Antimicrobial Stewardship/Statewide Antibiogram. Felicia Matthews Senior Consultant, Pharmacy Specialty BD MedMined Services

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1 Antimicrobial Stewardship/Statewide Antibiogram Felicia Matthews Senior Consultant, Pharmacy Specialty BD MedMined Services

2 Disclosures Employee of BD Corporation MedMined Services

3 Agenda CMS and JCAHO CDC Outpatient AMS Antibiogram Antibiotics

4 JCAHO and CMS

5 Regulatory JCAHO MMS Effective January 1, 2017 CMS Antimicrobial Stewardship requirement October 4, 2016 CMS published the final rule adding AMS to the 1986 infection control condition of participation (CoP) Hospitals must met CoP to receive payments

6 Regulatory CMS-3295-P Updates have been delayed because new administration has taken office 3/13 Seema Verma, MPH, confirmed as Medicare and Medicaid Administrator 3/24 House Republicans removed bill to repeal and replace the ACA from House floor vote Although it s not a controversial rule, it will be reviewed because it will cost money up to $1 billion Final ruling will be November 10th

7 Regulatory CMS-3295-P Infection Prevention Focus on prevention Ensuring the Infection Preventionist is actually trained in Infection Prevention Focus on transmission across the care continuum including patients, hospital personnel, visitors, environment and other outpatient facilities

8 Regulatory CMS-3295-P Antimicrobial Stewardship Require hospitals to have policies and procedures for, and to demonstrate evidence of, an active and hospital-wide antibiotic stewardship program. Hospitals would be required to improve their internal coordination among all components responsible for antibiotic use

9 CDC Outpatient Antimicrobial Stewardship

10 Regulatory CDC Outpatient Antibiotic Stewardship 3/2014 9/ /2016

11 Regulatory CDC Outpatient Antibiotic Stewardship 2009 $10.7 Billion Spent on Antibiotics in US 61.5% outpatient 33.6% inpatient 4.9% long-term care settings Suda KJ, A national evaluation of antibiotic expenditures by healthcare setting in the United States, JAC. 2013;68:715 8.

12 Regulatory CDC Outpatient Antibiotic Stewardship Intended Audiences Health care systems Urgent care clinics and clinicians Retail health clinics and clinicians Outpatient specialty and subspecialty clinics Primary care clinics Emergency departments (EDs) Dental clinics and dentists Nurse practitioners and physician assistants

13 Regulatory CDC Outpatient Antibiotic Stewardship Core elements Commitment Action for policy and practice Tracking and reporting Education and expertise

14 Regulatory CDC Outpatient Antibiotic Stewardship Commitment Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety by all healthcare team members

15 Regulatory CDC Outpatient Antibiotic Stewardship Action for policy and practice Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed. Diagnosis guidelines Prescribing guidelines Written justification in chart

16 Regulatory CDC Outpatient Antibiotic Stewardship Tracking and reporting Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves. Chart review Follow-up on initiatives

17 Regulatory CDC Outpatient Antibiotic Stewardship Education and expertise Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing Communication strategies Patient education

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19 AHQI Antibiogram

20 What is included? Isolates from 56 hospitals in Alabama Includes data from 1/2016 to 12/2016 One isolate per organism per 365 day period Duplicate isolates removed Significantly different susceptibility results are considered unique or non-duplicate

21 Community versus Hospital Community isolate That which is collected from an outpatient or an inpatient within the first 3 days of an admission who has had no admissions within the past 14 days Hospital isolate That which is collected from a inpatient on or after day 3 of an admission or within 14 days of discharge

22 Hospital Enterococcus Isolates (Non-Urine) % (29%) of Enterococcus isolates are the more resistant faecium strain 1149 E Faecium E Faecalis

23 Vancomycin Resistant E Faecium (Hospital Non-Urine) % E. faecium resistant to vancomycin down slightly from last year 80% (81%) Vancomycin Linezolid E. faecium resistance to linezolid increased to 6% (4%). Still below 2007 levels % * 95% of E. faecalis remain susceptible to vancomycin

24 Hospital MRSA (Non-Urine) MRSA has returned to it s lowest point in in 2013 at 57%. The percent still remains high relative to other regions in the US 55 57%

25 MRSA All HAIs

26 MRSA Hospital versus Community (Non-Urine) Hospital Community 57% 53% Hospital and Community saw declines in Community will include patients from nursing homes and long-term care hospitals and may not reflect Community in the traditional sense

27 Klebsiella pneumonia Isolates Resistant to Meropenem (KPC) 172 total 97 Comm Hosp 106 total 62 Previous presentations have reported K. pneumonia strains tested against imipenem. A greater number of hospitals have been testing meropenem instead of imipenem. We will report meropenem moving forward (N=6267) 2016 (N=6310) 2015 testing against imipenem showed 5549 isolates tested with 206 being resistant.

28 Hospital Non-Urine A. baumannii Isolates Susceptible to Meropenem 100% 90% 80% Carbapenem tested was changed to meropenem reflecting most health systems. 70% 60% 50% 64% 70% Multi-drug Resistant A. baumannii is associated with high mortality and is difficult to treat. 40% 30% 20% 10% Combination therapy of carbapenem with ampicillin/sulbactam, colistin or tigecycline still may be necessary 0% Total Isolates % Susceptible

29 Carbapenms R or I Acinetobacter NATIONAL HAIs

30 MDR Acinetobacter Isolate Alabama Hospitals

31 Hospital P. aeruginosa Non-Urine 100 Cefepime B-Lactams 90 Aztreonam Pip/Tazo 85% Pipercillin/Tazobactam and Cefepime are stable 80 83% Aztreonam has continued to steadily improve over the last 5 years 70 66% 60 50

32 Hospital P. aeruginosa Non-Urine % 91% 81% Aminoglycosides Amikacin and Tobramycin steady at over 90% Gentamicin continues to improve over the last 4 years Amikacin Tobramycin Gentamicin 50

33 100 Hospital P. aeruginosa Non-Urine Carbapenems Imipenem Meropenem P. aeruginosa susceptibility to imipenem at it lowest since data collection started, 68% % 68% Meropenem declining since 2011 Concern here as this one of our last lines of defense against resistant gram negative bacteria.

34 Hospital P. aeruginosa Non-Urine Levofloxacin Quinolones Poor activity against Pseudomonas % There is a trend towards improvement over the past 3 years and since

35 Antibiogram Summary Enterococcus faecium resistant to vancomycin or linezolid, hospital nonurine, remains stable (80%, 6%) MRSA, hospital non-urine, trend continues to decline. Geographically, still high. CRKP, hospital and community, declined in Monitor closely. A. baumannii, hospital non-urine, susceptibility improved (70% vs 64%). Still a dangerous pathogen. P. aeruginosa, hospital non-urine, resistance to carbapenems a concern with overall trend declining

36 AHQI Antibiotic Utilization 2016 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company.

37 Antibiotic National Comparison Antibiotics

38 Antibiotic National Comparison Carbapenems

39 Antibiotic National Comparison Piperacillin / Tazobactam

40 Antibiotic National Comparison Vancomycin, Linezolid, Daptomycin, Tigecycline

41 Antibiotic National Comparison Quinolones

42 Antibiotic National Comparison 3 rd /4 th Generation Cephalosporins

43 Antibiotic National Comparison Proton Pump Inhibitors

44 Thank you!