Antibiotic Use Metrics in VA facilities Caring for Veterans with Spinal Cord Injury Katie J. Suda, PharmD, M.S. Research Health Scientist VA Center of Innovation for Complex Chronic Healthcare Research Associate Professor University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Systems, Outcomes, and Policy August 29, 2017
Disclosures Presenter has no financial interests to disclose. PESG and PVA staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with PVA. PESG, PVA, and all accrediting organization do not support or endorse any product or service mentioned in this activity. 2
Learning Objectives At the conclusion of this activity, the participant will be able to: 1. To describe overall antibiotic prescribing in Veterans with SCI. 2. To assess differences in antibiotic prescribing in Veterans with SCI as compared to a general VA population. 3. To identify targets for antibiotic stewardship. 3
CE/CME Credit If you would like to receive continuing education credit for this activity, please visit: http://pva.cds.pesgce.com 4
Disclaimer The views expressed in this presentation are the presenters and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. 5
Co-Authors and Funding Co Authors: Charlesnika T. Evans, PhD, MPH Hines VA Stephen P. Burns, MD Seattle VA Margaret Fitzpatrick, MD Hines VA Linda Poggensee, MS Hines VA Swetha Ramanathan, MS Hines VA Funding: VA Rehabilitation Research and Development Service Merit Review Award (B 1583 P) 6
POLL QUESTION What type of position do you hold at the VA? Nurse Advanced practice provider Physician Therapist Doctoral level Researcher Other 7
BACKGROUND
ANTIBIOTICS ARE NOT SAFE DRUGS Primary reason for ED visits Bacterial resistance Clostridium difficile infection (CDI) No new antibiotics in the pipeline! CDC. Available at: http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf Luepke VeteranS KH, et al. HEALTH Lessons ADMINISTRATION in antibacterial economics past, present, and future: Increasing bacterial resistance, a limited pipeline, and societal implications. Pharmacotherapy. 2017;37(1):71-84.
RESISTANCE THREATS CDC threat level: URGENT Clostridium difficile* Cabapenem Resistant Enterobacteriaceae (CRE)* CDC threat level: SERIOUS MRSA* VRE Streptococcus pneumoniae ESBL* Pseudomonas aeruginosa* Acinetobacter sp.* Candida sp. Spinal cord injury? 10 CDC. Available at: http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf
REASONS FOR THE INCREASE IN MDR
WHAT CAN WE DO TO MODIFY THESE TRENDS? Infection Prevention Surveillance & improving diagnostic tools (rapid diagnostic testing) Antibiotic Stewardship Development Slide credit: L Hicks
EPIDEMIOLOGY OF INFECTIONS IN SCI Burden of HAI, CAUTI, CLABSI in SCI is greater as compared to a general patient population Outcomes in SCI with HAI compared to non infected SCI Increased length of stay (LOS) Increased subsequent hospitalizations In hospital mortality HAI = Healthcare Associated Infection; CAUTI = Catheter Associated Urinary Tract Infection; Central Line-Associated Blood Stream Infection Nicolle et al., ICHE 1988; Montgomerie, Clin Infect Dis 1997; Mylotte et al., Clin Infect Dis 2000; Mylotte et al., Am J Infect Control 2000; Evans et al., ICHE 2008; Edwards et al., Am J Infect Control 2008; Mylotte et al., ICHE 2001; LaVela et al., Am J Infect 13 Control 2007
PREVALENCE OF GNR ISOLATES AND MDR IN SCI N=8677 Patients; 27,897 cultures; 34,760 GN isolates 14 Evans, CT. Prevalence and factors associated with multidrug-resistant Gram-negative organisms in patients with SCI. Submitted.
Percentage of MDR Gram Negative Cultures 21.3% MDRGNO Cultures In Veterans without SCI/D Evans, CT, et al. Prevalence and factors associated with multidrug-resistant Gram-negative organisms in patients with 15spinal cord injury. Submitted.
Geographic distribution of MDRGNO in Veterans with SCI/D Overall: 3.1-53.1% SCI Center: 13.4-53.1% Non-SCI Centers: 3.1-44.8%
Independent predictors for MDRGNOs Older age Tetraplegia and Complete injury; shorter duration of injury Inpatient and long term care culture locations Polymicrobial cultures Pressure ulcer Healthcare encounters and antibiotics in the last 90 days 3 rd /4 th generation cephalosporins, fluoroquinolones, carbapenems, sulfonamides, nitrofurans Midwest and West associated with decreased MDRGNOs Evans, VeteranS CT, et al. HEALTH Prevalence ADMINISTRATION and factors associated with multidrug-resistant Gram-negative organisms in patients with spinal cord injury. Submitted.
CDI IN VETERANS WITH SCI/D Epidemiology: 14% of Veterans with SCI/D have CDI 33% decrease in CDI over 8 years Risk factors: Older age, Northeast region, antibiotics (especially high risk antibiotics), PPI/H2 blockers, antibiotics+ppi/h2 Protective factors: Longer SCI duration and care at a SCI specialty care center In those with CDI, 21.5% of Veterans with SCI have a first recurrence Risk factors: Older age, fluoroquinolones, longer LOS (>90 days) Protective factors: Cerebrovascular accident, tetracycline Ramanathan S, et al. Recurrence of Clostridium difficile infection among Veterans with spinal cord injury and disorder. Evans CT, et al. Healthcare facility-onset, healthcare facility-associated Clostridium difficile infection in Veterans with spinal cord injury and disorder. Submitted. 18
POLL QUESTION Antibiotic resistance is a major public health problem Agree Neutral Disagree I don t know 19
POLL QUESTION Antibiotic resistance is a problem at my facility Agree Neutral Disagree I don t know 20
ANTIBIOTIC USE METRICS IN SCI/D METHODS
RESEARCH OBJECTIVE The purpose of this study is to report on antibiotic use metrics across all Veterans Affairs (VA) facilities with a special emphasis on Veterans with SCI. Aim 1 Outcome: Prevalence of antibiotic prescribing Overall, by class, and by spectrum of activity Aim 2 Outcome: Antibiotic days (AD) and Days of Therapy (DOT) Overall, by class, and by spectrum of activity
METHODOLOGY Study Design: Retrospective cohort study VA Corporate Data Warehouse (CDW) Spinal Cord Dysfunction Registry / Spinal Cord Injury and Disorders Outcomes Study Setting: 1233 VA medical centers, VA outpatient clinics, CBOCs Study Timeframe: January 1, 2013 December 31, 2013 23
ANTIBIOTIC CLASS Systemic antibiotics were grouped into spectrum of activity and class as defined by VA drug classes Inpatient broad spectrum definition: carbapenems, quinolones, anti pseudomonal penicillins, 3 rd /4 th generation cephalosporins Outpatient broad spectrum definition: carbapenems, quinolones, anti pseudomonal penicillins, 3 rd /4 th generation cephalosporins, macrolides, tetracyclines, aminoglycosides 24
ANTIBIOTIC USE METRICS Standardized measurements of antibiotic use Can be used to assist in the identification of targets for stewardship efforts Can be used to assist in measuring the impact of stewardship efforts Klepser VeteranS ME, HEALTH al. A call to ADMINISTRATION action for outpatient antibiotic stewardship. J Am Pharm Assoc (press). Dobson EL, et al. Outpatient antibiotic stewardship: interventions and opportunities. J Am Pharm Assoc (press).
ANTIBIOTIC USE METRICS Antibiotic days (AD) Average number of days/patient where any antibiotic was administered Max=365 days Days of therapy (DOT) Average number of days/patient where a unique agent was administered No max Calculated at the patient level (across 2013) where >1 day and/or >1 dose of an antibiotic was administered.
ANTIBIOTIC USE METRICS - EXAMPLE Levofloxacin Days 5-20 Days 1-8 Piperacillin/tazobactam Day 1 Day 10 Day 20 Antibiotic Days (AD) = 20 days Antibiotics administered on days 1-20. Days of Therapy (DOT) = 24 days Levofloxacin = 16 total days Piperacillin/tazobactam = 8 total days 27
METHODOLOGY Statistical Analyses: Descriptive statistics Independent t test and Wilcoxon Rank Sum for continuous data Chi square test for categorical data A p value < 0.05 was considered statistically significant. 28
ANTIBIOTIC USE METRICS IN SCI/D RESULTS
STUDY COHORT Veteran SCI/D Cohort n = 19,641 patients Non SCI/D Cohort n = 6,881,193 patients Non ICU inpatients ICU patients Outpatients LTCF residents Antibiotic prescribed n = 9835 patient Antibiotic prescribed n=1,145,709 patients 30
PREVALANCE OF ANTIBIOTIC PRESCRIBING Veterans with SCI/D Cohort Non SCI/D Veteran Cohort 57.5% broad spectrum 71.1% broad spectrum P<0.001 31
ANTIBIOTIC METRICS *p<0.01
PREVALANCE OF ANTIBIOTIC PRESCRIBING SUBGROUPS Prevalence of Antibiotic Use (%) Prevalence of Broad Spectrum Antibiotic Use (%) Outpatient 18.4 56.9 Non ICU inpatients 78.4 52.7 Critical Care (ICU) 57.9 56.0 Long term care (LTCF) 58.6 57.1 Spinal Cord Injury (SCI) 50.1 71.1
ANTIBIOTIC METRICS BY SUBGROUP 34
PREVALENCE BY CLASS Class SCI (N=9919) Non SCI (N=1,142,277) P value Aminopenicillins 27.0% 28.3% 0.023 Extended Spectrum Penicillins 18.9% 5.5% <0.0001 1 st gen cephalosporins 21.4% 19.3% <0.0001 3 rd gen cephalosporins 21.2% 6.3% <0.0001 Macrolides 13.6% 22.3% <0.0001 Tetracyclines 16.1% 13.1% <0.0001 Fluoroquinolones 50.2% 29.4% <0.01 Sulfonamides 29.0% 14.1% <0.0001 Nitrofurans 15.3% 2.2% <0.0001 P<0.01 35
WHAT NOW? Infection Prevention Surveillance & improving diagnostic tools (rapid diagnostic testing) Antibiotic Stewardship Development Slide credit: L. Hicks
ANTIBIOTIC STEWARDSHIP Education Prospective audit with intervention and feedback Academic detailing Formulary restriction and preauthorization Guidelines and disease management pathways Clinical decision support systems Dose optimization De escalation (streamlining) of therapy Delayed prescribing Clin Infect Dis. 2016;62:1197-1202.
DOES STEWARDSHIP WORK? CDC. Available at: http://www.cdc.gov/getsmart/week/downloads/gsw-factsheet-cost.pdf 38
ANTIBIOTIC STEWARDSHIP Why is stewardship needed? Antibiotics are overprescribed Antibiotics are not safe drugs Antibiotic use increases the prevalence of resistance Antibiotic use increases the likelihood of colonization/infection with resistant organisms Associated with poor outcomes and mortality Antibiotic armamentarium is dwindling
HOW TO IDENTIFY TARGETS FOR ANTIBIOTIC STEWARDSHIP Compare antibiotic prescribing metrics for your facility to the results presented Prescribing for asymptomatic bacteriuria Prescribing for upper respiratory tract infections See goals in JAMA. 2016; 315(17):1864 1873. De escalation of broad spectrum antibiotic prescribing Quinolone prescribing for acute bacterial sinusitis, (ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and uncomplicated urinary tract infections (UTI) Per FDA, should be reserved Involve your facility s antibiotic stewardship team FDA. VeteranS Available HEALTH at: https://www.fda.gov/drugs/drugsafety/ucm511530.htm. ADMINISTRATION Accessed June 25, 2017.
REQUIREMENTS?!? The Joint Commission (TJC) Surveying based in new standard starting in January 2017 Centers for Medicare and Medicaid Services (CMS) Condition of participation by the end of 2017 for acute care? for LTCF State specific regulations California requires stewardship initiatives in acute care, long term care, and clinics Publically reportable measures pertaining to stewardship for acute care facilities are in development
NEW TJC STANDARD TJC. VeteranS Available HEALTH at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. ADMINISTRATION
CARF STANDARDS 1.H. 11. The organization implements procedures for infection prevention and infection control Example provided included policies/procedures providing education and surveillance on antibiotic usage and resistance 2.A. 20 26 Skin integrity Interdisciplinary intervention to prevent or reduce the risk of a wound developing 43
STEWARDSHIP RESOURCES ARE AVAILABLE AT SCI SPECIALTY CENTERS Infectious disease (ID) physician and a pharmacist with ID training Antibiotic stewardship policies and resources: IV to PO antibiotic switching De escalation of antibiotics Clinical guidelines for specific conditions Formulary restrictions Resources necessary to provide effective antibiotic stewardship to Veterans with SCI are available, but translating these resources into effective SCI specific initiatives will require further study. 44 Skelton F, et al. Spinal Cord Injury-Specific Results of a National Veterans Health Administration Survey on Antibiotic Stewardship. Submitted.
STEWARDSHIP TOOL CUSTOMIZED TO SCI/D Implementation of an antimicrobial stewardship tool, an antibiogram An aggregated report of bacterial susceptibilities to antibiotics for a specific facility, population, or community Single center study: Veterans with SCI were younger and sicker as compared to a general acute care population MRSA, ESBL, carbapenem resistant and CRE were more frequent Hill JN, et al. Development of a unit-specific antibiogram and planning for implementation: Pre-implementation findings. Am J Infect Control. 2015;43:1264-67. Suda VeteranS KJ, al. Bacterial HEALTH susceptibility ADMINISTRATION patterns in patients with SCI/D: an opportunity for customized stewardship tools. Spinal Cord. 2016;54:1001-9.
POLL QUESTION In the past year, how often have you used facility antibiograms (trends in antimicrobial resistance) in determining treatment for SCI patients? All of the time Some of the time Seldom Never 46
POLL QUESTION Are you interested in having an SCI specific antibiogram for your facility? Yes No If yes, we are assembling them for interested SCI specialty centers with support from SCI/D Services. Contact Dr. Suda if interested (katie.suda@va.gov). 47
STUDY CONCLUSION A greater proportion of Veterans with SCI received antibiotics with longer antibiotic days and days of therapy as compared to a non SCI VA cohort. While patients with SCI are reported to have more infections than those without SCI, the high prevalence of broad spectrum antibiotics is concerning. Thus, effective antibiotic stewardship strategies should be implemented in VA to target SCI and other special populations with high antibiotic use and at high risk for MDROs.
ACKNOWLEDGEMENTS Veterans VA Rehabilitation Research and Development Paralyzed Veterans of America VA QUERI CARRIAGE program VA Health Services Research and Development VA Center of Innovation for Complex Chronic Healthcare VA SCI/D Services VA Multidrug Resistant Organism office VA Antimicrobial Stewardship Task Force
ACKNOWLEDGEMENTS Hines VA Charlesnika Evans, PhD, MPH Margaret Fitzpatrick, MD, MS Dunni Kale, MPH Scott Miskevics, MS Linda Poggensee, MS Swetha Ramanathan, MPH Houston VA Barbara Trautner, MD, PhD Felicia Skelton, MD Madison VA Nasia Safdar, MD, PhD Salt Lake City VA Makoto Jones, MD, MS Seattle VA Stephen Burns, MD Barry Goldstein, MD, PhD
QUESTIONS KATIE.SUDA@VA.GOV Speed bump. Available at: www.speedbump.com. 51
POLL QUESTION Are antibiotic use metrics available at your facility to inform stewardship or other patient safety/quality improvement efforts? Yes No Other antibiotic data is used (e.g, SAAR) 52
POLL QUESTION By prescribing antibiotic drugs today, I increase the probability that my patients will be infected with drugresistance bacteria in the future Agree Neutral Disagree I don t know 53
POLL QUESTION What type of setting do you work in most of the time with patients with SCI? Inpatient unit Outpatient clinic Long term care Home care I work in a non patient care setting (ie. research, administration) 54
Antibiotic exposure and MDR Antibiotic Adjusted OR (95% CI) Sulfonamides 1.28 (1.11 1.49) Nitrofurantoins 1.41 (1.17 1.68) Fluoroquinolones 1.48 (1.31 1.67) 3 rd & 4 th Generation Cephalosporins 1.48 (1.23 1.79) Carbapenems 2.65 (1.93 3.64) Colistin 3.50 (0.99 12.43) Evans, CT, et al. Prevalence and factors associated with multidrug-resistant Gram-negative organisms in patients with 55spinal cord injury. Submitted.
METRICS BY CLASS Class SCI Mean+StDev (range) Non SCI Mean+StDev (range) P value Aminopenicillins 16.5+27.5 (1 345) 13.0+17.3 (1 365) <0.0001 Extended Spectrum Penicillins 11.2+14.7 (1 271) 6.1+6.5 (1 133) <0.0001 1 st gen cephalosporins 13.4+31.0 (1 350) 9.4+19.8 (1 365) <0.0001 3 rd gen cephalosporins 10.0+15.4 (1 324) 5.5+9.7 (1 365) <0.0001 Macrolides 11.9+32.0 (1 339) 10.9+30.9 (1 365) NS Tetracyclines 53.0+81.6 (1 347) 43.2+69.0 (1 364) 0.0006 Fluoroquinolones 17.4+25.3 (1 356) 13.3+20.0 (1 362) <0.0001 Sulfonamides 28.8+58.2 (1 365) 23.3+48.7 (1 365) <0.0001 Nitrofurans 64.3+97.1 (1 361) 33.2+67.4 (1 364) <0.0001 56
DRUG DEVELOPMENT Limited antibacterial drug development Older, more toxic antibiotics being used End of the antibiotic era? Bad bugs, need drugs 10 x 20 initiative FDA approved agents= ceftaroline IDSA. VeteranS Available HEALTH at: http://cid.oxfordjournals.org/content/early/2013/04/16/cid.cit152.full.pdf+html. ADMINISTRATION
OUTLINE Background Methods Results Antibiotic use metrics SCI vs non SCI SCI vs non SCI subgroups Antibiotic stewardship Study conclusions Questions Speed bump. Available at: www.speedbump.com.