution

Get Smart

:

Learn more about the issue by going to CDC’s “Get Smart” page

http://

www.cdc.gov/getsmart/community/index.htmlShare Smart:Pre-educate parents and children (conversations, PTA meetings, newsletters) before the ill child is taken to the healthcare provider, by disseminating “Get Smart” educational materials (available from NY “Get Smart” Campaign or by downloading).Live Smart:Use the information you have learned to make informed decisions about your own antibiotic useSlide46

Get Smart About Antibiotics Week

2015

November

16-22,

2015Key

component of CDC’s efforts to improve antibiotic stewardship in communities, healthcare facilities, and on farms In collaboration with state-based programs, nonprofit and for-profit partners Raises awareness of antibiotic resistance threat and importance of appropriate antibiotic prescribing and usewww.cdc.gov/getsmart/week/overview.htmlSlide47

Questions?