Outpa&ent An&microbial Stewardship: How do we tackle inappropriate an&bio&c use in the community?

Transcription

1 Outpa&ent An&microbial Stewardship: How do we tackle inappropriate an&bio&c use in the community? Alison Hornyak D.O. Pediatric Infec&ous Diseases Sanford Children s Hospital Fargo

2 Objec&ves Define an&microbial stewardship and explain why it is cri$cal Review published literature on outpa&ent an&microbial stewardship Who, what, when, where is the problem What strategies have been tried and what were the results Iden&fy areas of weakness in an&microbial stewardship at your clinic Inaccurate/unclear diagnosis Lack of familiarity with e&ology of infec&on or current guidelines for an&bio&c use Pa&ent/family pressures Plan ways to improve Where to start What to target How to reach and sustain outcomes

3 Defini&on An&microbial Stewardship: Cost-effec&ve use of an&microbials Appropriate dosing, route, and dura&on Maximizes clinical therapeu&c effect Minimizes drug-related toxicity and infec&ons (C. difficile) Minimizes development of an&microbial resistance "Ten Commandments" for the Appropriate use of An&bio&cs by the Prac&cing Physician in an Outpa&ent SeWng. Levy-Hara G, Amábile-Cuevas CF, Gould I, Hutchinson J, Abbo L, Saxynger L, Vlieghe E, Cardoso FL, Methar S, Kanj S, Ohmagari N, Harbarth S; Interna&onal Society of Chemotherapy An&microbial Stewardship Working Group. Front Microbiol Nov 24;2:230. doi: /fmicb ecollec&on An#microbial stewardship in daily prac&ce: Managing an important resource. Le Saux N; Canadian Paediatric Society, Infec&ous Diseases and Immuniza&on Commigee. Can J Infect Dis Med Microbiol Sep;25(5): An&microbial stewardship in outpa&ent sewngs: a systema&c review. Drekonja DM, Filice GA, Greer N, Olson A, MacDonald R, Rutks I, Wilt TJ. Infect Control Hosp Epidemiol Feb;36(2): doi: /ice Review.

4 Consequences are not only seen inpa&ent or in adults Macrolide resistance in Streptococcus pneumoniae Ampicillin (and trimethoprim/sulfa and cephalexin) resistance in Escherichia coli Oxacillin resistance in Staphylococcus aureus

5 Inpa&ent vs. Outpa&ent Inpa&ent ASP has been growing over the past decade, and con&nues to grow with new na&onal requirements However, the majority of an&bio&cs are prescribed outpa&ent

6 Na&onal Ac&on Plan for Comba&ng An&bio&c-Resistant Bacteria Established under President Obama in 2015 By 2020: Establishment of an&bio&c stewardship programs in all acute care hospitals and improved an&bio&c stewardship across all healthcare sewngs Reduc&on of inappropriate an&bio&c use by 50% in outpa&ent sewngs and by 20% in inpa&ent sewngs

7 Is there really a problem? Am I the problem? 2015: Franciscan Healthcare-Mayo Clinic Health System: queried EMR for ICD-9 codes and prescribed an&bio&cs Family Medicine, Pediatrics, ED/Urgent Care Appropriate an&bio&cs (1 st or 2 nd line in published treatment guidelines) vs. inappropriate an&bio&cs: CAP, AOM, SSTI CAP: nearly half of children < 5 years old received macrolides instead of first line an&bio&cs Highest prescribing of an&bio&cs by ED physicians, followed by FPs, and then pediatricians Guideline-concordant an&bio&c prescribing for pediatric outpa&ents with o&&s media, community-acquired pneumonia, and skin and sop &ssue infec&ons in a large mul&specialty healthcare system. Saleh EA, Schroeder DR, Hanson AC, Banerjee R. Clin Res Infect Dis Jan 10;2(1). pii: 1010.

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9 Physicians vs. Physician Extenders 2016 Suda et al, assessed an&bio&c use from An&bio&c prescrip&ons in the community by type of provider in the United States, Suda KJ, Roberts RM, Hunkler RJ, Taylor TH. J Am Pharm Assoc (2003) Nov - Dec; 56(6): e1. doi: /j.japh Epub 2016 Oct 10.

10 2016 McKay Systema&c Review Physicians who had been in prac&ce longer, who were interna&onal medical graduates, and who had high volume prac&ces were more likely to prescribe an&bio&cs inappropriately Physician-perceived pa0ent demand for an0bio0cs is associated with prescrip0on of an0bio0cs Staff physicians are more likely to prescribe an&bio&cs for viral RTI than trainees, and staff at non-teaching hospitals were more likely to prescribe an&bio&cs than staff at teaching hospitals Colds, URIs, and bronchi&s accounted for >20% of an&bio&c prescrip&ons prescribed by ambulatory physicians in the US Odds of a pa&ent repor&ng sa&sfac&on with a visit for acute RTI were higher when the pa&ent received informa&on or reassurance rather than an&bio&cs; if the pa&ent was expec&ng an&bio&cs, there was no difference in sa&sfac&on between receiving them and reassurance Systema&c Review of Factors Associated with An&bio&c Prescribing for Respiratory Tract Infec&ons. McKay R, Mah A, Law MR, McGrail K, Patrick DM. An&microb Agents Chemother Jun 20;60(7): doi: /AAC Print 2016 Jul.

11 CHOP: An&microbial Prescribing Review 29 primary care pediatric prac&ces no urgent care, family medicine or ED facili&es 1/1/ /31/2009 Broad spectrum an&bio&cs: amoxicillin/ clavulanate, 2nd and 3rd genera&on cephalosporins, and azithromycin An&bio&c prescribing rates amongst otherwise healthy children during acute care visits ranged from 18-36% Of children who received an&bio&cs, 42% were broad spectrum Varia&on in An&bio&c Prescribing Across a Pediatric Primary Care Network. Gerber JS, Prasad PA, Russell Localio A, Fiks AG, Grundmeier RW, Bell LM, Wasserman RC, Keren R, Zaou&s TE. J Pediatric Infect Dis Soc Dec;4(4): doi: /jpids/piu086. Epub 2014 Oct 30.

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14 CHOP: An&microbial Prescribing Review A child visi&ng a high use prac&ce was twice as likely to receive an an&bio&c and 4 &mes as likely to receive a broad spectrum an&bio&c compared to the same child visi&ng a low use prac&ce High an&bio&c use and high broad spectrum an&bio&c use tended to occur at the same prac&ces Worrisome range of rates of diagnosis of GAS pharyngi&s, AOM, and par&cularly sinusi&s

15 CHOP: Interven&on Study Large hospital-affiliated health system 18 Pediatrics prac&ces, no academic prac&ces Focused on an&bio&c prescribing for GAS pharyngi&s, acute sinusi&s, and CAP AAP guidelines for diagnosis and treatment Clinician educa&on followed by individual audit and feedback control prac&ces did not receive educa&on or feedback Broad spectrum an&bio&cs: amoxicillin/clavulanate, 2 nd and 3 rd genera&on cephalosporins, and azithromycin Penicillin or amoxicillin were considered first-line, per AAP guidelines June 2010-June 2011 Effect of an outpa&ent an&microbial stewardship interven&on on broad-spectrum an&bio&c prescribing by primary care pediatricians: a randomized trial. Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LM, Wasserman RC, Keren R, Zaou&s TE. JAMA Jun 12;309(22): doi: /jama

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18 CHOP: Durability of Outcomes Study Followed an&bio&c prescribing across interven&on and control sites for 18 months aper termina&on of the interven&on Durability of benefits of an outpa&ent an&microbial stewardship interven&on aper discon&nua&on of audit and feedback. Gerber JS, Prasad PA, Fiks AG, Localio AR, Bell LM, Keren R, Zaou&s TE. JAMA Dec 17;312(23): doi: /jama

19 CHOP: Post Interven&on Survey Semi-structured interview study that looked at physicians experience par&cipa&ng in the previous study and their overall thoughts on an&bio&c overuse 24 interviews: 15 women, most in prac&ce for years Percep&on of Interven&on: most respondents ignored or were skep&cal of audit reports, some admiged gaming behavior Pediatrician Percep&ons of an Outpa&ent An&microbial Stewardship Interven&on FREE. Julia E. Szymczak, PhD, Kristen A. Feemster, MD, MPH, MSHP, Theoklis E. Zaou&s, MD, MSCE, Jeffrey S. Gerber, MD, PhD Infec&on Control and Hospital Epidemiology, Vol. 35, No. S3, Preven&ng Healthcare-Associated Infec&ons: Results and Lessons Learned from AHRQ s HAI Program (October 2014), pp. S69-S78

20 Percep&on of An&bio&c Guidelines

21 Percep&ons of An&bio&c Overuse

22 Percep&ons of Parental Pressure #1 barrier to improving an&bio&c use 22 of 24 thought that there was a strong culture of expecta&on

23 What the CHOP group learned Audit and feedback works best when providers are mo&vated to change their behavior believe that an issue exists and can be changed In these studies, providers knew an&microbial overuse was a problem, but did not think it was their problem Biggest issue for providers is real or imagined parental expecta&ons

24 Drekonja Systema&c Review Various an&microbial stewardship interven&ons were tried, all yielded improved rates of an&microbial prescribing These changes did not lead to adverse pa&ent outcomes or increased drug costs Studies primarily focused on respiratory infec&ons Studies looking at sustainability were lacking An&microbial Stewardship Programs in Outpa&ent SeWngs: A Systema&c Review [Internet]. Drekonja D, Filice G, Greer N, Olson A, MacDonald R, Rutks I, Wilt TJ. Washington (DC): Department of Veterans Affairs; 2014 Feb.

25 IDENTIFYING AREAS OF WEAKNESS IN ANTIMICROBIAL STEWARDSHIP AT YOUR CLINIC

26 Inaccurate/Unclear Diagnosis Concrete Diagnoses (Or can be made concrete) UTI Pneumonia GAS pharyngi&s Subjec&ve Diagnoses AOM Celluli&s Sinusi&s Lymphadeni&s Fever + elevated WBC +/- elevated CRP/ESR

27 Inaccurate/Unclear Diagnosis Doing rapid strep tes&ng in pa&ents with symptoms consistent with strep pharyngi&s (no cough, no conges&on/rhinorrhea, no hoarseness) and wait for results before prescribing an&bio&cs CXR to make bacterial pneumonia diagnosis Culture! Culture! Culture! Interpret culture results for the clinical sewng An#microbial stewardship in daily prac&ce: Managing an important resource. Le Saux N; Canadian Paediatric Society, Infec&ous Diseases and Immuniza&on Commigee. Can J Infect Dis Med Microbiol Sep;25(5):241-5.

28 Lack of Familiarity of Bacterial E&ology Pharyngi&s - >80% viral e&ology Acute bacterial rhinosinusi&s follows 5% of viral URIs in children Lymphadeni&s: viral/reac&ve vs. bacterial * Fear of complica&ons

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30 Pa&ent/Family Pressures McKay Review: Odds of a pa&ent repor&ng sa&sfac&on with a visit for acute RTI were higher when the pa&ent received informa&on or reassurance rather than an&bio&cs if the pa&ent was expec&ng an&bio&cs, there was no difference in sa&sfac&on between receiving them and reassurance Having a dialogue so the pa&ent understands their &me, experience, and confidence is valued Providing an&cipatory guidance and recommenda&ons for suppor&ve care Assess the accuracy of an&bio&c allergies Systema&c Review of Factors Associated with An&bio&c Prescribing for Respiratory Tract Infec&ons. McKay R, Mah A, Law MR, McGrail K, Patrick DM. An&microb Agents Chemother Jun 20;60(7): doi: /AAC Print 2016 Jul.

31 PLAN WAYS TO IMPROVE

32 Where to start? CDC: Get Smart: Know When An&bio&cs Work hgps:// Acute sinusi&s, AOM, pharyngi&s, URI, bronchioli&s, UTI Handouts and posters for your office

33 Ways to Improve Provider educa&on sessions: diagnosis, journal clubs, communica&on skills CME online, Stanford An&bio&c Stewardship Course Dissemina&on of treatment guidelines in electronic and/or pocket guide formats Electronic decision support systems Requiring wrigen jus&fica&on in the EMR for nonrecommended an&bio&c prescribing Audit and feedback of an&bio&c orders Defer pa&ents who will not require an&bio&cs via nurse call centers or hotlines

34 Things to Target Choose bacterial infec&ons with clear cut guidelines CAP, GAS pharyngi&s, sinusi&s, AOM, celluli&s Focus on not prescribing an&bio&cs for viral diagnoses Choose an&bio&cs to limit

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36 Reaching and Sustaining Outcomes Set reasonable goals, and then con&nually reassess expecta&ons There are not published studies to support par&cular methods of sustaining outcomes Choose a clinician champion, and do your best to work with them

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38 QUESTIONS?