GET SMART Clinician-Patient Communication about Antibiotics

Transcription

1 GET SMART Clinician-Patient Communication about Antibiotics Wednesday, May 23, 11:30 12:30 Webinar Will Begin Shortly. Slides may be downloaded at: Call-In Number: (888) Access Code: This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINC

2 Speaker Disclosures Today s speakers have no conflicts of interest to disclose. In adherence to the regulation standards of the Connecticut Pharmacists Association, the Accreditation Council of Pharmacy Education, Northeast Multistate Division (NE-MSD) this notice confirms that the information contained in this presentation is free of commercial bias and the speakers have no related vested financial interest in any capacity, inclusion of shareholder, recipient of research grants, consulting or advisory committees. 2

3 GET SMART Provider-Patient Communication about Antibiotics. Dr. Alina Filozov MiddlesexHospital

4 Objectives Review: The rationale for antibiotic stewardship efforts. Unintended consequences of antibiotic use. Strategies to avoid unnecessary cultures and subsequently unnecessary antibiotics. Doctor-patient communication strategies in order to improve antibiotic prescribing for common infections. Antibiotic prescribing bias. Infection prevention strategies.

5 Antibiotic Stewardship Right drug - for the right patient - for the right indication - at the right dose - for the right duration....while avoiding unintended consequences

6 Use Antibiotics only when necessary.

7 Infection Control & Hospital Epidemiology, April million outpatient antibiotic prescriptions were filled by 39 million insurance beneficiaries. Azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin were the most commonly prescribed antibiotics. There was significant seasonal variation, with antibiotics 42 percent more likely to be prescribed during February than September From 2013 to 2016, annual national outpatient antibiotic prescribing practices remained unchanged

8 , No Carolina HealthSystem 448,990 visits of 281,315 unique patients (adults and children) to urgent care, family medicine, internal medicine, and pediatric practices Overall prescribing rates -407 per 1000 visits. Acute bronchitis had the highest rate of inappropriate prescription at 703 per 1000 visits. Adult patients seen by an advanced practice clinician had a 15% greater chance of receiving a prescription compared with those seeing a physician provider. For pediatric visits, older providers (between 51 and 60 years of age) were 4 times more likely to prescribe antimicrobials compared with providers 30 years (IRR, 4.21; 95% CI, ).

9 Unintended Consequences of Antibiotic Use Disruption of GI Bio flora Colonization with resistant organisms Antibiotic-Associated-Diarrhea C. difficileinfection Allergic reaction Drug -related Side effects

10 Common Antibiotics - Safety Issues Quinolones - Healthcare professionals should not prescribe systemic fluoroquinolones to patients who have other therapeutic options for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections due to the risks outweighing the benefits. RISKS: Peripheral neuropathy, CNS effects (psychosis, depression), cardiac effects (QT prolongation), tendinitis/tendon rupture, worsening myasthenia gravis, dermatologic and hypersensitivity reactions.

11 Common Antibiotics - Safety Issues Azithromycin, Clarithromycin - Health care professionals should consider the risk of fatal heart rhythms with azithromycin when considering treatment options for patients who are already at risk for cardiovascular events. FDA notes that the potential risk of QT prolongation with azithromycin should be placed in appropriate context when choosing an antibacterial drug: Alternative drugs in the macrolide class, or non-macrolides such as the fluoroquinolones, also have the potential for QT prolongation or other significant side effects that should be considered when choosing an antibacterial drug.

12 Cultures Should Predate Antibiotics When Possible Provide epidemiological info for patient and community. Helps you select the narrowest effective antibiotic.

13 Avoiding Unnecessary Cultures Checking routine cultures just to make sure is not indicated and is harmful Test of Cure for C.diff not indicated Performing urine cultures as part of physical is not helpful Performing a throat culture in a patient without a classic Strep throat presentation is not a standard of care.

14 Other Antibiotic-RelatedPrinciples Use narrowest spectrum antibiotic. Spectrum of activity of selected antibiotic should cover suspected infectious agent. Review allergy and consider trial of beta-lactams in patients with history of non-ige related reactions. *(To decrease adverse events: secondary to drug, readmission for the same infection, C.diff, ARF; CID 2016:63)

15 How to Talk to Patients about Antibiotics Acknowledge the validity of patient s symptoms. Explain the origin of patient s infection: i.e., viral bronchitis. Show your patient that there is a reasonable explanation to your decision not to prescribe antibiotics by engaging in a conversation. Provide recommendations on symptoms relief. Provide guidance on symptoms that should raise patients suspicion for worsening of current condition. Remind patients that frequent antibiotic use can lead to complications. Tell the patient that you are trying to provide the best care by using antibiotics only when necessary.

16 What You Call it Matters Pneumonia vs Chemical Pneumonitis Asymptomatic Bacteriuria vs UTI Viral sinusitis vs Bacterial sinusitis Bronchitis vs Pertussis vs COPD exacerbation Skin rash vs venous stasis dermatitis vs cellulitis Discolored secretions vs a sign of bacterial infection Positive culture vs infection

17 Asymptomatic Bacteriuria The frequency of ABU in different populations is as follows: Preschool girls, <2% Pregnant women, 2-9.5% Women aged years, 18-43% Men aged years, % Women older than 80 years, 18-43% Men older than 80 years, % The US Preventive Services Task Force advises against screening men and nonpregnant women for asymptomatic bacteriuria In LTC facilities, in noncatheterized residents, asymptomatic bacteriuria has been estimated at 18% to 57% for women and 19% to 38% for men. In residents with IUCs, the risk is timedependent, increasing at a rate of 3% to 8% each day of IUC use, reaching 100% prevalence at 30 days.

18 Discussing Antibiotics Therapy Example: Mr. Smith you have sinusitis caused by a virus. You don t need antibiotics. Antibiotics will not resolve your infection and can cause harm to you, like diarrhea, future infections due to resistant bacteria, other, even life-threatening side effects. If you develop worsening symptoms,such as fever, persistent severe symptoms after days I will consider additional medications. For now use OTC medications or no medications at all and call us with any concerns.

19 Watchful Waiting Prescribing - Safety Net Antibiotic Prescribing Adds an opportunity for the condition to improve. Safety net against a wrong diagnosis. Makes some patients more comfortable in leaving the doctor s office without an antibiotic to start.

20 Perception is Everything Doctors are more likely to prescribe antibiotics if they think patients expect the medications, according to a study published in Health Psychology. 436 doctors in the United Kingdom. Physicians were more likely to prescribe antibiotics if patients had high expectations of receiving the medications. This was true even if the doctor didn't think the patient had a bacterial infection.

21 The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, BrookRH Physicians' perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology. When physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. When physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Physician antimicrobial prescribing behavior was not associated with actual parental expectations for receivingantimicrobials.

22 Education is Needed For Patients and Providers Providers should manage patients expectations Display educational posters in the exam rooms. They can be referenced during the conversation with patient. Providers should influence patients criteria for satisfaction: medical outcomes, short and long term; evidence-based practice; provider s effort and options for treatment; assurance that patient s best interests are the guiding principle of treatment. Proper patient education should focus on improving knowledge regarding antibiotics and their indications

23 An Ounce of Prevention... Vaccinations: Influenza vaccine Prevnar and Pneumovax vaccines for immunocompromised and elderly Meningococcal vaccine Shingles vaccine

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27 ACPE Code communication Continuing Education Credits The Connecticut Pharmacists Association is accredited by the Accreditation Council of Pharmacy Education as providers of continuing pharmacy education. Pharmacists in attendance who complete an on-line evaluation can receive up to 0.5 contact hour of credit. Knowledge based activity: L04-P Certificate of Attendance Other attendees who complete an online evaluation will receive a certification of attendance. Questions regarding CE status may be submitted to Francis Kissi at fkissi@qualidigm.org. 27

28 Contact Information CONNECTICUT Francis Kissi MASSACHUSETTS Alyssa DaCunha x3241 MAINE Amanda Gagnon NEW HAMPSHIRE Gloria K. Thorington RHODE ISLAND Maureen Marsella VERMONT Regina-Anne Cooper