Advancing Antimicrobial Stewardship in Community and Rural Hospitals

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1 Advancing Antimicrobial Stewardship in Community and Rural Hospitals Whitney Buckel, PharmD, BCPS Infectious Diseases Clinical Pharmacist Intermountain Medical Center

2 Disclosures The SCORE study was supported by the Pfizer Grant for Learning and Change administered by The Joint Commission Co-investigator on investigator-initiated study on antimicrobial stewardship Primary Investigator: Eddie Stenehjem, MD, MSc

3 Objectives Define antimicrobial stewardship Give an example antimicrobial stewardship intervention

4 National Landscape September 2014: President s Executive Order, PCAST report March 2015: National Action Plan for Combating Antibiotic-Resistant Bacteria November 2015: Proposed Standard for Antimicrobial Stewardship by The Joint Commission (TJC) Coming soon: National Quality Partners (NQP) Antibiotic Stewardship Initiative Condition of Participation by Centers for Medicare and Medicaid Services (CMS)

5 What is Stewardship? Systematic efforts to optimize the use of antibiotics to maximize benefits, minimize resistance and decrease adverse events

6 Core Elements of a Stewardship Program Leadership commitment from administration Single leader responsible for outcomes Single pharmacy leader Antibiotic use tracking Regular reporting on antibiotic use and resistance Educating providers on use and resistance Specific improvement interventions

7 Types of Stewardship Interventions 7

8 Bartlett JG et al. Clin Infect Dis 2008;46:S12-8. Stevens V et al. Clin Infect Dis 2011;53:42-8. Nuila F et al. Infect Control Hosp Epi 2008;29: Mullane KM et al. Clin Infect Dis 2011;53: Stewardship and C. difficile Previous antibiotic use is the predominant risk factor for C. difficile All antibiotics carry this risk, but most commonly implicated are clindamycin, cephalosporins, beta-lactams and fluoroquinolones. Use of combination therapy and long-term receipt of antibiotic therapy are also risk factors Treatment with concomitant antibiotics compromises the initial response to C. difficile and the risk of recurrence Antimicrobial stewardship helps to reduce unnecessary antibiotic use, minimize combination therapy and reduce treatment duration, which all help to reduce the risk of C. difficile and improve outcomes

9 What about Community and Rural Hospitals? 2005 United State Hospitals 4935 Registered Hospitals 72% have < 200 beds Most of these are without antibiotic oversight All included in National Action Plan Very few studies of stewardship in these settings Rate of antibiotic use at these facilities is high

10 Polling Do you have a program for Antibiotic Stewardship in your facility? Yes Partial program Working to launch a program No 10

11 Days of Therapy per 1,000 Patient Days Present Antibiotic Use 750 NHSN AU option Excluding: Maternity Newborn Psychiatry Rehabilitatio n Small Large S13 S1 S4 S7 S2 S15 S3 S12 S9 S11 S10 S5 S14 S6 S8 L1 L4 L3 L2 Intermountain Facilities

12 SCORE study Stewardship in Community Hospitals Optimizing Outcomes and Resources Objective: Define an antibiotic stewardship strategy for Intermountain s smaller hospitals that optimizes outcomes while maximizing resources Setting: Community and rural hospitals less than 200 beds within Intermountain Healthcare Design: Cluster randomized controlled trial Program 1 (High resource): 5 hospitals Program 2 (Medium resource): 5 hospitals Program 3 (Low resource): 5 hospitals Timeline: 6 months curriculum development, 15 month intervention period

13 Types of Stewardship Interventions 13

14 Program 1 Program 2 Program 3 Access to ID clinicians and pharmacist s Antibiotic Best Practices 48 hour antibiotic timeout Antibiotic Indications IV to PO conversion Basic Antibiotic Stewardship Education Monthly hospital antibiotic utilization

15 Example Interventions Date: 08/29/ :00 To: Dr. Stenehjem, Mrs. Buckel in room T907 has been on vancomycin and piperacillintazobactam for 48 hours. This patient has allergies to no antibiotics, and appears to tolerate other oral therapies. Policies and Procedures (e.g., IV to PO, dose optimizations) The following microbiology data are available: Negative cultures to date The CDC recommends re-evaluating antibiotic therapy at this time based on new data and the current clinical picture. Sharing of Antibiotic Use Dat (e.g., Dashboard, ) Yes, I have acknowledged this patient s current regimen, and plan to tailor their antibiotics. Formalized Antibiotic Time Out at hours Yes, I have acknowledged this patient s current regimen, and wish to continue the current regimen.

16 Program 1 Program 2 Program 3 Access to ID clinicians and pharmacist s Antibiotic Best Practices 48 hour antibiotic timeout Antibiotic Indications IV to PO conversion Basic Antibiotic Stewardship Education Monthly hospital antibiotic utilization Advanced Antibiotic Stewardship Education Prospective audit and feedback: Limited Restrictions: Local Pharmacy Control Prospective audit and feedback: Full Restrictions: Infectious Diseases Control ID study staff review positive blood culture results and MDROs.

17 Pillar 1: Prospective Audit with Intervention and Feedback Pillar 2: Antimicrobial Restrictions Example Interventions (cont.)

18 Polling Is there a person at your facility responsible to review antibiotic orders for appropriateness? Yes No Uncertain 18

19 All Antibiotics Intervention vs Expected: Program 3 vs 1 RR 0.83 (0.72, 0.94) p = Intervention vs Expected: Program 2 vs 1 RR 0.96 (0.83, 1.10) p = 0.56

20 Restricted Drugs Intervention vs Expected: Program 3 vs 1 RR 0.39 (0.22, 0.68) p = Intervention vs Expected: Program 2 vs 1 RR 0.65 (0.39, 1.10) p = 0.10

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22 Cat 4/5 Antibiotics Intervention vs Expected: Program 3 vs 1 RR 0.73 (0.56, 0.95) p = Intervention vs Expected: Program 2 vs 1 RR 0.69 (0.53, 0.91) p = 0.007

23 SCORE Study Conclusions Antimicrobial use in SCH is comparable to larger facilities Stewardship is needed Stewardship is feasible in these settings Stewardship can lower antimicrobial use Which program type fits best, to be determined

24 Summary Antimicrobial stewardship is an important approach to reducing antimicrobial resistance, including C. difficile Soon, all facilities will be required to have antimicrobial stewardship programs in place and functioning Antimicrobial stewardship is feasible in all facilities, but most be tailored to unique site needs

25 Acknowledgements IMC ID Physicians Eddie Stenehjem (PI) Bert Lopansri Kristin Dascomb Brandon Webb John Burke Josh Caraccio Dustin Waters Jared Olson Doug Smith Robin Betts ID Pharmacists Administration Andy Pavia Adam Hersh Emily Thorell Tom Greene All the providers in the SCHs! Pediatric ID Partners Xiaoming Sheng Peter Jones Scott Evans Jim Lloyd Statistical Team Data Support

26 Thank you for your time and attention! Questions? Whitney Buckel, PharmD, BCPS 26