Antimicrobial Stewardship Beyond the Hospital Setting - PowerPoint Presentation

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 populationsSlide42
Slide43

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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