A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy - PowerPoint Presentation

1. A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumoniaFarnaz Foolad1, Angela M. Huang2, Cynthia T. Nguyen3, Lindsay Colyer4,5, Megan Lim4,5, Jessica Grieger6, Julius Li7, Sara Revolinski2,8, Megan Mack9, Tejal Gandhi10, J. Njeri Wainaina11, Gregory Eschenauer4,5, Twisha S. Patel4,5, Vincent D. Marshall4,5, Jerod Nagel4,51Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA; 3Department of Pharmacy, University of Chicago Medicine, Chicago, IL, USA; 4Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA; 5College of Pharmacy, University of Michigan, Ann Arbor, MI, USA; 6Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA; 7Department of Pharmacy, Ochsner Medical Center, New Orleans, LA, USA; 8Medical College of Wisconsin School of Pharmacy, Milwaukee, WI, USA; 9Division of Hospital Medicine, Michigan Medicine, Ann Arbor, MI, USA; 10Division of Infectious Diseases, Michigan Medicine, Ann Arbor, MI, USA; 11Section of Perioperative Medicine and Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA

2. Journal Club FormatIssue being studiedRationaleStudy design and methodologyResultsConclusionsStudy limitationsStudy implicationsQuestions/discussion

3. Issue Being Studied“[T]he objective of this study was to assess the impact of a multicentre, multifaceted stewardship initiative to promote compliance with IDSA/ATS [Infectious Diseases Society of America/American Thoracic Society] CAP [community-acquired pneumonia] recommendations regarding DOT in hospitalized CAP patients and its impact on patient outcomes.”

4. RationaleIDSA/ATS guidelines recommend 5 days of antibiotic therapy for clinically stable patients with CAP who are afebrile for 48-72 hours and have no more than one sign of CAP-related clinical instability and no extra-pulmonary infection.Though Centers for Medicare and Medicaid Services regulations govern approaches to timely therapy and culture for CAP, there are no regulatory requirements for guideline-compliant duration of therapy.

5. RationaleNational compliance with recommended duration of therapy for CAP is suboptimal, raising the risk for antibiotic-related adverse effects and Clostridium difficile infection.First-line recommended therapy for non-severe CAP = beta-lactam plus azithromycin OR a fluoroquinolone alone.Fluoroquinolones, third-generation cephalosporins, and ceftriaxone are often used due to ease of dosing and administration but raise the risk for C diff infections.

6. Study Design and MethodologyDesign: Multicenter, pre-post, quasi-experimental studyTime periods: Pre-intervention (historical control): November 2014 – April 2015Post-intervention: November 2015 – April 2016

7. Study Design and MethodologyPrimary objective: Assess impact of a multifaceted antimicrobial stewardship intervention on duration of antimicrobial therapy for CAP.Secondary objectives: Evaluate the impact of the intervention on patient outcomes, including mortality, readmission or presentation to an Emergency Department with pneumonia, and Clostridium difficile infection incidence 30 days after discharge.

8. Study Design and MethodologyThe intervention: Each institution’s guidelines for empirical CAP therapy were updated with appropriate duration of therapy recommendations based on the IDSA/ATS guidelines.Pocket cards describing duration-of-therapy recommendations were made, distributed, and posted on each hospital’s intranet.The stewardship team held educational sessions on duration of therapy for clinicians.

9. Study Design and MethodologyThe intervention: ID pharmacists conducted prospective audit and feedback on CAP patients admitted Monday-Friday, focusing on:Direct verbal recommendations on duration of therapy based on patient evaluationRecommendations that antibiotic therapy be discontinued when patients were afebrile and had no more than one sign of CAP-related clinical instability (heart rate > 100 bpm, respiratory rate > 24 breaths/minute, systolic BP < 90 mm Hg, arterial O2 saturation < 90% or partial pressure of O2 < 60 mm Hg on room air, altered mental status)

10. Study Design and MethodologyStudy Population: N = 600Historical controls: n = 307Intervention group: n = 293Inclusion criteria: Age > 18 years and admitted for CAPExclusion criteria: HCAP, HAP, VAP, empyema, necrotizing pneumonia, bacteremia, concomitant infection requiring antimicrobial therapy, cystic fibrosis, ICU admission, transfer from outside hospital, respiratory culture with non-fermenting gram-negative bacillus or Staphylococcus, died during pneumonia treatment

11. Study Design and MethodologyPatient characteristics:Patients in both groups had a similar severity of illness.Historical controls were more likely to chronically use systemic steroids.Patients in the intervention group were more likely to have had a myocardial infarction, chronic pulmonary disease, and suspected or witnessed aspiration.

12. ResultsNumber of patients who met the criteria for 5-to-6 day duration of therapy:96.4% pre-intervention91.5% in the intervention groupNumber of patients receiving only 5 days of therapy: 4.9% (15 patients) pre-intervention35.2% (103 patients) in the intervention group

13. ResultsMedian duration of therapy:9 days (range of 7-10) pre-intervention6 days (range of 4-7) in the intervention group (p < 0.001)Only one patient in the control group and four patients in the intervention group should have received more than 10 days of therapy.Guideline-concordant duration of therapy:5.6% (17 patients) pre-intervention42% (120 patients) in the intervention group (p < 0.001)

14. Results30-day post-discharge outcomes:Incidence of readmission for pneumoniaControls: 7.1%Intervention: 3.8%Incidence of ED presentation for pneumoniaControls: 6.8%Intervention: 4.4%30-day mortalityControls: 2.3%Intervention: 1%No incidences of C diff infection occurred in either group.

15. ConclusionsA 6-month stewardship intervention based on clinician education, expansion of existing empirical therapy guidelines, and prospective audit and feedback was associated with avoiding 586 days of unnecessary antibiotics for patients with CAP.Use of guideline-compliant duration of therapy in patients with CAP was not associated with adverse outcomes in three US healthcare systems.

16. Study LimitationsPatients with risk factors for severe disease or complications were excluded.Pharmacist audit and feedback only occurred on weekdays, potentially missing patients who became clinically stable on weekends.Educational sessions for clinicians were conducted once at each large teaching hospital, and new, rotating clinicians may not have received information.Follow-up only occurred in 58.1% of controls and 57.2% of patients in the intervention group and may have missed adverse events occurring after 30 days post-discharge.

17. Study ImplicationsThe stewardship intervention increased compliance with guideline-concordant duration of therapy for CAP, but many patients eligible for 5 or 6 day therapy still had unnecessarily extended antibiotic treatment, potentially due to the following factors:Pharmacist recommendations on duration were made upon documentation of patient clinical stability and not on the last day of appropriate therapy or at discharge, making it likely that stop dates could have been forgotten or not passed on to the responsible clinician.Clinicians may have been hesitant to write a discharge prescription for 1 to 3 days, even though this duration would have been sufficient.

18. Study ImplicationsThe study was the largest study evaluating the impact of antimicrobial stewardship on duration of therapy for CAP and patient outcomes at the time of publication.Educational and monitoring tools were shared between three large hospitals, creating a collaborative tri-state stewardship relationship and reducing the burden of the intervention on individual sites.Future explorations should focus on the economic impact of CAP duration of therapy and the role of inter-hospital collaborations in antimicrobial stewardship.

19. Questions and Discussion