"How to work around (with) administration to build an Antimicrobial Stewardship Program AND how to get dumb (oops reluctant) doctors to do the right thing" David Graham, MD
Disclosures Nothing Medically I own FiPhysician LLC, a financial planning and investment company (FiPhysician.com) 2
Objectives Try and start an AMS program that will build administrative support Learn how doctors think (or don t think) about antibiotics Discuss what interventions might work to decrease antibiotic use 3
How I got my start I just started. I didn t ask permission or try to get funding A year later, after our system supported AMS, I went in front of the QPSC to pitch for pharmacy support Program continued to grow with ID trained pharmacist 4
Slides from my talk 5
Additional slides in support 6
Summary slide from presentation A formal ASP program is supported by SCLHS and in the works Managed by pharmacy 1 FTE ASP pharmacist to run the program hopefully August 1 st Low hanging fruit still to be harvested IV to PO Review all antibiotics at 72 hours Need to focus on carbapenems Discussion on 0.25 0.5 FTE for physician leadership Opportunity to leverage technology and make it regional
Posted in the ED Please DON T give antibiotics if: 1. You suspect endocarditis. Endocarditis is a diagnostic emergency, not an antibiotic emergency. Standard of care is 3 sets of blood cultures in 24 hours (or in 8 hours if they are ill) PRIOR to giving antibiotics. (from UpToDate: Blood cultures should be obtained prior to initiation of antibiotic therapy. At least three sets of blood cultures should be obtained; in patients who have received recent antimicrobial therapy, additional blood cultures may be useful. If the tempo of illness is subacute and the patient is not critically ill, it is reasonable to delay initiation of antimicrobial therapy while awaiting the results of blood cultures and other diagnostic tests. In the setting of acute illness, three sets of blood cultures should be obtained over a one-hour period prior to initiation of empiric antimicrobial therapy.) 2. You suspect discitis. Blood cultures are often helpful in diagnosis. If they are not, we use CT guided biopsy to attempt to get a culture. No empiric antibiotics prior to CT guided biopsy. (If they have epidural abscess with neurological changes, or going straight to OR or ICU, then yes give antibiotics) 3. You suspect septic joint. Aspiration prior to empiric antibiotics 4. You suspect joint arthroplasty infection. Hold antibiotics until surgery. Notes on Surviving Sepsis (SS) and CMS s SEP 1 rule: For those with SEVERE sepsis or Septic SHOCK: SS suggests antibiotics in less than an hour and SEP 1 in less than 3 hours. Most folks with the above conditions will just have sepsis or not even meet those criteria. From my perspective diagnosis is much more important than antibiotics unless they are very ill. 8
Bugs and Drugs Digest Volume 1 A cellulitis question: can you tell just by looking if MRSA is likely or not? YES if there is purulence, it could be MRSA. If there is no purulence, it is not MRSA. Reference: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. CID. 10:1098 Please don t use vanco for nonpurulent infections, which are usually strep. Vanco is an old-fashioned poorly effective (crap) drug that we started using again because we had no alternatives, and we didn t know that MRSA doesn t cause nonpurulent infections. We have much more effective and safer antibiotics such as keflex or clinda by mouth, or ancef or clinda IV. Ceftriaxone can be given once in the ED or daily in the infusion center and will be much more effective than vanco. 9
From Infectious Diseases Society of America Skin and Soft Tissue Infection Guidelines 2014 http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full.pdf+html or google: idsa skin and soft tissue infection guidelines Notes: 1. If there is pus (Purulent) then I & D is necessary and cover for MRSA if moderate or severe 2. If there is NOT PUS (non purulent) then you do not need to cover for MRSA. Consider ancef or ancef/clinda if it looks bad. Or ceftriaxone 2gm/day. 3. Only if the nonpurulent infection is severe (in the ICU and calling general surgery to debride) do you need vanco/zosyn. 10
C. diff update for 2017 Attention will be paid to the culture around C. diff diagnosis and treatment in 2017. Hospital acquired C. diff is a Ministerial Excellence Goal for SCL this year, and not coincidentally, it will also be nationally reportable through CMS. We now understand that PCR testing over-diagnoses C. diff! Those who are colonized with C. diff are often falsely diagnosed and treated for C diff associated diarrhea (CDAD). Remember, to meet criteria for CDAD, you need to have 3 episodes of diarrhea in 24 hours. If there is just a single loose stool or episode of diarrhea, patients do not have CDAD even if they have a positive PCR for C. diff. In effort to decrease diagnosis of C. diff colonization, the lab will change its assay for C. diff in 2017. Testing will be for GDH and Toxin antigens. If both are positive, the result is positive. If bother are negative, the result is negative. If there are discordant responses, it will reflex to PCR for testing. Other things to remember: 1. We are not dinged for community onset C. diff, just hospital acquired C. diff (so please test for C. diff before 72 hours). 2. If someone presents with diarrhea, then acute testing with the GI multiplex PCR may be appropriate. If they have been in the hospital for a few days, the GI multiplex PCR is almost never appropriate (because it is expensive, and picks up mostly community associated causes of diarrhea, and will have the same issues with false positive C. diff PCRs). 3. Please try not to send any stool samples if someone has been on laxatives in the past 24-48 hours. Remember stopping antibiotics will often get rid of diarrhea (even if it is due to C. diff!) and may be the thing to do rather than testing for C. diff and continuing unneeded antibiotics. 4. We will be encouraging nursing NOT to call a physician after a single episode of diarrhea and directly asking for a C. dif test. While the nursing sniff test is rather sensitive for C. diff, it is not specific and testing after a single loose stool is usually not appropriate. Thanks. We have learned a lot about C. diff in the last few years and it is actually a rather complicated disease. I look forward to working though diagnosis and treatment of C. diff this year with everyone. David Graham, MD Infectious Disease and director of Infection Control and Antimicrobial Stewardship 11
Empiric Antibiotics: How to Kill Montana Bugs Sepsis must give broad spectrum (vancomycin or cefazolin alone do not count). Ceftriaxone, ampicillin/sulbactam, IV levofloxacin, etc are all broad spectrum (Must have reliable strep, staph, and e. coli coverage per CMS). Skin Infection Abscess Inpatient Outpatient No Abscess Inpatient Outpatient UTI CAP Inpatient Outpatient Inpatient Outpatient HCAP HAP Abdominal Inpatient Outpatient Drain! culture if moderate or worse Vancomycin Bactrim, Doxycycline Cefazolin, Nafcillin, Clinda (IV Ceftriaxone or Unasyn if Septic ) Cephalexin Ceftriaxone Cefuroxime, Cephalexin, Bactrim, Macrobid (cystitis only), Cipro Ceftriaxone + Azithromycin PCN Allergic: Ceftriaxone + Azithromycin Cephalosporin Allergic: IV Levofloxacin 500mg Amox, Cephalexin, Cefuroxime, Augmentin, Azithro, Doxy, Levo No longer exists, see CAP above In Montana ceftriaxone + azithro is great Consider Vanco in necrotizing PNA or known MRSA colonization Consider Antipseudomonal if IV Antibiotics in previous 90 days or critically ill Double gram negative coverage is unnecessary in Montana. Ceftriaxone + PO metronidazole PCN Allergic: Ceftriaxone + PO Metronidazole Cephalosporin Allergic: Levo + PO Metronidazole or Ertapenem Ceftin + Metronidazole, Bactrim + Metronidazole, Levo + Metronidazole, Moxi (Augmentin and Unasyn poor options if concern for E. coli) Diabetic Foot Ceftriaxone + PO metronidazole, ampicillin/sulbactam No need to cover MRSA or Pseudomonas unless patient critically ill ***as a special reminder please remember for Meningitis the CSF PCR has revolutionized our care. If someone is sick and has meningitis, do blood work (including blood cultures) then give ceftriaxone 2gm stat. The PCR (meningitis encephalitis panel on EPIC) will be positive even after antibiotics. You can then get CT (if needed) and then LP. Consider steroids/vanco if you suspect pneumococcus, add acyclovir if you think it is HSV-1, add ampicillin if you think it is listeria. Your ID team is happy to answer questions M-F (and off hours if you are kind) David Graham zipit or 406-697-1518 (text if able) Jeff Jansen zipit or 503-880-3096 12
Empiric OUTPATIENT Antibiotics: How to Kill Montana Bugs Skin Infection Abscess Drain! culture if moderate or worse Bactrim 2 DS BID OR Doxycycline 100mg BID 5 to 7 days UTI CAP No Abscess Cephalexin 1g TID Cefuroxime 500mg BID OR Cephalexin 1g BID Bactrim 1 DS BID Macrobid 100mg BID Amoxicillin 1g TID OR Azithromycin 500mg x1 then 250mg QD x4 OR Doxycycline 100mg BID 5 to 7 days 5 to 7 days 5 days 7 days 7 days 5 days 5 to 7 days If complicated or comorbid conditions: Cefuroxime 500mg BID PLUS Azithromycin 500mg x1 then 250mg QD x4 7 days 5 days COPD (C) Bronchitis (B) Sinusitis (S) Pharyngitis Abdominal PCN Allergy: Cefuroxime + Azithromycin Ceph Allergy: Levofloxacin 500mg QD *Not an antibiotic requiring vast majority of time* C,B: Azithromycin 500mg QD C,B,S: Doxycycline 100mg BID S: Amoxicillin 500mg BID or cefuroxime 250mg BID *Antibiotics only if Group A Strep positive* Amoxicillin 500mg BID PCN Allergy: Cefuroxime 250mg BID Ceph Allergy: Azithromycin 500mg x1 then 250mg QD x4 Cefuroxime 500mg BID PLUS Metronidazole 500mg TID As above 7 days 3 to 5 days 5 to 7 days 5 to 7 days 10 days 5 days 5 days 5 to 7 days 5 to 7 days PCN Allergy: Cefuroxime + Metronidazole Ceph Allergy: Levofloxacin 500mg QD PLUS Metronidazole 500mg TID As above 5 to 7 days Diabetic Foot and Animal Bites *Amoxicillin/clavulanic acid 875/125mg BID is a potential alternative therapy option but has poor susceptibility to e. coli (65% at baseline) *Diverticulitis does not require antimicrobial therapy if patient does not have a fever or leukocytosis [AVOD and DIOBOLO Trials]. Amoxicillin/Clavulanic Acid 875/125mg BID Cefuroxime 500mg BID PLUS Metronidazole 500mg TID 5 to 7 days, recommend close follow up if used empirically 7 to 14 days 7 to 14 days PCN Allergy: Cefuroxime + Metronidazole Ceph Allergy: Levofloxacin 500mg QD PLUS Metronidazole 500mg TID *These infections require close follow-up as surgical intervention may be necessary after initial presentation As above 7 to 14 days Your ID team is happy to answer questions M-F (and off hours if you are kind) David Graham, MD: zipit or 406-697-1518 (text if able) Jeff Jansen, PharmD: zipit or 503-880-3096 (call or text) 13
Procalcitonin will be available starting July 6 th from the lab. It is elevated in bacterial infections but not viral infections. It does not take the place of lactates for CMS sepsis protocol. In addition, if a patient meets sepsis critearia for CMS purposes, they will still need broad spectrum antibiotics even if they have a negative procalcitonin. 14
Additional Stewardship Implementations: 2017 Hiring of an infectious diseases trained pharmacist was completed in 03/2017 with start date of 07/2017 Initial steps towards regionalization through providing infectious diseases services to Holy Rosary Healthcare (Prospective review of HRH antimicrobial use on Tuesdays and Fridays). Infectious diseases E-consultations are also now available Empiric antimicrobial recommendations provided to emergency room physicians and pharmacist Daily prospective audits of patients on antimicrobial therapy for appropriateness of use Intensive care unit antimicrobial utilization recommendations. Infectious diseases pharmacist provides daily (weekdays) stewardship recommendations to ICU pharmacist and physically rounds with multidisciplinary team twice weekly (Monday and Thursday) Focused discussion to individual provider groups to improve patient care and decrease costs to both the health system and the patient Monthly reporting of stewardship outcomes to NHSN and local pharmacy and therapeutics committee Incidence of hospital acquired Clostridium difficile infections decreased by 60% in 2017 compared to 2016. Antimicrobial Stewardship Goals: 2018 Provide education and recommendations for standardized best clinical practices to outpatient providers and clinic personnel for antimicrobial stewardship in at least 3 of the following: o Sinusitis o o Bronchitis o o Community Acquired Pneumonia Pharyngitis Urinary Tract Infections Decrease Hospital-Wide antimicrobial utilization by 10% as determined by days of therapy per 1000 patient days as compared to 2017 Decrease Hospital-Wide carbapenem utilization by 20% as determined by days of therapy per 1000 patient days as compared to 2017 Decrease Intensive Care Unit antimicrobial utilization by 20% as determined by days of therapy per 1000 patient days as compared to 2017 Decrease Holy Rosary Hospital-Wide antimicrobial utilization by 10% as determined by days of therapy per 1000 patient days as compared to 2017 Maintain or improve hospital acquired Clostridium difficile rates as compared to 2017 Summary Overall, antimicrobial use at Saint Vincent decreased in 2017. This decrease was largely driven by a dramatic decrease in ICU antibiotic utilization. An increase in antimicrobial use was observed in 12/2017 (and continued in 01/2018). This is observed on an annual basis and is most likely partially associated with influenza season. Since the program informally began in 2015, total antibiotic use is down 33% while vancomycin use is down 61% and anti-pseudomonal use dropped 56%. Utilizing conservative numbers, our antimicrobial stewardship interventions either saved, prevented, or avoided ~$617,000 in 2017 which aligns with the published range of $200,000 to $900,000 by the Infectious Diseases Society of America (Clin Infec Dis 2007;44:159-77). 15
How do you get leadership buy in? Build it and they will come What resources do you already have available to work with? Don t ask for money or time. Do it and show how much money you are saving them. Then get a 30% raise 16
How do you get physician support? More important than leadership support Who can be your champion? Remember, they were trained in areas where broad spectrum empiricism probably made sense and where LESS THAN 1% of their TRAINING WAS DEVOTED TO ID YOU can be the expert 17
Projects Vanco Vanco/Zosyn Any antipsuedomonal for community processes (including diabetic foot!) PCN allergy No FQ use Procalcitonin Zosyn (piperacillin/tazobactam) 18
Live with the fear The first time is scary: HCAP with ceftriaxone/azithro Aspiration pneumonia with ceftriaxone alone Diabetic foot with ceftriaxone Stop the vanco in the am for simple cellulitis Challenge a true penicillin allergy with Cefs De-escalate right out of the ICU to community antibiotics 19