Presenter: Marc Meyer, BPharm, RPh, CIC, FAPIC Clinical Pharmacists, Infection Preventionist, Antibiotic Stewardship Pharmacist Southwest Health System, Cortez, Colorado
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How do AU vendors and NHSN AU work to drive stewardship efforts? Is infection prevention an important part of ASP? Does ASP save money? Be able to describe stewardship efforts in hospital, LTC, clinic, and dental settings. Be able to promote the value of community stewardship efforts.
Pharmacist-led antimicrobial stewardship SHS serves about 50,000 people in rural southwest Colorado, and in parts of Utah, Arizona, and New Mexico, including the Ute Mountain Ute and Navajo reservations. SHS has 25 inpatient beds and ten clinics.
The Review on Antimicrobial Resistance, 2014
The Review on Antimicrobial Resistance, 2014
$20 billion in added direct healthcare costs annually CDC. Antibiotic resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/
2011-14 antibiotic prescribing All ages: decreased 5% Pediatric: decreased 14% Adults: no change
Asolva Medici www.asolva.com Medici AU costs $1 per bed per month Pulls three files, MAR, Transfer, Admission Customizable antibiotic usage data Uploads to NHSN AU Free trial period Medici ASP costs $5 per bed per month Daily antibiotic and lab usage tool Customizable, broad-spectrum, time-outs, DOT Free trial period NHSN AU Upload CDA files from Medici AU into NHSN Benchmarking, SAAR (standardized antimicrobial administration ratio), rate days present NHSN LTC UTI and LabID
540 hospitals enrolled 46 states and DC 46 CAH 97 <50 beds
1.4 1.2 1 0.8 0.6 SHS ALL SAAR MS <25 beds SHS Mean Linear (SHS ALL SAAR MS) 0.4 0.2 0
1.4 1.2 1 0.8 0.6 SHS ALL SAAR ICU <25 beds SHS Mean Linear (SHS ALL SAAR ICU) 0.4 0.2 0
Arjun Srinivasan MD Associate Director for Healthcare Associated Infection Prevention Programs at the CDC Want to halt the spread of antibiotic resistance? Think infection prevention. Antibiotic stewardship and infection control need to be seen as inseparable sides of the same coin. Let s look at some data
Effect of antibiotic stewardship on the incidence of infection and colonization with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis The Lancet, June 2017
? I believe ASP s are patient safety programs and it s all about doing what is right for the patient. But let s take a look at some data and you decide!
According to the CDC, implementation of infection control and antibiotic stewardship will, in 5 years: Reduce MDR HAIs or CDI deaths by 37,000. Reduce MDR HAIs or CDI infections by 619,000.
DOT: MS, ICU, ED 450 400 350 DOT 300 250 Mean 200 150 100 Linear (DOT) 50 0 SHS SHS SHS SHS SHS SHS SHS SHS SHS SHS SHS Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 17-Aug 17-Sep 17-Oct 17-Nov
700 600 RateDaysPresent all locations 500 400 AU Mean 300 SHS Mean 200 100 Linear (RateDaysPresent all locations) 0
50 40 RateDaysPresent Etrapenem 30 SHS Mean 20 10 0 Linear (RateDaysPresent Etrapenem) -10
80 70 60 RateDaysPresent cefazolin 50 40 SHS Mean 30 20 10 Linear (RateDaysPresent cefazolin) 0 2016M01 2016M02 2016M03 2016M04 2016M05 2016M06 2016M07 2016M08 2016M09 2016M10 2016M11 2016M12 2017M01 2017M02 2017M03 2017M04 2017M05 2017M06 2017m07 2017M08 2017M09 2017M10 2017M11
140 120 RateDaysPresent ceftriaxone 100 AU Mean 80 60 SHS Mean 40 20 Linear (RateDaysPresent ceftriaxone) 0
Community-acquired pneumonia Nosocomial pneumonia Pyelonephritis Intra-abdominal infection Acute exacerbation of chronic bronchitis and COPD Acute bacterial sinusitis Cellulitis Chronic osteomyelitis 5-7 days 8-10 days 5-7 days 4 days 5-7 days 5-7 days 5-7 days 45 days JAMA Internal Medicine September 2016 Volume 176, Number 9, The New Antibiotic Mantra- Shorter Is Better
Yes
Pick your area of concern from your data. Do a search of professional societies for current guidances that match your area of concern. Pull current papers on your topic since the guidance was published; if no guidance is available, develop yours based on the studies. Consider a collaborative effort with another hospital, clinic, LTC, hospital association, LTC association, APIC, or pharmacy groups. You have a packet with all guidances we have used in the projects being discussed today.
Keep them simple and measureable. Don t look at too many items in your study. Do your own benchmarking with baseline data or make sure you can obtain a benchmark. Publish your goals and post your progress to your providers and staff. Readjust goals and guidance during the project if needed.
Go slow, be successful! Suggested first projects Form an official stewardship team Antibiogram program UTI, SSTI, URI, CAP/HAP guidance (IDSA, SHEA etc) Guideline-based OR prophylaxis (IDSA, APHA, SHEA, College of Surgeons) Restrict your formulary Monitor new antibiotic IV starts Monitor antibiotic total monthly costs DOT monitoring if feasible Choose an antibiotic class to monitor Review your handwashing program Antibiotic timeouts Daily patient care rounding as a team
20% reduction from baseline in duration of treatment 30% reduction in inappropriate antibiotic selection Monitor C. difficile rates using NHSN Education event There will be a paper coming out soon with this data for the combined 28 hospitals
CHA UTI Baseline (63) Intervention (110) 9 9 7 6 5 4 Total DOT Inpatient DOT Discharge DOT
CHA UTI Baseline Intervention 72% 44% 41% 49% 20% 19% 21% 21% 0% 2% 2% 3% 7% 9%
Reduction from baseline in duration of treatment Reduction from baseline in broad gram-negative antibiotic use Monitor C. difficile rates using NHSN Education event
CHA SSTI Baseline (8) Intervention (25) 11 9 7 7 4 3 Total DOT Inpatient DOT Discharge DOT
CHA SSTI Baseline Intervention 72% 50% 38% 13% 16% 12% 13% 20% 25% 25% 12% 24% 0% 0% 0% 0%
Goals Decrease DOT to 5-7 days adults, 7 to 14 days pediatrics Decrease quinolone use over baseline Education events Pediatric, Jason Newland, MD Adult, Katherine Fleming-Dutra, MD
10 9 9 9 8 8 7 6 6.5 6.6 5.9 5 4 Baseline UTI DOT Intervention 1 UTI DOT 3 2 1 0 DOT Adult DOT Ped DOT
50 45 43 40 35 30 25 30 29 26 30 28 Baseline UTI RX RATE 20 Intervention 1 UTI RX RATE 15 10 5 0 RX Rate Adult Rate Ped Rate
45 40 40 35 30 30 29 31 25 20 Baseline UTI Quin Rate Intervention 1 UTI Quin Rate 15 10 9 8 5 0 Quinolone Rate Adult Quinolone Rate Ped Quinolone Rate
Specialty # of RX in millions (%) RX/1000 Family Practice 64.6 (25) 672 Pediatrics 33.2 (13) 612 Internal Med 32.5 (13) 388 Dentistry 25.7 (10) 209 Nurse Practitioner 16.9 (7) 154 Hicks L A et al, N Engl J Med 2013 308 1461-1462
Antibiotic #mil % Per 1000 Amoxicillin 13.8 56.3 43.6 Clindamycin 3.53 14.4 11.2 Penicillin 3.24 13.2 10.2 Cephalexin 1.19 4.9 3.8 Azithromycin 1.14 4.7 3.6 Amox/Clav.56 2.3 1.6 Doxycycline.43 1.7 1.4 Ciprofloxacin.16.6.5 Erythromycin.09.4.3 SMZ/TMP.05.2.2 Hicks L A et al, N Engl J Med 2013 308 1461-1462
Antibiotic treatment is essential to treat septicemia Clinical signs include pyrexia, trismus, significant regional lymphadenopathy, gross facial swelling, closure of the eye, dysphagia, tachycardia, and rigors Historically, antibiotics have been prescribed in courses between 5 and 10 days duration. It is becoming increasingly evident that long courses of antibiotics are not required and may destroy the homeostasis of the oral micro-flora and lead to colonization resistance Usually they can be discontinued after 2 to 3 days
Following drainage and removal of the cause of infection, a three-day standard dose antibiotic regime was effective in the management of the acute dentoalveolar abscess in all reviewed patients The predominant organisms isolated from dentoalveolar abscesses derived from the periodontal tissues are obligate anaerobes Those derived from periapical tissues are mixed infections British Dental Journal 2011;211:591-594 S. J. Ellison
Prescribe only when clinical signs and symptoms of infection are present (fever, swelling, etc.) Use the most narrow-spectrum antibiotic for the shortest duration possible Revise antibiotic regimens based on patient progress and culture if needed Collaborate with referring specialist about prescribing protocols Fluent, Jacobson, Hicks: Considerations for Responsible Antibiotic Use in Dentistry, JADA 2016
20% reduction in total UTI s treated with antibiotics 20% reduction in total antibiotic days Shift the use of primary antibiotic away from fluoroquinolones to less broad spectrum agents Questions Can guidance and education, along with support, foster a stewardship environment in LTC? Does guidance have impact on cases meeting NHSN definition? Education event
12 10 8 9 8 7 7 7 10 6 Pre-intervention Intervention 4 2 0 DOT DOT No culture DOT Culture
45% 40% 39% 41% 35% 30% 32% 33% 25% 20% 15% 10% 5% 0% 20% 12% 11% 11% 9% 9% 9% 7% 6% 1% Cephalosporin Quinolone Nitrofurantoin SMZTMP Abx changes Abx resistant Quinoline ordered, ceph sensitive Pre-intervention Intervention
27% Reduction 350 300 250 200 150 320 UTI DX EMR 100 233 50 0 Pre-intervention Intervention
Can guidance and education, along with support, foster a stewardship environment in LTC? Yes, reduction in DOT (22%) and UTI Dx (27%) Does guidance increase cases meeting NHSN definition? No, 17% decline in case completion Can you use NHSN to drive stewardship projects? Yes, custom data along with regular fields They will move forward with a Phase Two project
2.5 2 <25 Beds 1.5 SHS MS MRSA SAAR 1 SHS Mean 0.5 Linear (SHS MS MRSA SAAR) 0 2017M012017M022017M032017M042017M052017M062017M072017M082017M092017M102017M11
120 100 RateDaysPresent Vancomycin 80 AU Mean 60 SHS Mean 40 20 Linear (RateDaysPresent Vancomycin) 0 2016M01 2016M02 2016M03 2016M04 2016M05 2016M06 2016M07 2016M08 2016M09 2016M10 2016M11 2016M12 2017M01 2017M02 2017M03 2017M04 2017M05 2017M06 2017M07 2017M08 2017M09 2017M10 2017M11
41 cases reviewed, mostly cellulitis 15% had a prior MDRO 17% had no culture 24% not de-escalated 58% met stewardship definition MRSA 17%, E faecalis 7% 60% sensitive to cefazolin We recommended that cefazolin be the drug of choice for cellulitis without history of prior MDRO or complications
2 1.8 Mean <25 Beds 1.6 1.4 1.2 SHS SAAR MS MDRO 1 0.8 SHS Mean 0.6 0.4 0.2 Linear (SHS SAAR MS MDRO) 0
120 100 RateDaysPresent Pip/Tazo 80 AU Mean 60 40 SHS Mean 20 Linear (RateDaysPresent Pip/Tazo) 0 2016M01 2016M02 2016M03 2016M04 2016M05 2016M06 2016M07 2016M08 2016M09 2016M10 2016M11 2016M12 2017M01 2017M02 2017M03 2017M04 2017M05 2017M06 2017M07 2017M08 2017M09 2017M10 2017M11
70% Pip/Tazo Audit 60% 60% 60% 50% 40% 37% 30% Pip/Tazo 20% 21% 10% 0% MDRO Culture De-escalated Meets Stewardship Increase our efforts to de-escalate antibiotic choice Increase our education of provider staff on days of therapy needed to treat
Clinic stewardship Hospital stewardship LTC stewardship Dental stewardship Can they make an impact in small communities? You decide?
10 9 9 9 8 8 7 6 6.5 6.6 5.9 5 4 Baseline UTI DOT Intervention 1 UTI DOT 3 2 1 0 DOT Adult DOT Ped DOT
20 18 16 14 12 10 8 SSI Infections Rate per 1000 Linear (SSI Infections) Linear (Rate per 1000) 6 4 2 0 Year 13 Year 14 Year 15 Year 16 Year 17
11 9 CHA SSTI Baseline (8) Intervention (25) 7 7 4 3 CHA UTI Total DOT Inpatient DOT Discharge DOT 9 Baseline (63) Intervention (110) 9 5 4 7 6 Total DOT Inpatient DOT Discharge DOT
500 400 300 200 DOT Mean Linear (DOT) 100 0 50 40 30 20 RateDaysPresent Etrapenem SHS Mean 10 0 Linear (RateDaysPresent Etrapenem) -10
12 10 8 9 10 8 7 7 7 6 4 Pre-intervention Intervention 2 0 DOT DOT No culture DOT Culture 27% Reduction UTI DX 350 300 250 200 150 100 50 0 320 233 UTI DX EMR
90 80 LTC project launch 70 60 50 40 Clinic Project Launch MDR Mean 30 20 10 0 MDR tracking began SSTI and UTI Hospital project Stewardship team officially formed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Stewardship along with infection prevention does save the health system money. Stewardship is a data-driven quality learning process for all areas of the medical system. The bulk of antibiotics are prescribed in the community setting, not the hospital. We need to fine-tune antibiotic usage in all care settings.
Marc J. Meyer R.Ph, BPharm, CIC, FAPIC 970-564-2194 Office mmeyer@swhealth.org