Misericordia Community Hospital (MCH) Antimicrobial Stewardship Report

Transcription

1 Misericordia Community Hospital (MCH) Antimicrobial Stewardship Report January June 215

2 Table of Contents I. Introduction... 3 II. CHASC Antimicrobial Utilization Reports... 4 III. Executive Summary... 6 IV. MCH Antimicrobial Utilization Reports... 8 A. Total MCH Antibiotic DDD and Expenditures... 8 B. Critical Care C. Emergency Department D. Home Parenteral Therapy E. Medical Dayward and IV Therapy Area F. Medicine G. Surgery V. Clostridium difficile Infection (CDI) Prospective Audit and Feedback VI. Antimicrobial Stewardship Pharmacist Interventions VII. Appendix 1 - Villa Caritas (VC) VIII. Glossary of Terms Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 2

3 I. Introduction Antibiotics are among the most commonly prescribed medications in acute care centres (Figure 1), yet can result in unintended patient toxicities, selection of pathogenic organisms, such as C. difficile and promotion of antibiotic resistance. Figure 1. MCH Drug Expenditures January - June 215 Antimicrobial expenditures Total drug expenditures 16.9 % 83.1 % Antimicrobial Stewardship is an interdisciplinary activity that promotes the optimization of antibiotic selection, dose, route and duration in order to improve patient clinical outcomes and safety, minimize antibiotic adverse effects and toxicity, decrease the selection of pathogenic organisms and reduce antibiotic resistance rates. An effective Antimicrobial Stewardship Program (ASP) has been demonstrated to achieve the above outcomes and as of 213, has been mandated as a Required Organizational Practice by Accreditation Canada. The Covenant Health Antimicrobial Stewardship Committee (CHASC) was developed in May 213 and has since implemented several initiatives including: 1. Formulary restriction and preauthorization for daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline 2. Development and promotion of an annual Covenant Health antibiogram 3. Prospective audit and feedback of piperacillin-tazobactam and other antimicrobials 4. Development of a Clostridium difficile Infection (CDI) Preprinted Patient Care Order (PPCO) with prospective audit and feedback 5. Collation of antibiotic utilization data 6. Circulation of a Covenant Health Antimicrobial Stewardship e-newsletter (CHASE) quarterly 7. Wide distribution and posting of formulary guidelines for the carbapenems and piperacillintazobactam to promote guideline concordant use 8. Development of a Preprinted Patient Care Order for the combined use of cefazolin and probenecid for simple cellulitis in outpatient areas Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 3

4 II. CHASC Antimicrobial Utilization Reports Antibiotic use at Covenant Health acute care sites is collated and examined by CHASC on a quarterly basis in conjunction with data collected from prospective audit and feedback and the restricted antibiotic preauthorization form in order to: Identify any antibiotic utilization trends or areas in need of intervention on a site and servicespecific basis. Ensure that the use of broad-spectrum antibiotics is guideline concordant. Generate bi-annual reports summarizing antibiotic trends and CHASC recommendations for prescribers as direct feedback on their antibiotic use. Methods Data on antibiotic use is extracted directly from the BDM Pharmacy computer system. When determining whether an antibiotic has been prescribed in a guideline concordant fashion, clinical information acquired from the antibiotic preauthorization form and/or prospective audit and feedback performed by the Antimicrobial Stewardship pharmacists is compared to the provincial formulary recommendations. Drug utilization data is provided in both DDD (Defined Daily Dose) and expenditures. DDD is a World Health Organization measure of drug consumption. The definition is the assumed average maintenance dose per day for a drug used for its main indication in adults. It relates all drug use to a standardized measure which is equivalent to one day s worth. DDD allows for comparing antibiotic use across different classes despite differences in potency and dosing. Examples: The usual dose of ertapenem is 1 g IV daily therefore every 1 gram of ertapenem is equivalent to one DDD. The usual dose of clindamycin is 6 mg IV every 8 hours therefore every 18 mg is equivalent to one DDD. Denominator Data DDDs are now provided over the denominator of actual patient days. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes over time meaning that changes in antibiotic utilization are due to changes in prescribing rather than changes in patient volume. Denominator Data - Inpatient Areas The inpatient denominator data is provided by Analytics [Data Integration, Measurement and Reporting (DIMR)]. It is a summary of the number of patient days at the site by unit and includes emergency admitted patients but excludes emergency non-admitted patients and patients less than one year of age. Patient days are calculated as follows: Emergency department inpatient days are counted from the time of decision to admit until the ED departure for patients admitted to an inpatient bed. Inpatient days are a daily census count. Patients admitted and discharged on the same day are counted as one day and the day of admission is counted but the day of discharge/death is not. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 4

5 The data is provided quarterly and is the same data that is used by Infection Prevention and Control (IPC) for monitoring C. difficile rates. Patient day data has been integrated into the utilization data to obtain DDDs and expenditures per 1 patient days. Denominator Data Outpatient Areas Patient visit denominator data for the Emergency Department is provided by Data and Decision Support using the Power Abstract Database. Emergency visits include patients discharged home, transfers to other clinics or facilities, and deaths. It excludes patients left without being seen (LWBS), patients left against medical advice (LAMA) and inpatient admissions. HPT patient numbers are provided from the Edmonton Zone HPT Access Database. It is a count of the number of new patients referred and accepted into the program. MCH Medical Dayward and IV Therapy Area unique patient numbers are provided by Alberta Health Services Regional Activity and Costing. Patients are counted only once regardless of how many visits the patient makes to the clinic. Outpatient denominator data has been integrated into the utilization data to obtain DDDs and expenditures per 1 patients (Medical Dayward and HPT) or visits (ED). Summary of MCH Services included: Critical Care Units (CCU and ICU) Emergency (ED) Home Parenteral Therapy (HPT) Medical Dayward and IV Therapy Area (similar to an intravenous therapy clinic) Medicine Family and Internal Medicine, Geriatrics, Emergency Inpatients (ERIP) Surgery Orthopedic, Other (General/Obstetrics & Gynecology/Urology) Antibiotic Utilization Graphs: Antibiotic utilization is provided in three graphical formats: 1. Total drug DDD and expenditures for the hospital 2. Total inpatient drug DDD and expenditures per 1 patient days 3. Total outpatient drug DDD and expenditures per 1 patients Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 5

6 III. Executive Summary Antibiotic utilization data is provided from July 213 to June 215. This current biannual report details data for the period of January 1 to June 3, 215 for the following: Guideline concordance rates for the six restricted antibiotics (daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline). The restricted antibiotic order form took effect in October 213. Piperacillin-tazobactam prescribing, including indications, guideline concordance rates, and rate of streamlining. Audit and feedback on piperacillin-tazobactam use began in March 214. Degree of guideline concordant treatment for C.difficile (CDI) and Preprinted Care Order (PPCO) use which was first introduced in December 213. Overall Antibiotic Use: Overall antibiotic use at MCH has remained stable since July 213. Cephalosporins continue to be the most commonly prescribed antibiotics. Restricted antibiotic use has declined in the last few quarters. Piperacillin-tazobactam use has fluctuated over the last six months but remains high since the return of one Internal Medicine unit to the MCH on May 1, 214. Restricted Antibiotics: Ertapenem and imipenem are the most commonly prescribed restricted antibiotics with the majority of orders deemed guideline concordant. Daptomycin continues to be used in prolonged courses for a few patients in a guideline concordant manner. The remaining restricted antibiotics are used at low levels. Compliance with the Restricted Antibiotic Preauthorization Form and Guideline Concordance Rates: Overall compliance with the restricted antibiotic form was 66% and could be improved upon. Guideline concordance for the restricted antibiotics was determined using the restricted antibiotic preauthorization forms. For the period of January 1 to June 3, 215, there were 13 orders for a restricted antibiotic of which 95 adhered to formulary guidelines (92% guideline concordance rate). There has been a reduction in the use of the restricted antibiotics compared to the previous biannual report (128 orders). Piperacillin-tazobactam Audit and Feedback: Piperacillin-tazobactam remains one of the most frequently prescribed antibiotics at MCH and has been targeted for prospective audit and feedback. Despite high use, it was primarily prescribed in a guideline concordant manner for the period of January 1 to June 3, 215 [314/327 (96%)]. 124/327 (38%) piperacillin-tazobactam orders were streamlined in three days on average which is within the de-escalation target of hours. Of the remaining 23 patients, 17 received a full course of piperacillin-tazobactam which was deemed appropriate. The remaining 96 patients did not receive a full course due to: death (31), received empiric therapy until definitive diagnosis (46), escalation to a broader antibiotic (13), transfer to another facility (5) or developed an adverse reaction (1). Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 6

7 C. difficile (CDI) Audit and Feedback: Prospective audit and feedback is performed on all new CDI cases to ensure treatment is guideline concordant. The number of CDI cases (34) for the period of January 1 to June 3, 215 remained the same as the previous biannual report. Of the 34 patients, 94% demonstrated initial guideline concordant therapy. This increased to 1% with ASP pharmacist interventions. Additionally, acid suppressive therapy was stopped in three cases by the ASP pharmacist. The CDI PPCO was used in only 38% of cases, a slight increase from 32% in the previous biannual report. Recommendations: Continue to improve rates of compliance in completing the restricted antibiotic preauthorization form. Continue the judicious use of the six restricted antibiotics by ensuring that these broadspectrum antibiotics are only being used for formulary approved indications and are narrowed upon culture availability if possible. Continue guideline concordant prescribing of piperacillin-tazobactam with continued deescalation within 48 to 72 hours according to culture availability and the patient s clinical status. Work with IPC and other disciplines to improve compliance with the use of the CDI PPCO to ensure optimized CDI management. Continue to monitor patient denominator data for identifiable trends. Please refer to the service-specific section of this report for further details regarding service-specific prescribing and Antimicrobial Stewardship recommendations. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 7

8 IV. MCH Antimicrobial Utilization Reports A. Total MCH Antibiotic DDD and Expenditures July 213 June 215 (Figure 2) Parenteral antibiotics account for the majority of the utilization and expenditures hospital-wide. Overall antibiotic use has remained stable for the period July 213 to June 215. Cephalosporins were the most commonly ordered IV antibiotic but carbapenems and piperacillin-tazobactam accounted for the majority of costs. The use of linezolid, meropenem and tigecycline was low. Daptomycin is occasionally being used in orthopedic patients intolerant of vancomycin. Compliance with the restricted antibiotic preauthorization form was 66% (68/13) and could be improved upon. Overall, the restricted antibiotics were prescribed in a guideline concordant manner in 92% (95/13) of cases (Table 1). Piperacillin-tazobactam use has fluctuatued for the period of January 1 to June 3, 215 (Figure 3). The most common clinical indications for use were intra-abdominal infections, pneumonia and sepsis NYD. There were 327 orders for the period of January 1 to June 3, 215 with a guideline concordance rate of 96% (314/327) (Table 2). Of these, 38% (124/327) of piperacillin-tazobactam orders were de-escalated, primarily by the attending team, in an average of three days (Table 3). In the remaining patients (17/327) the entire treatment course was completed with piperacillintazobactam and deemed guideline concordant. The remaining 96 patients did not complete a full course of piperacillin-tazobactam for various reasons such as death or transfer to another facility. The most common discordant use of piperacillin-tazobactam was community acquired pneumonia (CAP) or community acquired aspiration pneumonia treatment with ten orders (Table 3). Recommendations: Improve rates of completion of the restricted antibiotic preauthorization form (particularly in the ED and Medical Dayward and IV Therapy Area). Continue to use the six restricted antibiotics judiciously in a guideline concordant manner Ensure piperacillin-tazobactam is being prescribed in a guideline concordant manner Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 8

9 Figure 2. Total MCH Antimicrobial Usage and Expenditures MCH Total DDD MCH Total Expenditures 25 $25 2 $2 15 $ Oral Parenteral $1 $5 * $ * Oral Parenteral MCH DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin $14 $12 $1 $8 $6 $4 $2 $ * Fluoroquinolones * Vancomycin MCH Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin MCH DDD MCH Expenditures * Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $6 $5 $4 $3 $2 $1 $ * Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. *Return of Internal Medicine Unit to MCH Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 9

10 Table 1. Total MCH Compliance with Preauthorization Form and Guideline Concordance Rates Service Antibiotic Number of Orders January to June 215 Guideline Concordant Form Compliance Recommendations (Number and percent accepted) Cardiology Meropenem 1 1 (1%) 1 (1%) Total 1 1 (1%) 1 (1%) ED Ertapenem 4 4 (1%) 1 (25%) Total 4 4 (1%) 1 (25%) HPT Daptomycin 1 1 (1%) (%) Imipenem 1 1 (1%) 1 (1%) Total 2 2 (1%) 1 (5%) ICN Meropenem 1 1 (1%) (%) Total 1 1 (1%) (%) ICU Ertapenem 2 2 (1%) 2 (1%) 1 (1%) Imipenem (1%) 13 (93%) Meropenem 3 3 (1%) 3 (1%) Total (1%) 18 (95%) 1 (1%) Medical Dayward and IV Therapy Area Daptomycin 8 8 (1%) 2 (25%) Ertapenem 9 9 (1%) `5 (56%) Imipenem 1 1 (1%) (%) Total (1%) 7 (39%) Medicine Daptomycin 3 3 (1%) 2 (66%) Ertapenem 2 19 (95%) 14 (7%) 1 (1%) Imipenem 8 8 (1%) 4 (5%) Linezolid PO 1 1 (1%) (%) Meropenem 6 2 (33%) 6 (1%) 5 (4%) Total (87%) 26 (68%) 6 (5%) Psychiatry Daptomycin 1 1 (1%) 1 (1%) Total 1 1 (1%) 1 (1%) Surgery Daptomycin 3 3 (1%) 2 (67%) Ertapenem 8 6 (75%) 4 (5%) Imipenem 7 7 (1%) 6 (86%) Meropenem 1 (%) 1 (1%) Total (84%) 13 (68%) Grand Total (92%) 68 (66%) 7 (57%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 1

11 Figure 3. MCH Piperacilin-tazobactam Orders by Service January to June MCH Piperacillin-tazobactam Orders Bacteremia Discordant Febrile Neutropenia Genital HEENT IAI Native joint Osteomyelitis Other Pneumonia Pre-op prophylaxis Prosthetic joint Sepsis NYD SSTI UTI Table 2. MCH Piperacillin-tazobactam Orders by Service January to June 215 Prescribing Bacte Native Pre-op Sepsis Disco FN Genital HEENT IAI OM Other PNA PJI SSTI UTI Total Service remia Joint px NYD rdant* Cardiology ED ICU Infectious Diseases Medicine Family Medicine Internal Surgery Other Surgery Orthopedics Wound Care Total *Discordant: IAI (1), Native joint (1), Pneumonia (1), Pre-op prophylaxis (1) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

12 Table 3. MCH Piperacillin-tazobactam Orders Streamlined by Indication January to June 215 Clinical Number of Discordant Piperacillin-tazobactam Streamlined Indication Orders* Initiated by: Average # of days Orders ASP Attending team Bacteremia Febrile Neutropenia Genital HEENT Intraabdominal infection Native Joint Osteomyelitis Other Pneumonia Pre-op 1 1 prophylaxis Prosthetic joint infection Sepsis NYD SSTI UTI Total * The majority of patients received an average of 1.7 days of therapy before discontinuation or streamlining. Many patients only received one dose. One patient received a 1 day course of therapy. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

13 B. Critical Care Antibiotic Utilization (Figure 4) The utilization data per 1 patient days is provided for the Cardiac Care Unit (CCU) and Intensive Care Unit (ICU) combined. Patient denominator data has been integrated into the utilization data to obtain DDDs and expenditures per 1 patient days. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. The DDD and expenditures per 1 patient days have been increasing slightly over the last year. There was a decrease in the use of ertapenem and an increase in imipenem, meropenem, and piperacillin-tazobactam use in the last quarter. There were 19 orders for carbapenems and all were guideline concordant (Table 4). Compliance with the restricted antibiotic preauthorization form has remained acceptable at 95% (Table 4). Piperacillin-tazobactam use has fluctuated but maintains a high degree of guideline concordance (Table 5). The most common indications for use were intra-abdominal infections, pneumonia, and sepsis NYD (Table 2). Recommendations: The restricted antibiotic and majority of piperacillin-tazobactam orders are appropriate in the MCH Critical Care areas. No further recommendations can be made at this time. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

14 Figure 4. MCH Critical Care* Antimicrobial Usage and Expenditures per 1 Patient Days MCH Total Critical Care DDD/1 Patient Days Oral 2 Parenteral $16 $14 $12 $1 $8 $6 $4 $2 $ MCH Total Critical Care Expenditures/1 Patient Days Oral Parenteral MCH Critical Care DDD/1 Patient Days Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $7 $6 $5 $4 $3 $2 $1 $ MCH Critical Care Expenditures/1 Patient Days Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin MCH Critical Care DDD/1 Patient Days Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $2 $15 $1 $5 $ MCH Critical Care Expenditures/1 Patient Days Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline *CCU and ICU combined DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

15 Table 4. MCH Critical Care Compliance with Preauthorization Form and Guideline Concordance Rates Antibiotic Number of Orders January to June 215 Guideline Concordant Form Compliance Recommendations (Number and percent accepted) Ertapenem 2 2 (1%) 2 (1%) 1 (1%) Imipenem (1%) 13 (93%) Meropenem 3 3 (1%) 3 (1%) Total (1%) 18 (95%) 1 (1%) Table 5. MCH Critical Care Piperacillin-tazobactam Order Review January to June 215 Number of Orders Guideline Concordant (98%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

16 C. Emergency Department (ED) Antibiotic Utilization (Figure 5) Drug utilization data was recorded as ED prescribed if the patient resided in the ED and was not admitted as an inpatient at the time of dispensing. Once accepted by an inpatient team, the drug was thereafter recorded as prescribed by the admitting service regardless if the patient remained in the ED. Patient visit denominator data has been incorporated into the utilization data to obtain DDDs and expenditures per 1 patient visits. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. From July 213 to June 215, overall antibiotic usage and expenditures have remained stable. Oral antibiotics were ordered more frequently than parenteral although parenteral antibiotics were responsible for the vast majority of expenditures. The most commonly ordered antibiotics were the cephalosporins and fluoroquinolones. Use of the six restricted antibiotics has been low from July 213 to June 215. Over the last six months, there were only four ertapenem orders which all were deemed guideline concordant. In June 215, a Preprinted Patient Care Order (PPCO) was introduced for the combined use of cefazolin and probenecid for simple cellulitis in outpatients. This regimen provides a narrow spectrum once daily option for patients compared to the broader spectrum ertapenem or ceftriaxone. CHASC will be following the use of this combination to ensure it is being used appropriately and will be monitoring for any treatment failures. There were 32 piperacillin-tazobactam orders from January 1 to June 3, 215 and all were deemed guideline concordant (Table 7). The most frequent indications for piperacillin-tazobactam were skin and soft tissue infections and sepsis not yet diagnosed (Table 2). Recommendations: Improve completion rates of the restricted antibiotic preauthorization form to facilitate accurate data collection to inform ED prescribing. The ED has been effective in ensuring guideline concordant use of the six restricted antibiotics. No further recommendations can be made at this time. Continue guideline concordant prescribing of piperacillin-tazobactam. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

17 Figure 5. MCH ED* Antimicrobial Usage and Expenditures per 1 Patient Visits MCH Total ED DDD/1 Patient Visits Oral Parenteral $7 $6 $5 $4 $3 $2 $1 $ MCH Total ED Expenditures/1 Patient Visits Oral Parenteral MCH ED DDD/1 Patient Visits Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $45 $4 $35 $3 $25 $2 $15 $1 $5 $ MCH ED Expenditures/1 Patient Visits Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin MCH ED DDD/1 Patient Visits MCH ED Expenditures/1 Patient Visits Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $14 $12 $1 $8 $6 $4 $2 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

18 Table 6. MCH ED Compliance with Preauthorization Form and Guideline Concordance Rates January to June 215 Antibiotic Number of Orders Guideline Concordant Form Compliance Ertapenem 4 4 (1%) 1 (25%) Total 4 4 (1%) 1 (25%) Recommendations (Number and Percent Accepted) Table 7. ED Piperacillin-tazobactam Order Review January to June 215 Number of Orders Guideline Concordant (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

19 D. Home Parenteral Therapy (HPT) Antibiotic Utilization (Figure 6) Home parenteral therapy enables patients to receive intravenous antibiotics at home. Patients can be enrolled in HPT through the Medical Dayward and IV Therapy Area or from an inpatient hospital unit at the time of discharge. Patients (or their drug coverage plan) are responsible for the cost of these antibiotics. HPT is often used when the duration of therapy is expected to be prolonged; therefore, overall patient numbers are low but due to these long courses of therapy, one patient can greatly influence the utilization of a particular antibiotic (e.g. one patient on ertapenem for 1 weeks results in an increased ertapenem DDD of 7). Patient visit denominator data has been incorporated into the utilization data to obtain DDDs and expenditures per 1 patients. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. There were no identifiable trends in antibiotic use likely because the DDD and expenditures are greatly influenced by the number of patients in the program at any given time. Cefazolin was the most commonly prescribed antibiotic. Use of the six restricted antibiotics has been limited to a minority of patients. All orders were guideline concordant but form compliance has declined from 7% in the previous six months to 44% and needs to improve for a more accurate reflection of antibiotic use (Table 8). Recommendations: The six restricted antibiotics are prescribed at low levels and are guideline concordant. No further recommendations can be made at this time. Increase compliance with completing the restricted antibiotic form as this is important for accurate data collection and feedback to stakeholders. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

20 Figure 6. MCH HPT Antimicrobial Usage and Expenditures per 1 Patients MCH Total HPT DDD/1 Patients MCH Total HPT Expenditures/1 Patients Oral Parenteral $1 $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Oral Parenteral MCH HPT DDD/1 Patients MCH HPT Expenditures/1 Patients Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones $6 $5 $4 $3 $2 $1 $ Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin Vancomycin MCH HPT DDD/1 Patients MCH HPT Expenditures/1 Patients Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $5 $45 $4 $35 $3 $25 $2 $15 $1 $5 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline *Patient responsible for antibiotic costs DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 2

21 Table 8. MCH HPT Compliance with Preauthorization Form and Guideline Concordance Rates January to June 215 Antibiotic Guideline Concordant Form Compliance Location Initiated Daptomycin 1 HPT Ertapenem 2 1 Medicine Ertapenem 1 1 Surgery Imipenem 2 1 HPT Imipenem 1 Medicine Imipenem 2 1 Surgery Total 9/9 (1%) 4/9 (44%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

22 E. Medical Dayward and IV Therapy Area Antibiotic Utilization (Figure 7) The MCH Medical Dayward and IV Therapy Area functions as an area where patients attend to receive IV antibiotics when they are well enough to be treated as an outpatient and do not qualify for home parenteral therapy. Infectious Diseases, ED and Family Medicine physicians are the main prescribers. Patient denominator data has been incorporated into the utilization to obtain DDDs and expenditures per 1 patients. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. As patient volumes are low relative to inpatient wards, overall antibiotic use is affected by type of patients attending and their duration of therapy. Overall antibiotic use has decreased in the past six months. The most frequently prescribed antibiotic was cefazolin. Ertapenem use has increased slightly for the period of January 1 to June 3, 215 but remains significantly lower than the previous year. All orders for restricted antibiotics were deemed guideline concordant (Table 9). Completion of the restricted antibiotic preauthorization form has declined greatly from 62% to 39% (Table 9) and needs to be improved upon. In June 215, a Preprinted Patient Care Order (PPCO) was introduced for the combined use of cefazolin and probenecid for simple cellulitis in outpatients. This regimen provides a narrow spectrum once daily option for patients compared to the broader spectrum ertapenem or ceftriaxone. CHASC will be following the use of this combination to ensure it is being used appropriately and will be monitoring for any treatment failures. Recommendations: Improve compliance with completion of the restricted antibiotic form in order to facilitate accurate data collection and feedback to stakeholders. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

23 Figure 7. MCH Medical Dayward and IV Therapy Area Antimicrobial Usage and Expenditures per 1 Patients MCH Total Medical Dayward DDD/1 Patients MCH Total Medical Dayward Expenditures/1 Patients Oral Parenteral $18 $16 $14 $12 $1 $8 $6 $4 $2 $ Oral Parenteral MCH Medical Dayward DDD/1 Patients Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin MCH Medical Dayward Expenditures/1 Patients $12 $1 Carbapenems $8 Cefazolin $6 $4 $2 $ Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin MCH Medical Dayward DDD/1 Patients Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline MCH Medical Dayward Expenditures/1 Patients $14 Daptomycin $12 $1 Ertapenem $8 Imipenem $6 $4 Linezolid $2 Meropenem $ Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

24 Table 9. MCH Medical Dayward and IV Therapy Area Compliance with Preauthorization Form and Guideline Concordance Rates January to June 215 Antibiotic Number of Orders Guideline Concordant Form Compliance Daptomycin 8 8 (1%) 2 (25%) Ertapenem 9 9 (1%) 5 (56%) Meropenem 1 1 (1%) (%) Total (1%) 7 (39%) Recommendations (Number and percent accepted) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

25 F. Medicine Antibiotic Utilization (Figure 8) Medicine applies to Internal Medicine, Family Medicine (cannot be separated due to shared inpatient units), ED inpatients and Geriatrics. An Internal Medicine unit was temporarily relocated to the Royal Alexandra Hospital on May 3, 213 and returned to the MCH on May 1, 214. Data from May 1, 214 forward includes this unit. Patient denominator data has been integrated into the utilization data to obtain DDDs and expenditures per 1 patient days. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. Overall, DDD and expenditures per 1 patient days have been stable since May 214. An increase in use of cefazolin, piperacillin-tazobactam, and ertapenem is noted in the last quarter. Cephalosporins and fluoroquinolones were the most commonly prescribed antibiotics. The restricted antibiotics were used in a guideline concordant manner for 87% of the orders (Table 1). Prescribing meropenem, the most broad and costly carbapenem, inappropriately for pneumonia was the most common discordant use of the restricted antibiotics and needs to be rectified. Compliance with completion of the restricted antibiotic preauthorization form has continued to decline from 72% to 68% (Table 1). The largest proportion of piperacillin-tazobactam orders in MCH are from Internal Medicine prescribers. The guideline concordance rates were high at 94% (Table 11). Pneumonia and sepsis not yet diagnosed were the most common indications for use (Table 2). There were several instances where piperacillin-tazobactam was prescribed discordantly for CAP and aspiration pneumonia. In order to provide prescriber education and optimize treatment, the January edition of CHASE focused on appropriate empiric antibiotic selection and treatment duration for CAP and aspiration pneumonia. Recommendations: Further improve the rates of guideline concordant prescribing for meropenem as follows: Imipenem + Meropenem: Guidelines listed apply to both drugs unless otherwise indicated. 1. Therapy of severe infections involving Gram negative organisms in patients who are intolerant of, or unresponsive to, or whose isolates are suspected or documented to be resistant (e.g. ESBL, inducible (AmpC) ß-lactamases) to, first line agents and piperacillin-tazobactam (imipenem preferred if documented susceptibility) 2. Therapy of severe suspected or documented polymicrobial infections in patients who are intolerant of, or unresponsive to, or whose isolates are suspected or documented to be resistant to, first line agents and piperacillin-tazobactam (imipenem preferred if documented susceptibility) 3. Therapy of infections involving multi-drug resistant Pseudomonas aeruginosa where there is documented susceptibility to the carbapenem (cannot assume meropenem susceptibility from imipenem susceptibility and vice versa). 4. Empiric therapy in high risk febrile neutropenic patients +/- aminoglycoside (imipenem preferred if documented susceptibility). 5. Empiric therapy of post-traumatic/post-neurosurgical meningitis in combination with vancomycin. (MEROPENEM) 6. Alternative to ceftazidime for therapy of central nervous system (CNS) infections due to Pseudomonas Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

26 aeruginosa. (MEROPENEM) 7. As part of combination therapy of infections with Nocardia spp or nontuberculous Mycobacteria spp. (IMIPENEM) Ensure piperacillin-tazobactam is prescribed in a guideline concordant manner according to the provincial guidelines below: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (e.g. intra-abdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

27 Figure 8. MCH Medicine # Antimicrobial Usage and Expenditures per 1 Patient Days MCH Total Medicine DDD/1 Patient Days Oral Parenteral $4 $35 $3 $25 $2 $15 $1 $5 $ MCH Total Medicine Expenditures/1 Patient Days Oral Parenteral MCH Medicine DDD/1 Patient Days MCH Medicine Expenditures/1 Patient Days Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones $3 $25 $2 $15 $1 $5 $ Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin Vancomycin MCH Medicine DDD/1 Patient Days MCH Medicine Expenditures/1 Patient Days Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $12 $1 $8 $6 $4 $2 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline #Medicine and ERIP; * Return of Internal Medicine Unit to MCH DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

28 Table 1. MCH Medicine Compliance with Preauthorization Form and Guideline Concordance Rates Antibiotic Number of Orders January to June 215 Guideline Concordant Form Compliance Recommendations (Number and percent accepted) Daptomycin 3 3 (1%) 2 (66%) Ertapenem 2 19 (95%) 14 (7%) 1 (1%) Imipenem 8 8 (1%) 4 (5%) Linezolid PO 1 1 (1%) (%) Meropenem 6 2 (33%) 6 (1%) 5 (4%) Total (87%) 26 (68%) 6 (5%) Table 11. MCH Medicine Piperacillin-tazobactam Order Review January to June 215 Program Number of Orders Guideline Concordant Medicine Family (94%) Medicine Internal (94%) Total (94%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

29 G. Surgery Antibiotic Utilization (Figure 9) Surgical data incorporates orthopedics, general surgery, obstetrics and gynecology, and urology. Overall, antibiotic use has remained stable from July 213 to December 214 with cephalosporins being the most commonly ordered IV antibiotic. Patient denominator data has been integrated into the utilization data to obtain DDDs and expenditures per 1 patient days. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. The DDD and expenditures per 1 patient days increased in the last quarter due to use of cefazolin and piperacillin-tazobactam (Figure 9. MCH Surgery Antimicrobial Usage and Expenditures per 1 Patient Days ). Of the restricted antibiotics, there was a decrease in the use of daptomycin and ertapenem in the past quarter. Daptomycin use fluctuates depending on the orthopedic patients. Since the previous biannual report, there has been an improvement in the guideline concordance rate for imipenem but a decline for ertapenem (91% to 75%). Compliance with completion of the restricted antibiotic preauthorization form has declined from 82% in the previous six months to 68% and could be improved upon (Table 12). Piperacillin-tazobactam use has increased with the majority of orders being guideline concordant (98% -Error! Reference source not found.). The most common indications for use were intraabdominal infections, pneumonia, and sepsis NYD (Table 2). Recommendations: Improve compliance with completion of the restricted antibiotic preauthorization form to ensure more accurate data collection and timely feedback for prescribers. Further improve the rates of guideline concordant prescribing for ertapenem and meropenem as follows: Ertapenem: 1. Empiric therapy of polymicrobial complicated skin and skin structure infections, including bite wound infections. 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) ß-lactamases or extended-spectrum ß-lactamases (ESBLs) where there is resistance to first line agents and documented susceptibility to ertapenem. 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs). 4. Therapy of community-acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone and metronidazole). Imipenem + Meropenem: Guidelines listed apply to both drugs unless otherwise indicated. 1. Therapy of severe infections involving Gram negative organisms in patients who are intolerant of, or unresponsive to, or whose isolates are suspected or documented to be resistant (e.g. ESBL, inducible (AmpC) ß-lactamases) to, first line agents and piperacillin-tazobactam (imipenem preferred if documented susceptibility) 2. Therapy of severe suspected or documented polymicrobial infections in patients who are intolerant of, or unresponsive to, or whose isolates are suspected or documented to be resistant to, first line agents Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

30 and piperacillin-tazobactam (imipenem preferred if documented susceptibility) 3. Therapy of infections involving multi-drug resistant Pseudomonas aeruginosa where there is documented susceptibility to the carbapenem (cannot assume meropenem susceptibility from imipenem susceptibility and vice versa). 4. Empiric therapy in high risk febrile neutropenic patients +/- aminoglycoside (imipenem preferred if documented susceptibility). 5. Empiric therapy of post-traumatic/post-neurosurgical meningitis in combination with vancomycin. (MEROPENEM) 6. Alternative to ceftazidime for therapy of central nervous system (CNS) infections due to Pseudomonas aeruginosa. (MEROPENEM) 7. As part of combination therapy of infections with Nocardia spp or nontuberculous Mycobacteria spp. (IMIPENEM) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June 215 3

31 Figure 9. MCH Surgery Antimicrobial Usage and Expenditures per 1 Patient Days MCH Total Surgery DDD/1 Patient Days Ortho Surgery - Other MCH Total Surgery Expenditures/1 Patient Days $2 $15 $1 $5 $ Ortho Surgery - Other MCH Surgery DDD/1 Patient Days Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $7 $6 $5 $4 $3 $2 $1 $ MCH Surgery Expenditures/1 Patient Days Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin MCH Surgery DDD/1 Patient Days Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $3 $25 $2 $15 $1 $5 $ MCH Surgery Expenditures/1 Patient Days Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

32 Table 12. MCH Surgery Compliance with Preauthorization Form and Guideline Concordance Rates January to June 215 Antibiotic Number of Orders Guideline Concordant Form Compliance Daptomycin 3 3 (1%) 2 (67%) Ertapenem 8 6 (75%) 4 (5%) Imipenem 7 7 (1%) 6 (86%) Meropenem 1 (%) 1 (1%) Total (84%) 13 (68%) Recommendations (Number and percent accepted) Table 13. MCH Surgery Piperacillin-tazobactam Order Review January to June 215 Program Number of Orders Guideline Concordant Surgery General, Obstetrics, Urology (97%) Surgery Orthopedics (1%) Total 51 5 (98%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

33 V. Clostridium difficile Infection (CDI) Prospective Audit and Feedback The Antimicrobial Stewardship pharmacist performs an audit on all CDI patients to ensure guideline concordant treatment is initiated, to encourage the use of the CDI Preprinted Patient Care Order (PPCO) and to optimize CDI management as necessary. There were 34 chart audits performed for the period of January 1 to June 3, 215 (Table 14). CDI guideline concordant treatment was initiated in 94% of patients (32/34) and this increased to 1% following interventions made by the Antimicrobial Stewardship pharmacist. Additional interventions included optimizing therapy duration in five cases and discontinuation of acid suppressive therapy in three. Use of the CDI PPCO upon initial prescribing has increased slightly from 32% during the period of July to December 214 to 38% (13/34) at present. Improvements in this rate will likely achieve better initial guideline concordant treatment and would trigger the assessment of other offending therapies such as acid suppressive agents, concurrent unnecessary antibiotics, or other medications such as stool softeners or laxatives. There was one death attributable to CDI in February 215. Recommendations: CHASC to continue to work with IPC and other disciplines to ensure guideline concordant management of CDI and to increase the use of the CDI PPCO as one effective strategy. Month Number of cases Table 14. MCH C. difficile Infection Audits CDI Attributable Mortality* January to June 215 Guideline Concordant Treatment CDI PPCO Utilized Alter CDI Treatment Pharmacy Interventions Alter CDI Treatment Duration Discontinue acid suppressive therapy January 4 4 (1%) 2 (5%) 1 1 February (1%) (%) March 6 6 (1%) 3 (5%) 1 April 9 7 (78%) 4 (44%) 2 1 May 4 4 (1%) 1 (25%) 1 June 8 Not available 8 (1%) 3 (38%) Total (94%) 13 (38%) *Accurate at the time of this report but is subject to change due to ongoing IPC surveillance. Total for June is pending. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

34 VI. Antimicrobial Stewardship Pharmacist Interventions As part of the audit and feedback process of the restricted antibiotics, piperacillin-tazobactam and CDIs, the Antimicrobial Stewardship pharmacist provides recommendations to optimize patient care. Figure 1. MCH Antimicrobial Stewardship Pharmacist Interventions Accepted highlights the quantity, category and indication of antimicrobial stewardship interventions for the period of January 1 to June 3, 215. The attending team accepted 89% (41/46) of the recommendations provided. 16 Figure 1. MCH Antimicrobial Stewardship Pharmacist Interventions Accepted January to June Bacteremia CDI Febrile Neutropenia Genital IAI Osteomyelitis Pneumonia Sepsis NYD UTI Antimicrobial therapy unnecessary Dose optimization Duration of therapy optimization Medication discontinued Spectrum of antimicrobial agent Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

35 VII. Appendix 1 - Villa Caritas (VC) Total VC Antibiotic DDD and Expenditures July 213 June 215 (Figure 1) Patient denominator data has been integrated into the utilization data to obtain DDDs and expenditures per 1 patient days. Incorporating denominator data takes into account changes in utilization that may be due to fluctuations in patient volumes. Overall antibiotic utilization has been stable for the period of January 1 to June 3, 215 at Villa Caritas (Figure 1). Data collection on the restricted antibiotics began in October 213. Overall, there is low usage of the restricted antibiotics with one order for the period January 1 to June 3, 215. The order was deemed guideline concordant and the preauthorization form was completed appropriately (Table 1). Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

36 Figure 1. Villa Caritas Antimicrobial Usage and Expenditures per 1 Patient Days VC Total DDD/1 Patient Days VC Total Expenditures/1 Patient Days Oral Parenteral $4 $35 $3 $25 $2 $15 $1 $5 $ Oral Parenteral VC DDD/1 Patient Days VC Expenditures/1 Patient Days Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin $25 $2 $15 $1 $5 Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones $ Fluoroquinolones Vancomycin Vancomycin VC DDD/1 Patient Days VC Expenditures/1 Patient Days Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $14 $12 $1 $8 $6 $4 $2 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

37 Table 1. Villa Caritas Compliance with Preauthorization Form and Guideline Concordance Rates Antibiotic Number of Orders January to June 215 Guideline Concordant Form Compliance Recommendations (Number and percent accepted) Meropenem 1 1 (1%) 1 (1%) 1 (%) Total 1 1 (1%) 1 (1%) (%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June

38 VIII. Glossary of Terms ASP. Antimicrobial Stewardship Program CAP.Community Acquired Pneumonia CCU.... Coronary Care Unit CDI... Clostridium difficile Infection CHASC Covenant Health Antimicrobial Stewardship Committee CHASE.....Covenant Health Antimicrobial Stewardship e-newsletter DDD....Defined Daily Dose ED...Emergency Department ERIP...Emergency Inpatients ESBL...Extended Spectrum Beta-Lactamase FN.. Febrile Neutropenia HPT.....Home Parenteral Therapy IAI.. Intra-abdominal infection ICU..Intensive Care Unit ID....Infectious Diseases IPC Infection Prevention and Control L & D.Labour and Delivery Unit MCH......Misericordia Community Hospital MDR.....Multi-drug Resistant MSSA.... Methacillin Sensitive Staphylococcus Aureus NB.. Nota bena or Important, Note well NYD...Not Yet Diagnosed OM.Osteomyelitis PJI.. Prosthetic Joint Infection PPCO...Preprinted Patient Care Order SSTI.Skin and Soft Tissue Infection UTI. Urinary Tract Infection VAP....Ventilator Associated Pneumonia VC Villa Caritas Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of January June