Grey Nuns Community Hospital (GNCH) Antimicrobial Stewardship Report

H e a l i n g t h e B o d y E n r i c h i n g t h e M i n d N u r t u r i n g t h e S o u l Grey Nuns Community Hospital (GNCH) Antimicrobial Stewardship Report to 214

Table of Contents I. Introduction.. 3 II. CHASC Antimicrobial Utilization Reports 4 III. Executive Summary 6 IV. GNCH Antimicrobial Utilization Reports and Piperacillin-tazobactam audit and feedback 8 A. Total GNCH Antibiotic DDD and Expenditures 8 B. Emergency Department... 13 C. Home Parenteral Therapy... 17 D. Intensive Care Unit.. 2 E. Outpatient IV Clinic.. 23 F. Medicine... 26 G. Surgery... 3 V. Clostridium difficile Prospective Audit and Feedback. 33 VI. Glossary.. 34 Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 2

Covenant Health Antimicrobial Stewardship Report GNCH 214 I. Introduction Antibiotics are among the most commonly prescribed medications in acute care centres (Figure 1), yet can result in unintended patient toxicities, selection of pathogenic organisms, such as C. difficile and promotion of antibiotic resistance. Figure 1. Grey Nuns Community Hospital Drug Expenditures - 214 Antimicrobial Expenditures Total Drug Expenditures 14% 86% Antimicrobial Stewardship is an interdisciplinary activity that promotes the optimization of antibiotic selection, dose, route and duration in order to improve patient clinical outcomes and safety, minimize antibiotic adverse effects and toxicity, decrease the selection of pathogenic organisms and reduce antibiotic resistance rates. An effective Antimicrobial Stewardship Program (ASP) has been demonstrated to achieve the above outcomes and as of 213, has been mandated as a Required Organizational Practice by Accreditation Canada. The Covenant Health Antimicrobial Stewardship Committee (CHASC) was developed in 213 and has since implemented several initiatives. Evaluation of the program has been scheduled for 214. The following is a list of the initiatives that the Covenant Health Antimicrobial Stewardship Committee (CHASC) has implemented since 213: 1. Formulary Restriction and Preauthorization for daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline 2. Development and distribution of an annual Covenant Health Pocket Antibiogram 3. Prospective Audit and Feedback of piperacillin-tazobactam and other antimicrobials 4. Development of a C. difficile (CDI) Preprinted Care Order (PPCO) with Prospective Audit and Feedback 5. Collation of Antibiotic Utilization Data 6. Circulation of a Covenant Health Antimicrobial Stewardship e-newsletter (CHASE) quarterly 7. Wide distribution and posting of formulary guidelines for the carbapenems and piperacillin-tazobactam Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 3

II. CHASC Antimicrobial Utilization Reports Antibiotic use at Covenant Health acute care sites is collated and examined by CHASC on a quarterly basis in conjunction with data collected from prospective audit and feedback and the restricted antibiotic preauthorization form in order to: Identify any antibiotic utilization trends or areas in need of intervention on a site and service-specific basis. Ensure that the use of broad-spectrum antibiotics is guideline concordant. Generate bi-annual reports summarizing antibiotic trends and CHASC recommendations for prescribers as direct feedback on their antibiotic use. Methods Data on antibiotic use is extracted directly from Centricity (pharmacy computer system). When determining whether an antibiotic has been prescribed in a guideline-concordant fashion, clinical information acquired from the antibiotic preauthorization form and/or prospective audit and feedback performed by the antibiotic stewardship pharmacists is compared to the provincial formulary recommendations. Drug utilization data is provided in both DDD (Defined Daily Dose) and expenditures. DDD is a World Health Organization measure of drug consumption. The definition is the assumed average maintenance dose per day for a drug used for its main indication in adults. It relates all drug use to a standardized measure which is equivalent to one day s worth. DDD allows us to compare antibiotic use across different classes despite differences in potency and dosing. Examples: The usual dose of ertapenem is 1 g IV daily therefore every 1 gram of ertapenem is equivalent to one DDD. The usual dose of clindamycin is 6 mg IV every 8 hours therefore every 18 mg is equivalent to one DDD. In the near future, data will be presented as DDD/patient days to account for fluctuations in patient volume and therefore antibiotic prescribing. Summary of GNCH Services included: Emergency Home Parenteral Therapy Intensive Care Unit Intravenous Therapy Clinic Medicine which includes Palliative Care, Stroke, Geriatrics, Family and Internal Medicine Surgery which includes Vascular Surgery, General Surgery, Plastic Surgery, and Gynecology Antibiotic Groupings: Antibiotic utilization is provided in three graphical formats. 1. Total drug DDD and expenditures for the hospital and by service 2. Antibiotic classes as follows: Carbapenems ertapenem, imipenem and meropenem Cefazolin Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 4

Cephalosporins (3 rd generation) ceftriaxone, ceftazidime and cefotaxime Clindamycin Fluoroquinolones ciprofloxacin, levofloxacin and moxifloxacin Piperacillin-tazobactam Vancomycin 3. Restricted antibiotics (daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline) and piperacillin-tazobactam Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 5

III. Executive Summary Antibiotic utilization data is provided for the one year period of 213 to 214. Data on guideline concordance rates for the six restricted antibiotics (daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline) is provided for the period of 1 to 3, 214. The restricted antibiotic order form took effect in 213. Data on piperacillin-tazobacam prescribing, including indications, guideline concordance rates, and rate of streamlining is presented from 1 to 3, 214. The C. difficile (CDI) Pre-printed Care Order (PPCO) was introduced in 213 in conjunction with prospective audit and feedback of all new CDI cases. Data on degree of guideline-concordant treatment and PPCO use is provided for the period of 1 to 3, 214. Overall Antibiotic Use: Overall GNCH antibiotic use has remained stable over the period of 213 to 214. Cephalosporins continue to be the most commonly prescribed antibiotics. There has been an overall decline in the use of carbapenems. Piperacillin-tazobactam use has remained high and as a result has been targeted with prospective audit and feedback. Restricted Antibiotics: Ertapenem is the most commonly prescribed restricted antibiotic although the use has declined from 213 to 214 due to a reduction in use in the Emergency Department (ED) and IV Clinic. The remainder of the restricted antibiotics were used at low levels. Compliance with the Restricted Antibiotic Preauthorization Form and Guideline Concordance Rates: Overall compliance with the restricted antibiotic form continues to be excellent with an overall rate of 93%. Surgery, HPT and ICU have demonstrated 1% compliance. Guideline concordance for the restricted antibiotics was determined using the restricted antibiotic preauthorization forms. For the period of 1 to 3, 214, there were 22 orders for a restricted antibiotic of which 193 adhered to formulary guidelines (88% guideline concordance rate). Piperacillin-tazobactam audit and feedback: Piperacillin-tazobactam is one of the most frequently prescribed antibiotics at GNCH and has been targeted for audit and feedback. Despite high use, it is primarily being prescribed in a guideline concordant manner [144/149 (97%)]. 85/149 (56%) piperacillin-tazobactam orders were streamlined in 2.2 days on average which achieves the de-escalation target of 48 72 hours that was set out in the last bi-annual report. The remaining 65 patients completed a full piperacillin-tazobactam course that was deemed appropriate. C. difficile (CDI) audit and feedback: Prospective audit and feedback is performed on all new CDI cases to ensure treatment is guideline concordant. CDI audits from to 214 on 53 patients demonstrate initial guideline concordant therapy in 89% of patients. This increased to 98% with ASP pharmacist interventions. Additionally, acid Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 6

suppressive therapy was appropriately stopped in 7 cases by the ASP pharmacist. The CDI PPCO was used in only 4% of cases. Recommendations: Continue the excellent rates of compliance in filling out the restricted antibiotic preauthorization form. Continue the judicious use of the six restricted antibiotics by ensuring that these broad-spectrum antibiotics are only being used for formulary approved indications and are narrowed upon culture availability if possible. Continue guideline concordant prescribing of piperacillin-tazobactam with continued de-escalation within 48 to 72 hours according to culture availability and the patient s clinical status. Work with IPC and the Acute Care CDI Task Force Committee to improve compliance with the use of the CDI PPCO. Please refer to the service-specific section of this report for further details regarding service-specific prescribing and Antimicrobial Stewardship recommendations. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 7

IV. GNCH Antimicrobial Utilization Reports A. Total GNCH Antibiotic DDD and Expenditures 213 214 (Figure 2) Parenteral antibiotics account for the majority of the utilization and expenditures hospital-wide. Overall antibiotic use has remained stable for the period 213 to 214. Ertapenem is the most commonly prescribed restricted antibiotic although rates have decreased from 584 to 283 DDD ($3,5 to $14,8) with a nadir of 146 DDD in 214. Compliance with the restricted antibiotic preauthorization form was excellent with a 93% (25/22) completion rate. Overall, the restricted antibiotics were being prescribed appropriately with 87% (193/22) being guideline concordant (Table 1). Guideline concordant use of ertapenem could be improved on in the ED. Piperacillin-tazobactam use remains high but is stable and prescribed primarily in a guideline concordant manner. The most common indications were intra-abdominal infections, hospital acquired pneumonia, and sepsis NYD. There were 149 orders for the months of and 214 with a guideline concordance rate of 97% (144/149) (Table 2). 57% (85/149) of piperacillin-tazobactam orders were deescalated primarily by the attending team in an average of 2.2 days (Table 3). In the remaining patients (64/149), the treatment course was completed with piperacillin-tazobactam and deemed guideline concordant. A Guidelines for Use poster for piperacillin-tazobactam, ertapenem, imipenem and meropenem was widely distributed throughout the hospital to assist with education on the use of these broad spectrum antibiotics. Recommendations: Continue to use the six restricted antibiotics judiciously in a guideline concordant manner. CHASC to continue to follow piperacillin-tazobactam use to ensure guideline concordance and timely de-escalation as appropriate. Optimize the use of ertapenem in the GNCH ED according to formulary guidelines: Ertapenem 1. Empiric therapy of polymicrobial complicated skin and soft tissue infections, including bite wounds 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) β-lactamases or ESBLs where there is resistance to first line agents and documented susceptibility to ertapenem 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing ESBLs 4. Therapy of community-acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone + metronidazole) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 8

Figure 2. GNCH Total Antimicrobial Usage and Expenditures GNCH Total DDD GNCH Total Expenditures 9 8 7 6 5 4 3 2 1 Oral Parenteral $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Oral Parenteral 6 5 4 3 2 1 GNCH DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones $9 $8 $7 $6 $5 $4 $3 $2 $1 $ GNCH Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin Vancomycin GNCH DDD GNCH Expenditures 7 6 5 4 3 2 1 Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $35 $3 $25 $2 $15 $1 $5 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 9

Table 1. Total GNCH Compliance with Preauthorization Form and Guidelines Concordance Rates 1 to 3, 214 Service Restricted Antibiotic Number of Orders Guideline Concordant Form Compliance Recommendations (Number & Percent Accepted) ED Ertapenem 44 29 (65%) 37 (84%) 1 (1%) Imipenem 4 4 (1%) 4 (1%) Meropenem 4 4 (1%) 4 (1%) Total 52 37 (71%) 45 (87%) HPT Meropenem 1 1 (1%) 1 (1%) Total 1 1 (1%) 1 (1%) ICU Ertapenem 1 1 (1%) 1 (1%) Imipenem 25 25 (1%) 25 (1%) Linezolid IV 1 1 (1%) 1 (1%) Meropenem 5 4 (8%) 5 (1%) 2 (1%) Total 32 3 (94%) 32 (1%) IV Clinic Daptomycin 3 3 (1%) 2 (67%) Ertapenem 46 45 (98%) 43 (93%) 2 (1%) Imipenem 3 3 (1%) 3 (1%) Meropenem 1 1 (1%) 1 (1%) 1 (1%) Total 53 52 (98%) 49 (92%) L&D Ertapenem 1 1 (1%) 1 (1%) Total 1 1 (1%) 1 (1%) Medicine Ertapenem 19 19 (1%) 19 (1%) 1 (1%) Imipenem 3 23 (77%) 28 (93%) 3 (67%) Meropenem 1 8 (8%) 9 (9%) 4 (1%) Total 59 5 (85%) 56 (95%) Psychiatry Daptomycin 1 1 (1%) 1 (1%) Ertapenem 1 1 (1%) 1 (1%) Total 2 2 (1%) 2 (1%) Surgery Daptomycin 2 2 (1%) 2 (1%) Ertapenem 13 13 (1%) 13 (1%) Imipenem 4 4 (1%) 4 (1%) 1 (%) Tigecycline 1 1 (1%) 1 (1%) Total 2 2 (1%) 2 (1%) Grand Total 22 193 (88%) 25 (93%) 13/15 (87%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 1

Table 2. GNCH Piperacillin-tazobactam Orders by Service and 214 Vascular UTI SSTI Sepsis Pneumonia Other Osteomyelitis IAI FN Bacteremia Discordant Total Graft NYD (meeting criteria for use) orders CCU 1 1 2 4 ED 1 2 9 4 5 1 5 27 Family 1 1 3 5 1 2 1 1 Medicine 15 General 1 24 Surgery 25 Geriatrics 1 1 ICU 1 3 1 7 21 Infectious 1 1 1 Diseases 3 Internal 3 1 13 1 1 1 4 3 1 Medicine 37 Nurse 1 Practitioner 1 Obs-Gyne 2 2 4 Psychiatry 1 1 Surgery 1 9 Vascular 1 Grand Total 1 8 17 29 32 4 2 44 5 2 5 149 Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 11

Table 3. GNCH Piperacillin-tazobactam Orders and 214 Clinical Number Pip-tazo streamlined Completed course with pip-tazo Indication of piptazo Initiated by: Average # of days Appropriate Not appropriate orders ASP Attending team Sepsis NYD 29 24 1.4 5 Intraabdominal 44 23 2.6 21 infection Pneumonia 35 19 3.2 16 Bacteremia 2 2 1 Polymicrobial 19 1 8 3 1 skin and soft tissue infection Febrile 5 1 2 4 Neutropenia Other 4 2 1 2 UTI 8 4 1.5 4 Osteomyelitis 2 1 4 1 Vascular 1 1 graft infection Total 149 1 84 2.2 64 Discordant orders: 3 pneumonia (not meeting criteria for use) and 2 other (included in the above tally), all streamlined or discontinued. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 12

B. GNCH Emergency Department (ED) Antibiotic Utilization (Figure 3) Drug utilization data was recorded as ED-prescribed if the patient resided in the ED at the time of dispensing. Once the patient was transitioned to an inpatient ward or the GNCH IV Clinic, the drug was thereafter recorded as prescribed from the new location. Therefore, if patients were admitted but remained in the ED for prolonged periods of time on antibiotics, ED utilization data would be affected. In the GNCH ED, oral and parenteral antibiotics were ordered in equal frequency although parenteral antibiotics made up the vast majority of antibiotic expenditures. Overall, antibiotic use appears stable from 213 to 214 with cephalosporins and fluoroquinolones being the most commonly prescribed antibiotics. There was a sustained reduction in the use of carbapenems, mostly mediated by decreased ertapenem use. From 213 to 3, 214, the number of ertapenem DDD declined from 35 to 14 ($178 to $715) with reaching a low of 8 DDD. The remaining restricted antibiotics were ordered in low amounts. Despite the reduction in the use of ertapenem, the guideline concordance rate has decreased to 66% (29/44) for the period of to 214 compared to 79% ( to 213). Ertapenem was frequently ordered for simple cellulitis (non-diabetic with no open polymicrobial wounds) despite cefazolin or once daily ceftriaxone being the more streamlined choice. ED compliance with the restricted antibiotic preauthorization form was good at 83% (Table 4) Piperacillin-tazobactam use has been consistently high in the ED with a guideline concordance rate of 81% (22/27) for the months of and 214 (Table 5). It is most commonly prescribed for sepsis not yet diagnosed (NYD) (Table 2). Recommendations: Improve rates of guideline-concordant ertapenem prescribing in the ED by the following measures: o CHASC will continue with prospective audit and feedback to ED prescribers when ertapenem has been prescribed in a discordant manner to provide education and alternative antimicrobial options. o Table 4 summarizes the discordant ertapenem prescribing in the ED from to 214 for educational purposes. Of note, ertapenem is not warranted for simple cellulitis where the primary pathogens are suspected to be staphylococcus or streptococci. Ertapenem should not be used for convenience purposes. o Ensure that ertapenem is being prescribed according to the below formulary guidelines which have been posted across the hospital including the ED: Ertapenem 1. Empiric therapy of polymicrobial complicated skin and soft tissue infections, including bite wounds 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) β-lactamases or ESBLs where there is resistance to first line agents and documented susceptibility to ertapenem 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing ESBLs 4. Therapy of community-acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone + metronidazole) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 13

Continue with excellent restricted antibiotic form completion rates. Improve guideline concordant prescribing of piperacillin-tazobactam according to the provincial guidelines below: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (eg. intraabdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 14

Figure 3. GNCH ED Antibiotic Usage and Expenditures GNCH ED Total DDD GNCH EDTotal Expenditures 14 12 1 8 6 4 2 Oral Parenteral $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Oral Parenteral 8 7 6 5 4 3 2 1 GNCH ED DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $8 $7 $6 $5 $4 $3 $2 $1 $ GNCH ED Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin GNCH ED DDD GNCH ED Expenditures 7 6 5 4 3 2 1 Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $25 $2 $15 $1 $5 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 15

Table 4. GNCH ED Compliance with Preauthorization Form and Guideline Concordance Rates 1 to 3, 214 Recommendations (Number & Percent Accepted) Restricted Antibiotic Number of Orders Guideline Concordant Form Compliance Ertapenem 44 29 (66%) 35 (8%) 1 (1%) Imipenem 4 4 (1%) 4 (1%) Meropenem 4 4 (1%) 4 (1%) Total 52 37 (71%) 43 (83%) Table 5. ED Piperacillin-tazobactam Order Review 1 to 3, 214 Number of Orders Guideline Concordant 27 22 (81%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 16

C. GNCH Home Parenteral Therapy (HPT) Antibiotic Utilization Data (Figure 4) Home parenteral therapy enables patients to receive intravenous antibiotics at home. Patients can be enrolled in HPT through the Outpatient IV Clinic or from an inpatient hospital unit at the time of discharge. Patients (or their drug coverage plan) are responsible for the cost of these antibiotics. HPT is often used when the duration of therapy is expected to be prolonged; therefore, overall patient numbers are low but due to long courses of therapy, one patient can greatly influence the utilization of a particular antibiotic agent (eg. one patient on ertapenem for 1 weeks results in an increased ertapenem DDD of 7). Overall, cephalosporins were the most commonly used antibiotic. There have been fluctuations over time in use with a recent increase over the past three months. Use of the broad spectrum antibiotics (particularly piperacillin-tazobactam and ertapenem) has declined. The majority of the restricted antibiotic prescribing is initiated in either an inpatient ward or the IV Clinic. Table 6 provides information on the location where the restricted antibiotic was initiated. All restricted antibiotics were guideline concordant and form compliance was 1%. Data on piperacillin-tazobactam guideline concordance is lacking as the patient s therapy was initiated in an area other than HPT, such as an inpatient ward or the IV Clinic, and would therefore have been accounted for in that data set (Table 2 and 3). Recommendations: The use of the six restricted antibiotics is at low levels and is guideline concordant. There are no recommendations required at this time. CHASC needs to reconcile HPT piperacillin-tazobactam use at the time of prescribing for better representation of guideline concordance rates. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 17

Septemb Figure 4. GNCH HPT Antibiotic Usage and Expenditures GNCH HPT Total DDD GNCH HPT Total Expenditures* 9 8 7 6 5 4 3 2 1 Oral Parenteral $18 $16 $14 $12 $1 $8 $6 $4 $2 $ Oral Parenteral 8 7 6 5 4 3 2 1 GNCH HPT DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $18 $16 $14 $12 $1 $8 $6 $4 $2 $ GNCH HPT Expenditures* Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin GNCH HPT DDD GNCH HPT Expenditures* 1 8 6 4 2 Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $5 $4 $3 $2 $1 $ Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Note: patient is responsible for their antibiotic costs Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 18

Table 6. GNCH HPT Compliance with Preauthorization Form and Guideline Concordance Rates 1 to 3, 214 Restricted Antibiotic Guideline Concordant Form Compliance Location Initiated Ertapenem 1 1 Surgery Ertapenem 3 3 IV Clinic Ertapenem 1 1 Medicine Imipenem 1 1 IV Clinic Imipenem 2 2 Medicine Meropenem 1 1 ICU Meropenem 1 1 HPT Total 1 (1%) 1 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 19

D. GNCH Intensive Care Unit (ICU) Antibiotic Utilization (Figure 5) GNCH ICU drug utilization data pertains strictly to the Intensive Care Unit. Coronary Care Unit (CCU) data was collated separately but due to low antibiotic prescribing has not been incorporated into this specific report. If desired, please contact AntimicrobialStewardship@covenanthealth.ca for CCU antibiotic utilization data. Overall, antibiotic prescribing from 213 to 214 is stable with a spike in the month of 214, particularly with the use of piperacillin-tazobactam. This was likely due to increased patient acuity. In general, piperacillin-tazobactam is the most commonly prescribed broad-spectrum antibiotic. The restricted antibiotics have been used at low levels. There were 32 orders for restricted antibiotics with a guideline concordance rate of 97%. Form completion rate is 1% (Table 7). There were 21 orders for piperacillin-tazobactam for the months of and 214 and all were guideline concordant (Table 8). The most common indications were pneumonia and intra-abdominal infections (Table 2). Recommendations: The use of the six restricted antibiotics and piperacillin-tazobactam is guideline concordant. No further recommendations are required at this time. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 2

Septemb Figure 5. GNCH ICU Antibiotic Usage and Expenditures GNCH ICU Total DDD GNCH ICU Total Expenditures 45 4 35 3 25 2 15 1 5 Oral Parenteral $7 $6 $5 $4 $3 $2 $1 $ Oral Parenteral 3 25 2 15 1 5 GNCH ICU DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $4 $35 $3 $25 $2 $15 $1 $5 $ GNCH ICU Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin 14 12 1 8 6 4 2 GNCH ICU DDD Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $25 $2 $15 $1 $5 $ GNCH ICU Expenditures Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 21

Table 7. GNCH ICU Compliance with Preauthorization Form and Guideline Concordance Rates 1 to 3, 214 Recommendations Restricted Antibiotic Number of Orders Guideline Concordant Form Compliance (Number & Percent Accepted) Ertapenem 1 1 (1%) 1 (1%) Imipenem 25 25 (1%) 25 (1%) Linezolid IV 1 1 (1%) 1 (1%) Meropenem 5 4 (8%) 5 (1%) 2 (1%) Total 32 31 (97%) 32 (1%) Table 8. GNCH ICU Piperacillin-tazobactam Order Review 1 to 3, 214 Number of Orders Guideline Concordant 21 21 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 22

E. GNCH Outpatient IV Clinic Antibiotic Utilization (Figure 6) The GNCH IV Clinic is an outpatient clinic that patients attend to receive IV antibiotics when they can be managed as an outpatient and do not qualify for home parenteral therapy. Prescribers in the IV clinic include the following: Nurse Practitioners (NPs) who see direct referrals from the Emergency Department (ED) Infectious Diseases (ID) physicians who see ID referrals from the ED, community, or upon discharge from hospital General Internists who see direct referrals from the ED Cephalosporins accounted for the majority of antibiotic prescribing in the GNCH IV clinic. Overall, antibiotic use and expenditures declined from to 213 which has been sustained from to 214. There was a recent rise in antibiotic use particularly with ertapenem in 214 likely due to an increase in the number of patients receiving long courses of ertapenem therapy. There were 53 orders for restricted antibiotics from to 214 with ertapenem being the most commonly prescribed restricted antibiotic. The guideline concordance rate was 98% and the form completion rate was 92% (Table 9). Piperacillin-tazobactam use was low during the months of and 214 and in all cases was guideline concordant (Table 1). Recommendations: CHASC will continue to monitor the use of ertapenem and ensure that it remains guideline concordant given the recent increase in use. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 23

Figure 6. GNCH IV Clinic Antibiotic Usage and Expenditures 14 12 1 8 6 4 2 GNCH IV Clinic DDD Oral Parenteral $3 $25 $2 $15 $1 $5 $ GNCH IV Clinic Total Expenditures Oral Parenteral 14 12 1 8 6 4 2 GNCH IV Clinic DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $3 $25 $2 $15 $1 $5 $ GNCH IV Clinic Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin 45 4 35 3 25 2 15 1 5 GNCH IV Clinic DDD Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline $25 $2 $15 $1 $5 $ GNCH IV Clinic Expenditures Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 24

Table 9. GNCH IV Clinic Compliance with Preauthorization Form and Guideline Concordance Rates 1 to 3, 214 Recommendations Restricted Antibiotic Number of Orders Guideline Concordant Form Compliance (Number & Percent Accepted) Daptomycin 3 3 (1%) 2 (67%) Ertapenem 46 45 (98%) 43 (93%) 2 (1%) Imipenem 3 3 (1%) 3 (1%) Meropenem 1 1 (1%) 1 (1%) 1 (1%) Total 53 52 (98%) 49 (92%) Table 1. GNCH IV Clinic Piperacillin-tazobactam Order Review 1 to 3, 214 Number of Orders Guideline Concordant 4 4 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 25

F. GNCH Medicine Antibiotic Utilization (Figure 7). Medicine applies to Internal Medicine, Family Medicine (cannot be separated due to shared inpatient units), Stroke Neurology, Geriatrics and Palliative Care. Overall, antibiotic utilization from 213 to 214 has remained stable. There has been a recent spike in meropenem use attributed to a single patient requiring a long course of therapy which was deemed guideline-concordant. Piperacillin-tazobactam use has declined substantially from 213 to 214. There were 59 orders for restricted antibiotics and the guideline concordance rate was 85% (5/59). The majority of guideline-discordant orders pertained to carbapenem use in patients with sepsis NYD who had no risk factors for multi-drug resistant organisms. In this scenario, piperacillin-tazobactam would have been a more appropriate first line agent (see below formulary guidelines). Form compliance rates were excellent at 95% (56/59) (Table 11). Piperacillin-tazobactam use was guideline concordant in all cases (Table 12). The most common indications were sepsis NYD and pneumonia (Table 2). A Guidelines for Use poster for piperacillin-tazobactam, ertapenem, imipenem and meropenem was widely distributed throughout the hospital and particularly on the medicine units to help with information and education on the use of these broad spectrum antibiotics. Recommendations: Further improve the rates of guideline-concordant prescribing for the 3 carbapenems as follows: Ertapenem: 1. Empiric therapy of polymicrobial complicated skin and skin structure infections, including bite wound infections. 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) ß-lactamases or extended-spectrum ß- lactamases (ESBLs) where there is resistance to first line agents and documented susceptibility to ertapenem. 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs). 4. Therapy of community-acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone and metronidazole). Imipenem + Meropenem: Guidelines listed apply to both drugs unless otherwise indicated. 1. Therapy of severe infections involving Gram negative organisms in patients who are intolerant of, or unresponsive to, or whose isolates are suspected or documented to be resistant (e.g. ESBL, inducible (AmpC) ß-lactamases) to, first line agents and piperacillin-tazobactam (imipenem preferred if documented susceptibility) 2. Therapy of severe suspected or documented polymicrobial infections in patients who are intolerant of, or unresponsive to, or whose isolates are suspected or documented to be resistant to, first line agents and piperacillintazobactam (imipenem preferred if documented susceptibility) 3. Therapy of infections involving multi-drug resistant Pseudomonas aeruginosa where there is documented susceptibility to the carbapenem (cannot assume meropenem susceptibility from imipenem susceptibility and vice Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 26

versa). 4. Empiric therapy in high risk febrile neutropenic patients +/- aminoglycoside (imipenem preferred if documented susceptibility). 5. Empiric therapy of post-traumatic/post-neurosurgical meningitis in combination with vancomycin. (MEROPENEM) 6. Alternative to ceftazidime for therapy of central nervous system (CNS) infections due to Pseudomonas aeruginosa. (MEROPENEM) 7. As part of combination therapy of infections with Nocardia spp or nontuberculous Mycobacteria spp. (IMIPENEM) Continue to prescribe piperacillin-tazobactam in a guideline concordant manner. Continue with the excellent restricted antibiotic form completion rates. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 27

Figure 7. GNCH Medicine Antibiotic Usage and Expenditures GNCH Medicine Total DDD GNCH Medicine Total Expenditures 35 3 25 2 15 1 5 Family & Internal Medicine Palliative Care $3 $25 $2 $15 $1 $5 Stroke/Geriatrics $ Family & Internal Medicine Palliative Care Stroke/Geriatrics 14 12 1 8 6 4 2 GNCH Medicine DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $2 $15 $1 $5 $ GNCH Medicine Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin 25 2 15 1 5 GNCH Medicine DDD Daptomycin Ertapenem Imipenem Linezolid Meropenem $8 $7 $6 $5 $4 $3 $2 $1 $ GNCH Medicine Expenditures Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 28

Table 11. GNCH Medicine Compliance with Preauthorization Form and Guideline Concordance Rates 1 to 3, 214 Restricted Antibiotic Number of Orders Guideline Concordant Form Compliance Recommendations (Number & Percent Accepted) Ertapenem 19 19 (1%) 19 (1%) 1 (1%) Imipenem 3 23 (77%) 28 (93%) 3 (67%) Meropenem 1 8 (8%) 9 (9%) 4 (1%) Total 59 5 (85%) 56 (95%) Table 12. GNCH Medicine Piperacillin-tazobactam Order Review 1 to 3, 214 Program Number of Orders Guideline Concordant Family Medicine 15 15 Geriatrics 1 1 Internal Medicine 37 37 Total 53 53 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 29

G. GNCH Surgery Antibiotic Utilization (Figure 8). Overall antibiotic utilization and expenditures (top pair of graphs) has been separated into two groups: Vascular Surgery (Unit 41 and 41-IMCU) and all other surgical areas combined (Day Surgery, PAC, Unit 42). The remaining graphs combine all surgical areas. Antibiotic utilization and expenditures has been stable from 213 to 214 with a recent increase in piperacillin-tazobactam use in 214. Vascular surgery accounts for slightly less than 5% of all surgical antibiotic prescribing. Cefazolin accounted for a large proportion of antibiotic use and likely reflects surgical prophylaxis. The fluoroquinolones and piperacillin-tazobactam were also commonly used. The restricted antibiotics were prescribed in low amounts with an overall decline in imipenem use. There were 2 orders for restricted antibiotics for the period of to 214 and all were guideline concordant. There was 1% compliance with the restricted antibiotic preauthorization form (Table 13). For the months of and 214, piperacillin tazobactam was prescribed in 39 patients (Table 14). The majority of the piperacillin-tazobactam was used in general surgery primarily for polymicrobial intraabdominal infections (Table 2). All piperacillin-tazobactam use was guideline concordant. Recommendations: Continue guideline concordant prescribing of the restricted antibiotics and piperacillin-tazobactam. Continue excellent restricted antibiotic form completion rates. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 3

Figure 8. GNCH Surgery Antibiotic Usage and Expenditures GNCH Surgery Total DDD GNCH Surgery Total Expenditures 18 16 14 12 1 8 6 4 2 Surgery Other Surgery Vascular $25 $2 $15 $1 $5 $ Surgery Other Surgery Vascular 12 1 8 6 4 2 GNCH Surgery DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin $16 $14 $12 $1 $8 $6 $4 $2 $ GNCH Surgery Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Vancomycin 18 16 14 12 1 8 6 4 2 GNCH Surgery DDD Daptomycin Ertapenem Imipenem Linezolid Meropenem $7 $6 $5 $4 $3 $2 $1 $ GNCH Surgery Expenditures Daptomycin Ertapenem Imipenem Linezolid Meropenem Tigecycline Tigecycline DDD=Defined Daily Dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 31

Table 13. GNCH Surgery Compliance with Preauthorization Form and Guideline Concordance Rates 1 to 3, 214 Restricted Antibiotic Number of Orders Guideline Concordant Form Compliance Recommendations (Number & Percent Accepted) Daptomycin 2 2 (1%) 2 (1%) Ertapenem 13 13 (1%) 13 (1%) Imipenem 4 4 (1%) 4 (1%) 1 (%) Tigecycline 1 1 (1%) 1 (1%) Total 2 2 (1%) 2 (1%) Table 14. GNCH Surgery Piperacillin-tazobactam Order Review 1 to 3, 214 Program Number of Orders Guideline Concordant Surgery Other 29 29 Surgery Vascular 1 1 Total 39 39 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 32

V. GNCH C. difficile (CDI) Prospective Audit and Feedback GNCH Infection Prevention and Control notifies the Antimicrobial Stewardship Pharmacist of all positive C. difficile (CDI) results. These patients could have community acquired, hospital acquired (attributed to GNCH or another hospital) or healthcare associated CDI. The Antimicrobial Stewardship pharmacist performs an audit on all CDI patients to ensure that guideline concordant treatment is initiated, to encourage the use of the CDI Preprinted Patient Care Order (PPCO), and to make interventions to optimize CDI management as necessary. There were 53 chart audits performed for the period of to 214 (Table 15). CDI guideline concordant treatment was initiated in 87% of patients (47/53) and this increased to 98% (52/53) following interventions made by the ASP pharmacist. Additional interventions included optimizing therapy duration in 11 cases and discontinuation of acid suppressive therapy in seven. The CDI PPCO has been used in 4% (21/53) of cases upon initial prescribing. Improvements in this rate will likely achieve better initial guideline concordant treatment and would trigger the assessment of other offending therapies such as acid suppressive agents, concurrent unnecessary antibiotics, or other medications such as stool softeners or laxatives. There were five CDI attributable deaths for the period of to 214. There were 2 CDI attributable deaths for the period to 213. Recommendations: CHASC will continue to work with IPC, the CDI Task Force and other disciplines to ensure guideline concordant management of CDI and to increase the use of the CDI PPCO as one strategy Month Number of cases CDI Attributable Mortality Table 15. CDI Audit and Feedback 1 to 3, 214 Guideline Concordant Treatment CDI PPCO Utilized Alter CDI Treatment Pharmacy Interventions Alter CDI Treatment Duration Discontinue acid suppressive therapy 8 1 5(63%) (%) 2 2 1 9 9 (1%) 5 (56%) 2 2 8 2 6 (75%) 2 (25%) 2 2 1 14 13 (93%) 9 (64%) 1 3 2 7 1 7 (1%) 2 (29%) 2 1 7 1 7 (1%) 3 (43%) Total 53 5 47 (87%) 21 (4%) 5 11 7 Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 33

VI. Glossary of Terms ASP....Antimicrobial Stewardship Program CDI....Clostridium difficile Infection CHASC...Covenant Health Antimicrobial Stewardship Committee CHASE...Covenant Health Antimicrobial Stewardship E-Newsletter DDD.. Defined Daily Dose ED...Emergency Department ESBL..Extended Spectrum β-lactamase HPT Home Parenteral Therapy ID...Infectious Diseases IPC.Infection Prevention and Control IMCU..Intermediate Care Unit MDR.Multi-Drug Resistant MRSA...Methacillin Resistant Staphylococcus aureus MSSA.Methacillin Sensitive Staphylococcus aureus NB.Nota bena or Important, Note well NP...Nurse Practitioner NYD...Not Yet Diagnosed PAC.Pre-Admission Clinic PPCO...Preprinted Patient Care Order Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of 214 214 34