NSHA ANTIMICROBIAL STEWARDSHIP PROGRAM. Quarterly Report Q1 2018/19

NSHA ANTIMICROBIAL STEWARDSHIP PROGRAM Quarterly Report Q1 2018/19 Sep 16, 2018

Table of Contents Summary... 1 NSHA ASP Structure... 2 Interventions... 2 Results & Metrics... 4 Education... 13 Research... 13 Guidelines... 13 Microbiology... 13 Other Activities... 13 Strategic Planning... 14 Acknowledgements... 14

Summary The vision of the NSHA Antimicrobial Stewardship Program (ASP) is to ensure the safe and effective use of antimicrobial agents in patients cared for in Nova Scotia Health Authority. NSHA s ASP will aim to improve patient care by modelling and promoting best antimicrobial use practices. Over time, effective ASPs influence the culture of antimicrobial use by changing behaviors of physicians, pharmacists, nurses, students, patients and their families. The NSHA ASP will aim to: Promote a culture of optimal antibiotic use in NSHA Respect and promote regional strengths Act in collaborative and engaging manner Make evidence-based recommendations Maintain an open/transparent program Start small, build on success The NSHA ASP team was fully formed in the July 2017. Our early activities have focused on forming the structure of the program and surveying the current Antimicrobial Stewardship (AMS) activities throughout NSHA. A significant focus has been placed on our communication strategy and presentations to introduce the NSHA ASP to all healthcare workers. In addition, our ASP pharmacists have been receiving Infectious Diseases and AMS training through online courses and observerships within NSHA and abroad. We have established zonal subcommittees with oversight by the NSHA ASP Steering Committee (see organizational chart below). These committees are multidisciplinary including pharmacists, physicians (representing a variety of services), microbiology, nursing, infection prevention and control (IPAC), and quality improvement. A strategic plan has been developed and approved by our sponsors. This plan outlines the vision, structure, and planned initiatives of this program. There is cross representation on the NSHA Antimicrobial Subcommittee. The Strategic Plan is currently being updated for the next 3 years. In addition, we have spent significant time obtaining quality, validated antimicrobial use, process, and outcomes measures. This task has been complicated by different electronic medical record (EMR) systems across NSHA. We have been working with Meditech to obtain reliable dispensing data (Defined Daily Dose (DDD) and/or Days of Therapy (DOT)) outside of Central Zone. The DOT reports have been finalized and are available in this report. The DDD reports are nearly finalized and should be available for the next quarter. Within Central Zone, DDD and cost data is available. Once we have obtained dispensing AMU data, data will be validated over the next 6 to 12 months using secondary data sources and manual chart review. We have initiated NSHA-wide initiatives based on baseline stewardship activities, level of ASP pharmacist training, and a point prevalence survey conducted in 2015 (Black E, Neville H, Losier M, Harrison M, Abbass K, Slayter K, Johnston K, Sketris I. CPJ. 2017; 150(4):S35) We have successfully met the five tests for compliance for the Accreditation Canada Antimicrobial Stewardship required organizational practice (ROP). 1

NSHA ASP Structure Interventions The main clinical focus of the NSHA ASP is prospective audit and feedback with academic detailing. Prospective audit and feedback (PAF) is a core clinical strategy of ASPs. PAF occurs in two intensive care units in the Eastern Zone (Cape Breton Regional ICU and CCU). In Northern Zone (Colchester East Hants Health Centre) specific antimicrobials are targeted throughout the hospital. In Central Zone, PAF was initiated in the two medical surgical ICUs (Victoria General (VG) and Halifax Infirmary (HI) sites). For Western Zone, PAF includes the Valley Regional Hospital (VRH) ICU and bacteriuria among inpatients. The NSHA Pharmacist Initiated IV to PO Conversion of Antimicrobials Policy and Procedure was implemented in July/August 2017 with the plan to measure clinical pharmacist utilization and changes in IV rates over time. A Redundant Antimicrobial Therapy Policy has been developed and is now awaiting approval by the Antibiotic Subcommittee (ASC) and Drugs and Therapeutics (D&T). 2

A NSHA Antimicrobial Handbook is being developed and designed (see Guidelines below). With the amalgamation of health authorities, there has been the need to review the formularies across the province. We have done a review of these formularies to streamline the unified NSHA formulary. Guidelines for appropriate use of 36 antimicrobials have been developed and are awaiting approval by ASC and D&T. Collaborating with Dalhousie Academic Detailing services to update outpatient antibiotic guidelines for common infections in the community. The planned competition date is November 2018. Pre-printed Order (PPO) management is handled through representation on NSHA Antimicrobial Subcommittee (ASC) of the Drugs and Therapeutics Committee. Zone IV to PO PAF SUMMARY OF INTERVENTIONS Handbook Guidelines Antibiogram Formulary Review Cascading sensitivities Eastern CBRH Western VRH Northern Colchester Central HI/VG PAF: prospective audit and feedback Future interventions are currently being developed as part of our strategic plan. 3

Results & Metrics Website traffic: April: 367 page views (299 unique views) 18% decrease from March May: 436 page views (362 unique views) 16% increase from April June: 476 page views (380 unique views) 9% increase from May 600 500 400 300 200 100 Website Use 0 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Page views Unique Page views NORTHERN Colchester AMS PAF Intervention Outcomes FY 2018-2019 QTR1: Total Number of Interventions (April 1 st to June 30 th 2018): 15 Agree: 33%; Disagree: 27%; AMS Team Agreed with Intervention (Continue Therapy): 40% PAF Outcomes CEHHC FY 2017/2018 Q1 Type of Service Attending PAF Cases Continue 40% Agree 33% Hospitalist 47% Surgeon 53% Disagree 27% 4

Cumberland NUMBER OF SUGGESTED CHANGES BY CATEGORY OF RECOMMENDATION 25 20 15 10 5 0 NUMBER OF SUGGESTED CHANGES DOSE CHANGE DRUG CHANGE IV TO PO STOP DRUG 20 22 5 3 ACCEPTANCE OF SUGGESTIONS 69% 16% 16% NO YES NOT TRACKED 5

EASTERN In Eastern Zone, the antimicrobial interventions performed by clinical pharmacists is recorded in Meditech. 1st Quarter 2018 Renal/hepatic dose adjustment Labs/imaging recommended Escalate therapy Dose optimization De-escalation Duration optimization Change empiric therapy IV to PO Discontinue abx 0 10 20 30 40 50 No. accepted No. pharmacist interventions Total documented antimicrobial-related interventions: 191 Total accepted interventions: 151* (see next two bullets) Not included in table: 9 allergy interventions / confirmations documented resulted in either monitoring or change of therapy; not recorded as accepted because n/a Renal / Hepatic interventions: Interventions recorded by pharmacists to confirm appropriate dosing are not recorded as MD accepted because a change to the original antimicrobial order was not required. However, they are recorded as part of the total no. of interventions. Antimicrobial indications recorded / documented on the patient Meditech profile: Total for Zone: 753 6

Western Zone 25 20 15 10 5 0 AMS Acceptance Rates Dose Drug Duration Deescalation Discontinuation Total Total Accepted Acceptance Rate = 96% Days of Therapy (DOT) Days of therapy is a metric used to measure consumption of antimicrobials. It represents simply the number of days that patient is on an antibiotic, regardless of the dose. This makes it advantageous over Defined Daily Doses in renal dysfunction as well as pediatric populations. The following tables report the DOT collectively for the zones of Eastern, Northern and Western. It contains use of antimicrobials for admitted patients. It would exclude the doses of antimicrobials that would be given in the ER prior to admission and doses of given in the OR for surgical prophylaxis. 7

DOT / 100 BED DAYS 9 8 EZ NZ WZ 7 6 5 4 3 2 1 0 CEFTRIAXONE/ CEFOTAXIME METRONIDAZOLE LEVOFLOX/MOXIFLOX PIPTAZO CEFAZOLIN CIPROFLOXACIN AMOXCLAV VANCOMYCIN CEPHALEXIN AZITHRO/CLARITHRO CEFUROXIME DOXYCYCLINE AMOXICILLIN TMP-SMX AMPICILLIN MEROPENEM NITROFURANTOIN 60 50 40 30 20 10 0 Total DOT/100 BED DAYS by Quarter EZ NZ WZ Q4 2017/18 Q1 2018/19 CENTRAL Biofire Trial The Biofire uses multiplex PCR to provide early identification of bacteria and some resistance mechanisms including: MRSA (meca), VRE (vana/b), and Klebsiella pneumoniae carbapenemase (KPC). The AMS team in Central Zone did a trial to identify if earlier identification of microorganisms and feedback to prescribers with results could impact antimicrobial prescribing. Study Period Feb 2018 May 2018 174 positive blood cultures reviewed by AMS team 73% of interventions were narrowing antimicrobial therapy 8

When AMS recommendations were accepted 57% of patients received cefazolin as final therapy Median duration of antibiotic use was shorter when AMS intervention was accepted ASP started PAF in mid-july 2017 (Q2) at VG and HI ICUs. Below we summarize the 5 most commonly used antimicrobials for Q1 in each ICU (per DDD/100 bedday). In addition, we graphed the use of broad spectrum antimicrobials by quarter. Finally, we included tables of overall antimicrobial use and cost by quarter. VG ICU: There is an ongoing downward trend in all antibiotic use including piptazo and meropenem. Vancomycin has decreased as well. Total cost has decreased consistently. HI ICU: Overall antibiotic use has increased from last quarter although cost slightly decreased. There was more broad-spectrum use, particularly meropenem. Much of this use was for a few patients with cystic fibrosis receiving high doses and multi-drug therapy. 9

VG ICU VG ICU TOP 5 ANTIMICROBIALS Q1 Rank Drug Route DDD/100 bedday Cost/100 bedday 1 Vancomycin IV 13.0 128.4 2 Piptazo IV 11.8 209.9 3 Cloxacillin IV 11.4 26.8 4 Fluconazole IV 10.8 67.8 5 Cefazolin IV 8.4 33.3 VG ICU Antimicrobial Summary Total Antimicrobial Cost Total Antimicrobial costs/ Total Antimicrobial DDDs/ 100 beddays 100 bed days FY17-18 Q1 $26,709 $4,474 240.60 Q2 $13,389 $2,457 156.76 Q3 $10,549 $1,939 141.89 Q4 $15,529 $2,505 147.80 FY18-19 Q1 $11,543 $2,158 127.54 Systemic Antibacterial Systemic Antibacterial Systemic Antibacterial Cost costs/ 100 beddays DDDs/ 100 bed days FY17-18 Q1 $7,515 $1,259 106.17 Q2 $7,180 $1,317 113.33 Q3 $5,253 $966 95.98 Q4 $7,223 $1,165 115.99 FY 18-19 Q1 $4,091 $765 91.83 Systemic Antifungal Cost Systemic Antifungal Systemic Antifungal costs/ 100 beddays DDDs/ 100 bed days FY17-18 Q1 $17,827 $2,986 66.83 Q2 $929 $173 34.59 Q3 $4,396 $808 38.42 Q4 $6,669 $1,076 19.92 FY18-19 Q1 $3,267 $611 21.40 25 20 VG ICU DDD/100 BEDDAYS Q1 Q2 Q3 Q4 Q1 35 30 VG ICU (antifungals) DDD/100 BEDDAYS Q1 Q2 Q3 Q4 Q1 25 15 20 10 15 5 10 5 0 Piptazo Meropenem Vancomycin Ceftriaxone Cipro IV 0 Fluc IV Fluc PO Micafungin

HI ICU HI ICU TOP 5 ANTIMICROBIALS Q1 Rank Drug Route DDD/100 bedday Cost/100 bedday 1 Meropenem IV 19.8 282.9 2 Cefazolin IV 17.8 69.3 3 Vancomycin IV 14.1 142.7 4 Ceftriaxone IV 11.7 32.4 5 Piptazo IV 10.0 175.2 HI ICU Antimicrobial Summary Total Antimicrobial Cost Total Antimicrobial costs/ Total Antimicrobial DDDs/ 100 beddays 100 bed days FY17-18 Q1 $10,513 $1,268 153.56 Q2 $12,674 $1,491 147.64 Q3 $10,711 $1,260 141.07 Q4 $16,267 $1,865 151.25 FY18-19 Q1 $14,278 $1,700 163.30 Systemic Antibacterial Systemic Antibacterial Systemic Antibacterial Cost costs/ 100 beddays DDDs/ 100 bed days FY17-18 Q1 $8,059 $972 124.05 Q2 $10,179 $1,198 130.43 Q3 $8,553 $1,006 113.65 Q4 $10,279 $1,179 103.27 FY18-19 Q1 $11,124 $1,324 135.15 Systemic Antifungal Cost Systemic Antifungal Systemic Antifungal costs/ 100 beddays DDDs/ 100 bed days FY17-18 Q1 $753 $91 6.39 Q2 $1,361 $160 11.29 Q3 $778 $92 11.29 Q4 $2,953 $339 8.83 FY18-19 Q1 $1,325 $158 6.96 HI ICU DDD/100 BEDDAYS 25 Q1 Q2 Q3 Q4 Q1 20 15 10 5 0 Piptazo Meropenem Vancomycin Ceftriaxone Cipro IV 11

Outcomes Data *Data not available, delay in reporting from Q1. Will include in next report. 12

Education Eastern Zone: Presentation on ESBL Education Session with Critical Care Nurses by EZ AMS Pharmacist AMS rotation for 1 Infectious Diseases Fellow Research Collaborating with Emily Black of Dalhousie Pharmacy Department for NSHA Research Foundation Establishment Grant: Optimizing Antimicrobial Stewardship Interventions to Improve Management of Urinary Tract Infections in Hospitalized Adults Project to modify laboratory reporting to minimize treatment of asymptomatic bacteriuria: Pilot Project to Reduce the Unnecessary Use of Antibiotics in Patients with Asymptomatic Bacteriuria Working to support a variety of residency (MD and pharmacy) research projects Developing a research proposal on Characterizing Outpatient Antimicrobial Use in Nova Scotia. This will use data collected in the Drug Information System to quantify antimicrobial use in Nova Scotia and develop feedback tools to prescribers. Guidelines NSHA Antimicrobial Handbook The formation of a NSHA Antimicrobial Handbook was initiated prior to the formation of the NSHA ASP by the Central Antimicrobial Agents Subcommittee. This handbook will provide guidance on antimicrobial use for a broad range of syndromes. It will also include information on best practices, therapeutic drug monitoring, and surgical prophylaxis. Updates will be done by priority of topic to facilitate workflow and approval. The first topic (Staphylococcus aureus bacteremia) is approved and posted on the AMS website, Candida bloodstream infections, meningitis, aminoglycosides, vancomycin, asymptomatic bacteriuria, and uncomplicated cystitis are under review and waiting approval from ASC. Academic detailing: collaborating to update the Dalhousie Academic Detailing curriculum for common outpatient Infectious Diseases syndromes. Microbiology Antibiogram for all zones have been updated and are posted on the AMS website. We are exploring options to stratify the antibiogram by patient location/type A template has been developed to unify antibiograms across NSHA. We have improved on our time to identification of blood culture isolates using rapid diagnostic technologies. This currently is being done with direct identification of positive blood culture bottles using our MALDI-TOF-MS in Central Zone. Developing a pilot project in conjunction with the Hospitalist Medicine Unit (8.4 at the Halifax Infirmary) to improve the processing of specimens in the microbiology lab to minimize reporting and treated for asymptomatic bacteriuria. Site visits to peripheral labs by Dr. Davis. Representation on the Susceptibility testing subcommittee of the Microbiology Service Advisory Committee Other Activities NSHA ASP website live on May 6, 2017 Frequently updated as material becomes available 13

Strategic Planning Collaborating with other Atlantic Canadian stewardship programs Collaborating with other Choosing Wisely Collaborate with Department of Health and Wellness (DHW) Nova Scotia AMS Co-Leads worked with World Health Organization (WHO) to develop an AMS toolkit for Low to Middle Income Countries. Acknowledgements Executive sponsors: Dr. Lynne Harrigan (VP Medicine & Integrated Health Services) and Colin Stevenson (VP Quality, System Performance and Transformation) Gail Blackmore (Senior Director Quality Improvement, Safety, Patient Relations), Dr. Steven Soroka (Senior Medical Director Pharmacy Services), and Glenn Cox (Senior Director Pharmacy Services) Dr. Todd Hatchette: Chief of the Division of Microbiology in the Department of Pathology and Laboratory Medicine Dr. Shelly McNeil, Division Head Infectious Diseases Tammy MacDonald, Central Zone Director, Quality Improvement, Safety & Patient Relations and NSHA Infection Prevention and Control Lead Heather Neville & Stephen MacKay, analyzing antibiotic use metrics Emily Black: collaborating and sharing study results SHS-UHN ASP: sharing resources, education of team members, and collaborations David Evans: Application Specialist Meditech Pharmacy Program 14