7/25/2016. Disclosures. Disclosure. Inserting a Silver Lining into Infection Management: Antibiotic Stewardship in Long Term Care

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1 Inserting a Silver Lining into Infection Management: Antibiotic Stewardship in Long Term Care MARILYN N. BULLOCH PHARMD, BCPS ASSOCIATE CLINICAL PROFESSOR OF PHARMACY PRACTICE HARRISON SCHOOL OF PHARMACY, AUBURN UNIVERSITY ADJUNCT ASSISTANT PROFESSOR DEPARTMENT OF INTERNAL MEDICINE UNIVERSITY OF ALABAMA COLLEGE OF COMMUNITY HEALTH SCIENCES MJN0004@AUBURN.EDU Disclosures Alabama Medicaid DUR Board Member Pharmacy Times Contributor Disclosure There is very little (recent) data on antibiotic use, resistance, ect from studies conducted in the United States It is ingrained in me to say patient instead of resident 1

2 It is not difficult to make microbes resistant to penicillin.the time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under dose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant. - Alexander Fleming Nobel Prize Acceptance Lecture 1945 Alexander Fleming Penicillin Selman Waksman Streptomycin Ampicillin Vancomycin Metronidazole Rifampin Lincomycin Trimethoprim Aminoglycosides Tetracyclines Fluoroquinolones Carbapenems Oxazolidinone Aztreonam 1920s 1930s 1940s 1950s 1960s 1970s 1980s Gerhard Domagk Sulfonamides Methicillins Nitrofurantoin Macrolides Cephalosporins Polymyxin William Stewart US Surgeon General It s time to close the book on infectious diseases Daptomycin Superbug investigation: It s likely that more of these will be found, CDC says Washington Post Infections resist 'last antibiotic' in US - BBC Another Nail In The Antibiotic Coffin Popular Science 2

3 Long-Term Care Today > 16,000 long-term care facilities Approximately 1.5 million older adult patients 22,743 patients in Alabama By in 5 people in the United States will be 65 years Approximately 30 million will have functional limitations Result - need for long-term care High HP. Clin Infect Dis.2009;48: Infection s Perfect Storm Diabetes Obstructive lung disease Urinary obstruction Impaired swallowing Poor dentition Implanted prosthetic device Comorbid Diseases Chronic immobility Altered mental status Functional Limitations Impaired immunity Adaptive B & T cell Innate surface expression or function of Toll-like receptors risk of Listeria, M. tuberculosis, and varicella-zoster virus response to vaccines influenza, pneumococcal, zoster Age-related impaired immunity Infection Living in close quarters (LTC) High KP et al. Clin Infect Dis. 2009;48:

4 Antibiotics in the Nursing Home Up to 70% of LTC patients receive 1 course of antibiotics each year Up to 75% of antibiotics in LTC facilities are prescribed inappropriately Less than half of antibiotic recipients have a physician bedside visit within 1 day of index prescription Median duration of therapy is approximately 10 days (interquartile range 7-30 days) Mode duration of therapy is 7 days Approximately 50% of antibiotics used in nursing homes are given longer than needed 20% of prescribers account for ~ 80% of antibiotics prescribed Daneman N et al. J Antimicrob Chemother.2011;66: Lim et al Clin Interven Aging 2014;9: Nicolle et al. Infect Control Hosp Epidemiol. 2000;21: Smith PW et al. Ann Long Ter Care. 2011;19(4) Infections in Long-Term Care Gastroenteritis Pneumonia Prosthetic-deviceassociated infections Skin/Soft Tissue Infections Urinary Tract Infections High KP et al. Clin Infect Dis. 2009;48: Antibiotic Trivia Who coined the term Antibiotic? A. Alexander Fleming B. Salman Waksman C. Eli Lily D. Louis Pasteur 4

5 What is being Prescribed Daneman N et al. JAMA Intern Med. 2015;175: Daneman N et al. J Antimicrob Chemother.2011;66: Problems with Antibiotic Use Patients in high antibiotic use facilities have 24% higher risk of antibioticrelated complications High use = > 62 antibiotic days/1,000 resident day Clostridium difficile Resistance Adverse effects Antibiotic allergies Factors that Increase Antibiotic Harm Risk High-use nursing home Rural location Increased age Male Each year in LTC DNR order PEG tube IV medications Indwelling foley catheter Incontinence (bladder or bowel) Moderate assistance for ADLs Comorbidities Diabetes Peripheral vascular disease Dementia Cancer GI disease Liver disease Kidney disease Each medication (OR 1.03) Emergency room visit in past year Inpatient admission in past year Daneman N et al. JAMA Intern Med. 2015;175:

6 Resistance The Resistance Cycle Increased use of antibiotics in LTC Increased use of antibiotics in the hospital Antimicrobial Resistance Antimicrobial Resistance 2 million infections per year 23,000 deaths annually $20 billion direct costs annually $35 billion indirect costs annually Most common drug-resistant organisms MRSA VRE Increasing frequency of resistance Klebsiella Acinetobacter CDDEP Report

7 Consequences of Resistance Less effective treatments More expensive treatment Increased health utilization office visits, emergency room, urgent care, ect Increased and longer hospitalizations Prolonged recovery period Increased mortality MRSA Isolate CDDEP 2015 Resistance in LTC Patients O Fallon et al Lautenbach et al Micek et al Setting 750-bed NH 63 LTC facilities 121 patients from NH admitted to urban teaching hospital Time months in Isolate type Ciprofloxacin-resistant GNB 1805 GNB Urine cultures Results from 7% to 13% FQ-resistant E.coli 51% Ceftazidime-resistant Klebsiella 26% Imipenem-resistant Klebsiella 6% Pneumonia MRSA, Pseudomonas, or ESBL-producing bacteria isolated in 72% NH: Nursing home; LTC: long-term care; GNB: gram-negative bacteria; FQ: fluoroquinolone Drinka P. J Am Med Dir Assoc. 2010;11:

8 New Colonization with Antibiotic-Resistant Organisms Figure 1 and Table 4. Fisch J et al. J Clin Microbiol.2012;50: Perceptions on Antibiotic Use Antibiotic Prescribing Concerns Resistance concerns Physicians Nurses Pharmacists 80% admit to over prescribing most just in case the patient deteriorates Lim et al. BMC Infect Dis 2014;14:410 50% believe resistance an issue in LTC most due to UTIs, long-term prophylaxis, and chronic wound colonization Over prescribing for viruses, asysmptomatic bacteria, & empiric treatment without cultures Low staff awareness & inadequacy of existing infection control efforts Stewardship Supportive promotes EBM Supportive good for quality improvement strategies and educational support Stewardship barriers Physician autonomy hinder acceptance of policies/guidelines Heterogeneous prescribing Workload concerns Concern over physician acceptance Main concern duration of therapy not uncommon for durations > 10 days when prescribed without stop dates Not assessed Supportive more prescribing uniformity and compliance with guidelines Lack of on-site availability Lim et al. BMC Infect Dis 2014;14:410 Antibiotic Stewardship 8

9 What is Antibiotic Stewardship? The limitation of inappropriate antimicrobial use while optimizing antimicrobial drug selection, dosing, route, and duration of therapy in order to maximize clinical cure and to limit unintended consequences, such as the emergence of resistance, adverse drug events, and the selection of pathogenic organisms. Daneman N et al. J Antimicrob Chemother.2011;66: What the IDSA Says Implementing ASPs at nursing homes and skilled nursing facilities is important and must involve point-of-care providers to be successful. The traditional physician-pharmacist team may not be available on-site and facilities might need to investigate other approaches to review and optimize antibiotics IDSA Antibiotic Stewardship Guidelines Barlam et al. Clin Infect Dis.2016;62: Benefits and Goals of Antibiotic Stewardship Better patient outcomes Reduce unnecessary and suboptimal antibiotic use Improve adherence to treatment guidelines Conservation of antibiotic spectrum - less toxic medications Decreased resistance Current strains Super bugs Reduce harm from antibiotic adverse events Reduce costs Helps comply with current regulations 9

10 F-Tabs F-tag 441: Infection control Documentation/analysis of surveillance data Antibiotic review to determine the most appropriate use of antibiotics in the facility population F-Tag 329: Unnecessary drugs Facility reviews with prescriber rationale for placing patient on an antibiotic to which the organism is resistant or when the patient stays on antibiotic therapy without adequate monitoring, without appropriate indication, or for excessive duration F-Tag 428 Drug regimen review for new medications Should include dosing and administration data Renal and hepatic dosing Potential drug-interactions (drug, disease, and nutrient) National Action Plan for Combatting Antibiotic-Resistant Bacteria By 2020 Develop and implement antibiotic stewardship programs in nursing homes Core Elements 10

11 Ideal Stewardship Team Epidemiologist Other Staff Pharmacist Nurses Antimicrobial Stewardship Team Microbiologist Other Physicians Infection Control Medical Director Information Technology Your Role Medical Directors Set antibiotic prescribing standards for all prescribers Oversee adherence to these prescribing practices Review antibiotic use data Ensure best practices Directors of Nursing Establish standards for nursing staff to monitor and report patient conditions that might impact antibiotic need/use Use influence as a nurse leader to ensure antibiotics are prescribed only when appropriate Educate front line staff on the importance of stewardship Explain facility policies designed to improve antibiotic use CDC. Core Elements for Antibiotic Stewardship in Nursing Homes. Driving the Culture Change Identify clinical providers as antibiotic stewardship champions Engage administrators - ensure they understand rationales and goals Use a multidisciplinary group Perform a gap analysis Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package

12 Using Resources Well Focus efforts and resources on the conditions that represent: The most antimicrobial orders The Pareto Principle Law of the Vital Few 80% of outcomes result from only 20% of potential causes The most inappropriate antimicrobial orders The most common infections Consider focusing on areas with the most inappropriate antibiotic use Units Providers Hamilton KW et al. Infect Dis Clin N Am. 2014;28: The Most Basic Principles Use Drug The Right Dose and Route Duration Antibiotic Trivia Which antibiotic class can precipitate an acute benzodiazepine withdrawal in a patient taking benzodiazepines chronically? A. Cephalosporins B. Macrolides C. Fluoroquinolones D. Aminoglycosides 12

13 Creating Minimum Criteria A FOUNDATION TO ANTIBIOTIC PRESCRIBING Evaluation Difficulties Blunted infection-related temperature change Cognitive impairment Off-site laboratory services Non-daily physician coverage Sub-optimal nurse:patient ratios Staffing inconsistencies Crnich et al. Drugs Aging.2015;32: Developing Minimum Criteria Develop diagnostic criteria for specific types of infection Criteria should clearly identify when antibiotics should be started Criteria should clearly identify when antibiotics should not be started A list of differential diagnoses should be included Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package

14 Suspecting Infection Functional Status Decline New or increased Confusion Incontinence Falling Deteriorating mobility Reduced food intake Fever Single oral temperature > 100 F (> 37.8 C) Repeated oral temperatures > 99 F (> 37.2 C) Rectal temperature > 99.3 F (> 37.5 C) Increase in temperature > 2 F (> 1.1 C) from baseline Failure to cooperate High KP et al. Clin Infect Dis. 2009;48: Minimum Criteria for Antibiotics UTI With Catheter Temperature 100 F or 2.4 F above baseline New costovertebral tenderness Rigors with or without identified cause New onset delirium UTI Without Catheter One of the following Acute dysuria Temperature 100 F or 2.4 F above baseline Plus one of the following New or worseingin urgency New or worsening frequency New or worsening suprapubic pain Gross hematuria Costovertebral angle tenderness Urinary incontinence Loeb et al. Infect Control Hosp Epidemiol.2001;22: Minimum Criteria for Antibiotics: SSTIs Criteria New/increasing purulent drainage at a wound, skin or soft tissue site OR 2 of the following Temperature 100 F or 2.4 F above baseline Redness Tenderness Considerations Consider osteomyelitis in infected diabetic or decubitus ulcer Surgery required for necrotizing fasciitis or gas gangrene Criteria do not apply to burns Differential diagnosis gout, DVT Bilateral disease consider heart failure Warmth New/increased swelling at infected site Loeb et al. Infect Control Hosp Epidemiol.2001;22:

15 Minimum Criteria for Antibiotics: Respiratory Infections Criteria Temperature > 102 F Respiratory rate > 25 breaths/minute OR Productive cough Temperature 100 F or 2.4 F above baseline Cough plus 1 of the following Heart rate > 100 beats/minute Considerations If a chest x-ray shows new infiltrate, only need one of the following: RR> 25, productive cough, or Temperature 100 F or 2.4 F above baseline Evaluating a CBC is strongly encouraged Delirium Rigors Respiratory rate > 25 breaths/minute Loeb et al. Infect Control Hosp Epidemiol.2001;22: Minimum Criteria for Antibiotics Unknown Source Temperature 100 F or 2.4 F above baseline 1 of the following Delirium Rigors Investigate but do not start empiric antibiotics Reduced functional activities Withdrawal Decreased/loss of appetite Loeb et al. Infect Control Hosp Epidemiol.2001;22: Laboratory Tests CBC and differential All patients suspected of having an infection Within hours of symptom onset Urinalysis/Urine culture Indwelling catheter suspected urosepsis Blood culture Rarely recommended Highly suspected bacteremia if quick access to laboratory Pulse oximetry Respiratory rate > 25 breaths/minute Chest X-ray O2 saturation < 90% Stool cultures Patient who received antibiotics within 30 days High KP et al. Clin Infect Dis. 2009;48:

16 Antibiotic Trivia Which antibiotic can cause a disulfram-like reaction when alcohol, or alcohol containing products, is ingested? A. Penicillin B. Cefotetan C. Azithromycin D. Minocycline Stewardship Practices INDIVIDUAL COMPONENTS TO INCORPORATE INTO YOUR BROADER PROGRAM 16

17 Simple Interventions Make national guidelines available Develop a formulary Develop infection-specific treatment algorithms Require pre-authorization for certain antibiotics Avoid tests of cure after clinical resolution and appropriate treatment course for infection May show asymptomatic colonization - may inappropriately be treated Fundamental Prescribing Practices Empiric Treatment Consistent with guidelines If not consistent with guidelines, logical reasoning is documented Appropriate tests are obtained Indication is documented (including rationale; prophylaxis vs. treatment) During therapy Daily review of pertinent tests Narrow therapy when cultures and sensitivities become available Parenteral to oral conversion when possible (if applicable) Stop therapy at appropriate time Keep Track of Isolates Maintain bacteriology database Sort by Nursing unit Organism Antibiotic sensitivity Date Utilize laboratory to help with this Only include one isolate of a given type per resident Drinka P. J Am Med Dir Assoc. 2010;11:537-9 Smith PW et al. Ann Long Ter Care. 2011;19(4) 17

18 Communication Tool Structured tool for guiding nurse-physician interactions Key information: clinical history, new symptoms/complaints, physical exam findings Relevant information: previous C & S results, current medications, allergy information May include options for management Hydrate and monitor Send for diagnostic tests Initiate treatment Should become part of the medical record AHRQ Example: Medical Care Referral Form AHRQ Example: Medical Care Referral Form 18

19 AHRQ Example: Medical Care Referral Form

20 Allergies Only 10-15% of patients with reported penicillin allergies have positive reactions to skin testing Patients with allergies often get broader-spectrum, suboptimal, or more toxic antibiotics Hamilton KW et al. Infect Dis Clin N Am. 2014;28: Allergies Determine drug class Ask about other agents within that class Example: Have you ever taken anything such as Amoxicillin or Augmentin Ask about agents in classes with cross-reactivities Example (patient with a penicillin allergy): Have you ever taken anything like Keflex or Omnicef? Determine if the reaction was an intolerance vs. allergy vs. adverse drug reaction Example: if the patient says they experienced itching or rash, ask if it was localized or widespread Red flags: whelps, shortness of breath, full body rash, anaphylaxis Determine how long ago the last reaction occurred Only 20% of IgE-mediated reactions remain after 10 years Involve the family in identifying/confirming allergies Hamilton KW et al. Infect Dis Clin N Am. 2014;28: Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package

21 Passive Monitoring of Antibiotic Use Used along with resistance monitoring Data to collect Days of therapy including if this was pre-specified Defined daily doses per 1,000 patient days Number of patients treated with antibiotics per month Antibiotics ordered Routes of administration Costs Orders made via phone vs. in person If cultures obtained before antibiotic ordered Where order for antibiotic initiated nursing home vs. transferring facility Changes in antibiotic therapy during course of treatment Indication Adverse events related to antibiotics CDC Point Prevalence Proportion of patients receiving antibiotics in a given time % Patients receiving antibiotics = # patients on antibiotics x 100 Total patients in facility % New admissions receiving antibiotics = # patients admitted on antibiotics x 100 Total new admissions Easier way to capture data May highlight unnecessary antibiotic use May not show the full magnitude of antibiotic use May not be adjusted for severity of infection CDC Ibrahim OM et al. Infect Dis Clin N Am.2014;28: Tracking Antibiotic Starts For antibiotics initiated in the nursing home Per 1000 patient days Rate of new antibiotic starts= # new antibiotic prescriptions x 1000 Total # patient-days Rate of new antibiotic starts by indication= # new antibiotic prescriptions for (infection) x 1000 Total # patient-days Track effectiveness of interventions focused on reducing unnecessary antibiotic use Most helpful for identifying and educating inappropriate antibiotic initiation Less helpful in addressing duration of therapy or de-escalation Ibrahim OM et al. Infect Dis Clin N Am.2014;28: Crnich et al. Drugs Aging. 2015;32: CDC 21

22 Antibiotic Days of Therapy Antibiotic utilization ratio: ratio of antibiotic DOT to total patient-days Antibiotic day: each day a patient receives a single antibiotic Patient 1: 7 day course of cephalexin = 7 antibiotic days Patient 2: 7 day course of ceftriaxone PLUS 7 day course of azithromycin = 14 antibiotic days Antibiotic DOT: sum of all antibiotic days for all residents in the facility during a given time Rate of antibiotic DOT= Total monthly DOT x 1000 Total # monthly patient-days Current US Standard Does not measure dosage or compare different antibiotics May underestimate exposure in patients with kidney dysfunction Ibrahim OM et al. Infect Dis Clin N Am.2014;28: Antibiotic Trivia Which antibiotic may decrease the effectiveness of penicillins? A. Cephalexin B. Azithromycin C. Ciprofloxacin D. Doxycycline Transitions of Care For patients admitted from the inpatient setting Determine length of therapy of appropriate antibiotics already received in the hospital Duration of antibiotics upon transfer often incorrect Prescriber may have counted day of transfer as Day 1 of antibiotic therapy when it is not Example: A male patient with a UTI received 5 days of ceftriaxone IV in the hospital for a sensitive uropathogen. Upon NH transfer, a 14-day course of ciprofloxacin is ordered Determine the need for continued parenteral antibiotics versus changing to an enteral agent Determine appropriate monitoring is occurring Hamilton KW et al. Infect Dis Clin N Am. 2014;28: Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package

23 Post-prescription Review & Feedback What it is Delivery Benefits Limitations Most likely to help Prospective audit and feedback to providers Phone Electronic messaging inappropriate antibiotics costs C. difficile and nosocomial infections with resistant pathogens Impact future prescribing habits Clinical data availability may increase acceptance Flexibility in timing Preserve prescriber autonomy Impersonal communication Time & labor intensive Requires appropriate resources Voluntary acceptance Dose changes Escalation of therapy Change to agents with similar spectrums Hamilton KW et al. Infect Dis Clin N Am. 2014;28: Barlam et al. Clin Infect Dis.2016;62: Antibiotic Trivia Which antibiotic used for uncomplicated UTIs has the shortest duration of therapy? A. Nitrofurantoin B. SMX/TMP C. Ciprofloxacin D. Cefdinir Antibiotic Timeout What it is Delivery Benefits Limitations Most likely to help Prescriber led review Persuasive or enforced prompting Electronic Performed at set intervals Every 2-3 days ideal Could be as a hard stop-date Improves routine review of regimens regimens to the shortest effective duration ADRs costs Prescriber resistance Logistic difficulty in nursing home Duration of therapy IV-to-po conversions IDSA Recommended Barlam et al. Clin Infect Dis.2016;62: Crnich Et al. Drugs Aging.2015;32:

24 Antibiotic Time Out Key questions Does the patient have an infection that will respond to antibiotics? Is the patient on the most appropriate regimen (agent(s), dose, route)? Can the therapy be de-escalated (narrow therapy or shorten duration)? Would the patient benefit from additional antibiotic expertise to ensure optimal treatment? Algorithms and Order-sets What it is Delivery Benefits Limitations Most likely to help Facility specific practice guidelines Paper Electronic Standardize prescribing based on local epidemiology adequate initial therapy Provide standardized dosing Can include dose adjustments as needed Use narrowerspectrum antibiotics duration of therapy Automatic stop dates prescriber autonomy May limit antibiotics in patients with special circumstances Requires interventions to maintain adherence Antibiotic selection Dosing Duration of therapy IDSA Recommended Barlam et al. Clin Infect Dis.2016;62: Algorithms and Order-sets Start with Most common infections Most used antibiotics Most incorrectly encountered antimicrobial prescribing Incorporate facility susceptibility data Use electronic health record with clinical decision support Consider stop dates Antibiotics could be reordered after the initial time has elapsed Factors to consider Infection site/type Pharmacokinetics/pharmacodynamics Pathogens Drug-drug interactions Drug-disease interactions Drug-nutrition interactions Toxicity Infection severity Cost Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package

25 Antibiotic Pre-authorization What it is Delivery Benefits Limitations Most likely to help Required approval by infectious disease expert or other practitioner to use certain antibiotics Paper Electronic Telephone unnecessary and suboptimal antibiotics broad-spectrum antibiotic use review of clinical data and prior cultures at start of therapy costs Control over antibiotic use Logistics difficulty in the nursing home Impacts on the restricted agents prescriber autonomy May delay treatment Antibiotic selection IDSA Recommended Barlam et al. Clin Infect Dis.2016;62: Antibiotic Tracking Sheet Greater New York Hospital Association. Antibiotic Trivia Which antibiotic should not be used in patients with a CrCl less than 60 ml/min? A. Nitrofurantoin B. Levofloxacin C. Azithromycin D. Doxycyline 25

26 Required Cultures Develop prompts at time of antibiotic prescribing Electronic or facility policy Incorporate indo algorithms or order sets Provide guidance on appropriate specimen type for cultures for common infections Provide guidance on inappropriate culturing practices Examples: swabbing wounds, urine cultures in asymptomatic patients Consider making culture orders a nurse order Place visual clues near antibiotics to ensure cultures obtained Ensure timely transport of culture to laboratory. Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package.2012 Antibiotic Trivia According to a Harris Poll, what percentage of Americans believe that antibiotics are at least somewhat helpful in the treatment of colds? A. 0% B. 17% C. 46% D. 89% Education Sources: posters, in-services, computer training, s, newsletters Advertise: Costs, C. difficile rates Facility resistance rates/patterns Adverse drug events Antibiotic utilization Facility policies Institute for Healthcare Improvement. Update Antibiotic Stewardship Drivers and Change Package

27 What is not recommended Education as a solo intervention Antibiotic cycling Laboratory tests Urinalysis/urine culture in asymptomatic patients Surface swab cultures for wounds Except conjunctivitis Barlam et al. Clin Infect Dis.2016;62: High KP et al. Clin Infect Dis. 2009;48: Targets for Antibiotic Stewardship Initial Target - UTIs Many patients in nursing homes do not have symptoms that are localized to the urinary tract Asymptomatic bacteriuria one of if not the most commonly inappropriately treated infections in long-term care Reduce unnecessary use of antibiotics for UTI prophylaxis Protocols for management of symptomatic vs. asymptomatic UTIs Lim et al. BMC Infect Dis 2014;14:410 Crnich et al. Drugs Aging.2015;32:

28 UTI ASP Example Author Setting Design Intervention Doernberg et al. 3 community Prospective weekly LTCFs audit and feedback N. California Pre-intervention (7 mo) Sept 2011-May Intervention (7 mo) 2012 Weekly visits by ID pharmacist Identify patients on antibiotics for UTIs Consulted ID physician Recommendations made using Loeb clinical consensus criteria via phone or fax p<0.001 Doernberg SB et al. Antimicrobial Resistance and Infection Control.2015;4:54 Real World Examples Study Location ASP Design Results Jump et al 2012 Schwartz et al Fleet et al. Single VA LTC facility Public LTC facility 20 salaried physicians 30 nursing homes England ID consult service 24/7 telephone availability Weekly on-site case review Physician education Guideline implementation Present baseline antibiotic use data Written educational materials for nursing staff Used tool to record compliance with good practice points at treatment initiation and hours 30.1% systemic antibiotic use (p<0.001) positive C. difficile tests (p=0.04) 25.9% in antibiotic initiation 29.7% in duration of therapy Results sustained at 2-year follow-up 4.9% in antibiotic consumption over 12 weeks (p=0.02) Barlam et al. Clin Infect Dis.2016;62: Real World Examples Study Location ASP Design Results Loeb et al Zimmerma n et al nursing homes Ontario and Idaho 12 nursing homes North Carolina Diagnosis and treatment algorithm for UTI fewer antibiotic courses per 1,000 patients Guideline education Larger decrease in prescribing rates at 9- Sensitization to months vs. comparison homes (-3.65 per antibiotic prescribing for 1,000 patient days vs.-0.9 per 1,000 nursing and family patient days; p=0.05) Prescribing feedback for prescribers and nursing Barlam et al. Clin Infect Dis.2016;62:

29 Patient and Family Education Meeker et al. JAMA Intern Med.2014;174: Summary First Rule of Antibiotics Try not to use them Second Rule of Antibiotics Try not to use too many of them Marino PL. "Antimicrobial therapy". The ICU book. Hagerstown, MD: Lippincott Williams & Wilkins. p. 817 Questions THE BEST DOCTOR GIVES THE LEAST MEDICINES BENJAMIN FRANKLIN 29