Kevin B. Spicer, MD, PhD, MPH Antibiotic Resistance Coordinator, HAI/AR Program Kentucky Department for Public Health

Kevin B. Spicer, MD, PhD, MPH Antibiotic Resistance Coordinator, HAI/AR Program Kentucky Department for Public Health

Objectives 1) Explore relationship between antibiotic use and unintended consequences 2) Review antibiotic resistance, including mechanisms of resistance 3) Discuss importance of antimicrobial stewardship in all healthcare settings 4) Examine the core elements of antimicrobial stewardship, with discussion of statewide facility data 5) Discuss relationship between antimicrobial stewardship and infection prevention & control 2

Common Types of Bacteria Gram positive Most are cocci, round bacteria Streptococcus, Staphylococcus, Enterococcus Clostridium difficile (C. diff) is a Gram positive rod Gram negative Most are bacilli, rod-shaped bacteria Enterobacteriaceae: E coli, Klebsiella, Enterobacter, Proteus Pseudomonas, Acinetobacter

Terminology Antibiotic Produced by an organism to kill, or inhibit growth of, another organism Antimicrobial Agent able to kill, or inhibit growth of, another organism (can be natural or synthetic) Antibacterial An antimicrobial directed towards bacteria Antibiotic often used to refer to an antibacterial agent 4

Antibiotics 101 Antibacterials are grouped into classes based on their structure and activity Narrow-spectrum target a few specific bacteria Broad-spectrum can kill a wide variety of bacteria Infection prevention programs track certain bug-drug combinations for evidence that the bacteria is getting resistant Bacteria with resistance can cause patients to have more severe, costly infections which are harder to treat

Time Magazine-Feb 25, 1966 Nearly all experts agree that (by the year 2000) bacterial and viral diseases will have been wiped out. Probably arteriosclerotic heart disease will also have been eliminated. 6

Antibiotic Use and Misuse in Hospitals In a 2011 single-day point prevalence survey in roughly 200 Emerging Infection Program Hospitals, 50% of patients were receiving at least one antibiotic Approximately 30% of antibiotic use in hospitals is unnecessary or inappropriate Magill S et al. Oral Presentation Session 37, abstract 114, presented at ID Week 2012. San Diego, CA. 7

Unintended Consequences of Antibiotic Use Antibiotic exposure is the single most important risk for Clostridium difficile Infections Exposure to antibiotics increases the risk of C. diff infection by at least 3 fold for at least a month Up to 85% of patients with C. diff infection have antibiotic exposure in the 28 days before infection Antibiotics account for nearly 1 in 5 drug-related adverse events >140,000 ER visits/year due to adverse effect of antibiotics Admission required for 6.1% of adverse events

Antibiotic Use Drives Resistance Johnson et al. Am J. Med. 2008; 121: 876-84.

Resistance from Antibiotic Pressure At first the susceptible bacteria (green) are killed by the drug Once they are wiped out, the resistant bugs take over (red)

Science 2008;321:356-361. 11

Science 2008;321:356-361. 12

Mechanisms of Antibiotic Resistance Production of proteins that destroy antibiotics Beta-lactamases Carbapenemases Change their cell structure so antibiotics can t bind and block their function Reduce their antibiotic exposure Pump drugs out Increase cell barriers to keep drug out http://bioinfo.bact.wisc.edu/themicrobialworld/bactresanti.html

New York Times February 26, 2010 Rising Threat of Infections Unfazed by Antibiotics

History of Antimicrobial Use 2000 B.C. Here, eat this root. 1000 A.D. That root is heathen. Here, say this prayer. 1850 A.D. That prayer is superstition. Here, drink this potion.

History of Antimicrobial Use 2000 B.C. Here, eat this root. 1000 A.D. That root is heathen. Here, say this prayer. 1850 A.D. That prayer is superstition. Here, drink this potion. 1940 A.D. That potion is snake oil. Here, take this penicillin; it s a miracle drug. 1985 A.D. Penicillin is worthless. Here, take this new antibiotic; it s bigger and better. 2010 A.D. Those antibiotics don t work any more. Here eat this root.

Antimicrobial Resistance and Patient Outcomes Increase in mortality, morbidity, length of hospitalization, and cost of care Staphylococcus aureus Enterococci Gram-negative bacilli Delays in therapy or severity of illness likely contribute to the worse outcomes Cosgrove SE, CID, 2006;42 Suppl 2:S82-9.

Defining Multidrug-Resistance Resistant to treatment by several antibiotics from unrelated classes Sometimes just one key drug resistance will define an important MDRO, for example, methicillin-resistance in Staphylococcus aureus Bacteria sometimes acquire resistance to several classes, often seen in Gram negative rods Cephalosporin-resistance is a big concern in bacteria like E coli/klebsiella which often cause UTIs Pseudomonas can be resistant to fluoroquinolones, penicillins, cephalosporins, and carbapenems

ABC s of MDROs Bacteria Abbrev. Antibiotic Resistance Staphylococcus aureus Enterococcus (faecalis/faecium) Enterobacteriaceae (E coli/klebsiella, etc) MRSA VRE CRE (KPC) Methicillin-resistant Vancomycin-resistant Carbapenem-resistant Pseudomonas/ Acinetobacter MDR Many drug classes

Carbapenem-resistance in Gram Negative Bacteria Growing threat in the treatment of infections Bacteria in the family Enterobacteriaceae are common Klebsiella spp. and E. coli are examples of Enterobacteriaceae Colonize the human GI tract Often cause infections in both the community and healthcare settings Currently CRE has been limited to people with high exposure to healthcare 21

Patients with KPC-producing Carbapenem-resistant Enterobacteriaceae (CRE) reported to the Centers for Disease Control and Prevention (CDC) as of January 2017, by state

Patients with NDM-producing Carbapenem-resistant Enterobacteriaceae (CRE) reported to the Centers for Disease Control and Prevention (CDC) as of January 6, 2017, by state

Patients with VIM-producing Carbapenem-resistant Enterobacteriaceae (CRE) reported to the Centers for Disease Control and Prevention (CDC) as of January 6, 2017, by state

MDROs in the Healthcare Setting DEVELOPMENT Antibiotic pressure Most common predictor of antibiotic resistance is prior exposure Device utilization Biofilm formation on central lines, urinary catheters, etc. SPREAD Patient to patient transmission via healthcare workers Environmental / equipment contamination Role of colonization pressure on acquisition 25

Good Antimicrobial Stewardship is the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. Gerding DN, Jt Comm J Qual Improv, 2001;27:403-4.

APIC-SHEA Position Paper Antimicrobial stewardship: a collaborative partnership between infection preventionists and health care epidemiologists Assist with early identification of infected patients Surveillance of problematic organisms Emphasis upon compliance with standard and transmissionbased precautions Education and promotion of infection prevention strategies Hand hygiene Care bundles Roles of staff, patients, and visitors in potential spread of infections Moody et al., Am J Infect Control, 2012;40:94-5. 27

Antimicrobial Stewardship and Infection Prevention Complementary components to improving antimicrobial use and potentially limiting development of antimicrobial resistance Infection control programs rely on stewardship programs to Minimize inappropriate and/or excessive antibiotic exposure Decreases likelihood that patients may acquire a multidrug-resistant organism Antimicrobial stewardship programs rely on IPC programs to Minimize spread of multidrug-resistant organisms between patients Decreases use of broad-spectrum antibiotics Nagel et al., Infect Dis Clin N Am, 2016;30:771-84. 28

AID Stewardship Model Antibiotic stewardship Infection prevention stewardship Diagnostic stewardship Dik et al., Future Microbiol, 2015;11:93-102. 29

Infection Prevention Stewardship Close surveillance of multidrug-resistant organisms (MDROs) Early detection of infections with MDROs Emphasis of transmission precautions and limiting spread of infections/organisms Increased response with any possible transmission of an MDRO Enhanced intra- and inter-facility communication to limit transmission of infections with patient movement Dik et al., Future Microbiol, 2015;11:93-102. 30

What is Antibiotic Stewardship? A set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use Antimicrobial stewardship interventions can lead to: Improved individual resident outcomes Prevention of the emergence of antibiotic resistance Saving healthcare dollars

Antibiotic Stewardship Programs Antibiotic stewardship ensures that the patient only receives an antibiotic when needed AND the right drug, dose, and duration is prescribed CDC recommends that all hospitals should have antimicrobial stewardship programs Programs will look different in various hospitals, depending on the size and complexity of the patient population Fridkin SK, Srinivasan A. Clin Infect Dis. 2013 Oct 25. 32

Strategies and Challenges to Improving Antibiotic Use Convince prescribers that their actions are linked to resistance Survey and focus group study Resistance was national problem more than institutional or practice (95% vs. 77% vs. 65%) Convince patients and the public that their actions are linked to resistance State the vision for these activities as improving rather than controlling or restricting use Giblin TB et al., Arch Intern Med, 2004;164:1662-8.

Potential Benefits of Antimicrobial Stewardship Decreased antimicrobial resistance More discriminate use of new agents Improved quality of care Improved patient outcomes Improved physician education Cost containment

Eight Proposed Principles of Antibiotic Therapy 1) Antibiotics are prescribed only when there is clear rationale (e.g., clinical signs of a bacterial or fungal infection are present) 2) When empirical therapy is necessary (i.e., the organism has not been identified), reasonable, evidence-based prescribing guidelines are followed 3) Specimens are routinely sent for culture 4) Antibiotic treatment is tailored promptly according to the laboratory results 5) The appropriate dose is prescribed at the correct frequency of administration (including continuous infusion when necessary) 6) Antibiotic therapy is not prolonged unnecessarily 7) Antibiotics with overlapping spectrum of activity are avoided unless there is clear rationale 8) The change from IV to oral therapy is made as early as possible Best Care Always, 2011, http://www.bestcare.org.za/file/view/antibiotic+stewardship+getting+started+guide+v1.pdf 35

Core Elements of Hospital Antibiotic Stewardship Programs Leadership Commitment Accountability Drug expertise Action to improve use Tracking Reporting Education http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

Core Contributors to Stewardship Programs (in addition to physicians and pharmacists) Infection Preventionists Laboratory Nursing Information Technology (IT) Risk assessment and prevention planning skills Collect, analyze and report antibiotic-related data Input into specimen collection and proper use of relevant tests Review information flow of results to clinicians Create and interpret a facility antibiotic resistance report Review medications as part of their routine duties Could contribute through prompting discussions of antibiotic treatment, indication, and duration Create ways integrate guidelines and policies with decision support at point of care Track antibiotic use through medication administration records

National Healthcare Safety Network Antibiotic Stewardship Programs c Stewardship questions were added to NHSN for first time in 2015 >4,000 hospitals respondents Questions applied to calendar year 2014 http://www.cdc.gov/nhsn/forms/57.103_pshospsurv_blank.pdf

Hospitals Meeting all Core Elements 35% 33% 52% 58% 42% AK 39% 13% 50% 23% 24% 50% 56% 29% 30% 54% 30% 21% 37% 25% HI 21% 19% 29% 28% 29% 31% 36% 44% 36% 29% 21% 37% 36% 38% 41% 33% PR 24% 43% VT 41% 49% 48% 47% 50% 7% 55% NH M A 28% RI 58% CT 30% NJ 27% DE 49% M 50% D 50% DC 13% 7 28% 29 35% 36 48% 49 58% Overall percentage was 39.2% (1642 of 4,184) Data: NHSN 2015 Annual Facility Survey

Kentucky Hospitals Meeting Core Elements - 2015 2015 Core Elements State Data (68 facilities) 24, 35% Core Elements Met 29, 43% 7 5,6 <5 15, 22%

Kentucky Hospitals Meeting Core Elements - 2016 2016 Core Elements State Data (68 facilities) 9, 13% Core Elements Met 7 18, 27% 5,6 41, 60% <5

KY Medicaid Regions

Hospitals Meeting Core Elements 2015 Medicaid Regions 1-4 2015 Core Elements Medical Regions 1-4 (33 facilities) 11, 35% 9, 29% Core Elements Met 7 5,6 <5 11, 36%

Hospitals Meeting Core Elements 2016 Medicaid Regions 1-4 2016 Core Elements Medicaid Regions 1-4 (33 facilities) 6, 18% Core Elements Met 18, 55% 7 5,6 <5 9, 27%

Hospitals Meeting Core Elements 2015 Medicaid Regions 5-8 2015 Core Elements Medicaid Regions 5-8 (35 facilities) 20, 57% 11, 31% Core Elements Met 7 5,6 <5 4, 12%

Hospitals Meeting Core Elements 2016 Medicaid Regions 5-8 2016 Core Elements Medicaid Regions 5-8 (35 facilities) 3, 8% 23, 66% 9, 26% Core Elements Met 7 5,6 <5

Antimicrobial Use in NHs Over 4 million individuals receive care in nursing homes/skilled nursing facilities (NH) every year The majority are coming directly from hospitals to receive skilled nursing care/rehabilitation Antimicrobials are frequently prescribed in NHs Over the course of a year, 50-70% of residents will receive a systemic antimicrobial 25-75% of antimicrobial use in NHs may be inappropriate Daneman N et al. JAMA Int Med 2013;173:673-82 Benoit et al. JAGS 2008;56: 2039-2044 Nicolle LE et al. ICHE 2000;21:537-545

Nursing Homes are Reservoirs of MDROs NH residents colonized with MDR-Gram Negative Rods (~20% prevalence) O Fallon et al. Infect Control Hosp Epidemiol 2009; 30: 1172-1179 NH residents colonized with MRSA (40-50% prevalence) Mody et al. Clin Infect Dis 2008; 46(9): 1368-73 Stone et al. Infect Control Hosp Epidemiol 2012; 33(6): 551-7 NH residents colonized with VRE (5-10% prevalence) Pop-Vicas et al J Am Geriatr Soc. 2008 56(7):1276-80 Benenson et al. Infect Control Hosp Epidemiol. 2009 30:786-9 48

Long Term Care Facilities and Antimicrobial Resistance Fewer or limited resources Personnel, including those devoted to infection prevention Laboratory/diagnostic services Access to prescribing medical providers Access to infectious disease consultation Consequences of limited resources Potential increased misuse of antimicrobial agents Frequent transfer of residents to acute-care hospitals Giannella et al., Exp Rev Anti-Infect Ther, 2016;14:219-30. 49

Nurses in LTCFs Particularly influential in terms of antimicrobial use and resistance Bedside care Decision to test Escalation to health care provider prescribers 50

Spotlight on Infection Prevention in NHs Sept. 2012 CDC released the LTCF infection reporting component within NHSN Oct. 2012 Updated infection surveillance definitions for LTC published by CDC/SHEA April 2013 Dept. of Health and Human Services (HHS) released the National Action Plan to Prevent Healthcare-associated Infections in LTCF NHSN reporting from nursing homes was #1 priority Feb 2014 Office of the Inspector General released report on adverse events and harms in skilled nursing facilities 1 in 5 post-acute residents experienced an adverse event within the first 30 days of their admission

Spotlight on Antibiotic Stewardship in NHs Sept. 2014 The White House announces an Executive Order to develop an Action Plan to Combat Antimicrobial Resistance March 2015 The White House releases the National Action Plan for Combating Antimicrobial Resistance Call to action for implementing antibiotic stewardship programs and activities in all healthcare settings, including long-term care July 2015 CMS proposes new Federal Regulations for Long-term care facilities including new infection prevention and antibiotic stewardship activities September 2015 CDC releases the Core Elements of Antibiotic Stewardship for Nursing Homes

Nursing Home Antimicrobial Stewardship Guide The Agency for Healthcare Research and Quality recently updated its NH antimicrobial stewardship guide that includes toolkits on: Starting and monitoring an antimicrobial stewardship program Communication and decision making for suspected infections Using an antibiogram Materials for resident and family engagement and education http://www.ahrq.gov/nhguide/index.html

CDC Core Elements of Antibiotic Stewardship for Nursing Homes Provide a framework for assessing current and new antibiotic stewardship activities, and for monitoring and improving antibiotic use: Leadership Commitment Accountability Drug Expertise Action Tracking Reporting Education http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

Nursing Home Core Elements: Appendix A Evidence-based examples of policies, actions and interventions that to improve antibiotic prescribing http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-a.pdf

Other Partners Who Support Stewardship Infection prevention and control coordinator: Tracking antibiotic starts as part of infection surveillance Monitoring adherence to evidence-based published criteria on evaluation and management of infections Reviewing antibiotic resistance and CDI as part of surveillance Consultant laboratory: Developing a process of notifying the facility if certain antibiotic resistant organisms are identified Providing education for NH staff on use of diagnostic tests Creating a summary report of antibiotic susceptibility patters (i.e., antibiogram) State and local health departments: Proving educational support and resources Engaging facilities in coordinated activities (e.g., stewardship collaboratives) to promote shared learning

Education-Staff Provide education about antibiotic stewardship to clinicians and nursing staff May be the first element implemented to establish support among staff Different mechanisms (flyers, newsletters..), strongest evidence for academic detailing (i.e. face-to-face interactive workshops) Address staff concerns and barriers to changing antibiotic use practices http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp.ltc/ http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/nh-aspguide/module1/index.htm https://nursinghomeinfections.unc.edu/

Colonization versus Infection The presence of bacteria is normal and expected in certain parts of the human body Especially those parts exposed to the environment Skin, nose, mouth, throat, intestinal tract, urogenital tract (especially with older age) Medical devices allow bacteria access and increase risk of colonization, e.g., urinary catheters and tracheostomies Many of the normal colonizing bacteria are helpful to our system Digest and absorb nutrients; protect us from invasion from harmful bacteria (e.g., C. difficile in the GI tract) Presence of bacteria in a culture specimen not necessarily indicative of infection Signs and symptoms of inflammation are important to distinguish colonization from infection

Make Antibiotic Use Decisions Well-informed Understand and address the knowledge, attitudes and perceptions of the clinical providers, staff and residents Promote antibiotic use guidelines and training Share provider specific antibiotic use data Educate and empower front-line NH staff Educate residents, families and NH staff on the risks of antibiotic use

Explore the Gaps with Clinical Providers to Improve Antibiotic Use Evaluate the discrepancies between surveillance data and clinical/mds data as a process improvement exercise Ask for their input in identifying the reasons why events treated with antibiotics don t meet surveillance (or other practice guideline) criteria Identify ways to improve: Assessments Documentation Diagnostic testing Follow-up after antibiotics have been initiated

Snapshot of Resistance Patterns: Facility Antibiograms A yearly summary of the common bacteria from facility cultures and their susceptibility patterns to antibiotics Allows you to see trends in resistance over time Ask your microbiology lab about it

Tracking Monitor at least one process measure and at least one outcome measure from antibiotic use in your facility Prescribing process measures Adherence to documenting prescribing elements Completeness of resident assessment documentation Appropriateness of antibiotic selection (based on facility guidelines) Antibiotic use measures Point prevalence of antibiotic use Antibiotic starts/ 1,000 resident days Days of antibiotic therapy/ 1,000 resident days Outcome measures C.difficile and multidrug-resistant organisms Adverse events and/or costs related to antibiotic use

Action-Broad Practice Improvements Broad practice improvements Standardize the assessment of patients suspected of an infection and the communication between onsite nursing and offsite providers Ask providers and nurses input on barriers and opportunities for improvement Ensure staff is communicating all the relevant data to make appropriate treatment decisions Consider using Standard Assessment and Communication Tools i.e. SBAR http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1-toolkit1/utisbar-form.html

National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB) Released March 27, 2015 Outlines steps to implement the National Strategy and address policy recommendations Significant outcomes expected by 2020 65 65

National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB) Objective 1.1: Implement public health programs and reporting policies that advance antibiotic resistance prevention and foster antibiotic stewardship in healthcare settings and the community. Goal: Reduction of inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings. 66

NHSN Antimicrobial Use Option Objective: Measure antibiotic use to provide risk-adjusted inter- and intra-facility comparisons Antibiotic resistance surveillance option also available NHSN AU Protocol http://www.cdc.gov/nhsn/acute-care-hospital/aur/index.html

Action Items 1) Learn about your facility s antimicrobial stewardship program (ASP) and how the Infection Prevention team can be involved 2) Increase awareness of staff (medical, nursing, etc.) regarding the 8 principles of antibiotic therapy 3) Review your facility s antibiogram to understand local problematic organisms (especially occurrence of carbapenem-resistant organisms) 4) Encourage and support your facility s use of NHSN and the NHSN antibiotic use and resistance (AUR) module 71

Acknowledgements (for use of selected slides) Lauri Hicks, DO CDC, Director, Office of Antibiotic Stewardship Kurt Stevenson, MD, MPH The Ohio State University Medical Center Nimalie Stone, MD, MS CDC, Division of Healthcare Quality Promotion Theo Zaoutis, MD, MSCE The Children s Hospital of Philadelphia 72

Resources - 1 https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html http://www.ahrq.gov/nhguide/index.html http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/ https://www.gnyha.org/whatwedo/quality-patient-safety/infection-controlprevention/antimicrobial-stewardship http://www.mi-marr.org/ltc_toolkit.php https://www.cdph.ca.gov/programs/hai/pages/aspinnursinghomeswebinarseries2016.aspx

Resources - 2 http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html https://nursinghomeinfections.unc.edu/ https://robinjump.coursesites.com/ http://www.choosingwisely.org/patient-resources/antibiotics-for-people-withcatheters/ http://www.choosingwisely.org/patient-resources/antibiotics-for-urinary-tractinfections-in-older-people/

Resources - 3 Advancing Excellence in America s NH campaign, Infections Goal: http://www.nhqualitycampaign.org CDC Get Smart for Antibiotic Use in Healthcare: http://www.cdc.gov/getsmart/healthcare/ CDC/SHEA Infection surveillance definitions for LTC http://www.jstor.org/stable/10.1086/667743 CDC s resources for LTC (update coming soon): http://www.cdc.gov/hai/settings/ltc_settings.html CDC s infection reporting system for LTCFs: http://www.cdc.gov/nhsn/ltc/

Supplemental, Informational Slides

Unintended Consequences of Antibiotic Use: Antibiotic Resistance Some of the reasons for this are out of our control The ability of bacteria to mutate to resist antibiotics BUT- some of the most important ones are very much in our control Overuse of antibiotics Spread of resistant organisms in healthcare settings through poor infection control practices

Do Antimicrobial Agents Cause Resistance? 6 5 No. of Prescriptions per 100 persons 5 4 4 3 2 1 Pneumococci with Reduced Susceptibility to Fluoroquinolones (%) 3 2 1 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 0 Chen DK et al., N Engl J Med, 1999;341:233-9.

Urinary Tract Infections and Previous Exposure to Antibiotics Children age 6 months to 6 years First diagnosis of urinary tract infection (UTI) Recent exposure to amoxicillin (i.e., within 30 days) was associated with increased resistance of identified organism to ampicillin and amoxicillin-clavulanate Paschke AA et al., Pediatrics, 2010;125:664-72. 80

Observed Association between Antimicrobial Use and the Emergence of Resistance Changes in use are paralleled by changes in resistance Resistance more prevalent in healthcare-associated infections (HAI) Patients with HAI are more likely to have received antibiotics Areas with high use also have high resistance Increased duration of use increases likelihood of colonization with resistant organisms Dellit TH et al., CID, 2007;44:159-77.

C. difficile Infection (CDI) and Antibiotics CDI is the most common cause of acute diarrhea in LTC Antibiotics are a major driver of C. difficile acquisition and infection Fluoroquinolone antibiotics have been associated with CDI with a more severe strain of C. difficile Longer antibiotic exposure carries higher risk McDonald LC et al Emerg Infect Dis 2006; Simor AS, J Am Geratrc Soc. 2010.

Mechanisms of Resistance Cross-resistance to structurally unrelated antimicrobial agents occurs primarily through 1 of 2 mechanisms: 1) Efflux pumps that can remove a variety of antimicrobials from the bacterial cell 2) Presence of resistance islands without the genetic material of the organism that confer resistance to a variety of antimicrobials through diverse mechanisms Nagel et al., Infect Dis Clin N Am, 2016;30:771-84. 83

ESKAPE Pathogens E vancomycin-resistant Enterococcus spp (VRE) S methicillin-resistant Staphylococcus aureus (MRSA) K Klebsiella pneumonia A Acinetobacter baumannii P Pseudomonas aeruginosa E Enterobacter spp. Bad Bugs, No Drugs 2004, Infectious Diseases Society of American campaign Boucher et al., CID, 2009;48:1-12. 84

Healthcare Facilities as Source of MDROs Sengstock DM, et al. Clin Infect Dis. 2010 50(12): 1611-1616. 85

http://emerald.tufts.edu/med/apua/news/news-newsletter-vol-29-no-3-2.shtml

Shifting The Way We Approach Improving Antibiotic Use We need to learn from the successful model of hospital infection control For decades, preventing infections in hospitals was viewed as the primary responsibility of the infection control program Preventing infections is increasingly viewed as the primary responsibility of all healthcare providers Systems approach Surveillance 87

Antimicrobial Stewardship Active Interventions Prospective audit with intervention and feedback (A-I) Direct interaction with infectious disease physician or clinical pharmacist trained in ID Formulary restriction and preauthorization (A-II) Antibiotic approvals by Infectious Diseases physicians or PharmD s Restricted drugs at start of use

Antimicrobial Stewardship Supplemental Strategies Guidelines and clinical pathways (A-I) Dose optimization (A-II) Streamlining or de-escalation of therapy (A-II) Education (A-III) Parenteral to oral conversion (A-III) Antibiotic order forms (B-II) Antimicrobial cycling (C-II) Combination therapy (C-II)

Harm from Infections among SNF Residents Infections were among the most common causes of harm; accounting for 26% of adverse events Type of Harm Adverse events (n=148) Events related to infection Infection events deemed preventable Transfers to hospital from infection event 39 (25.8%) 22 (59%) 34 (87.2%) Temporary (n=113) 20 (16.8%) 9 (45%) NA Hospitalizations from infections were estimated to cost ~83 million dollars (the most expensive cause of harm) OIG report: Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries (OEI-06-11-00370), February 2014 90

Gaps/Opportunities to Prevent Infections Better recognition of the problem Recognizing and documenting changes in clinical status Standardize the way infections are defined and reported to monitor the burden of the problem Improved documentation of the response Inadequate documentation of actions leads to incomplete information and missed opportunities Provide guidance and standards for implementing best practices Improve communication across care transitions Increased accountability for prevention Facility practices to prevent infection should be monitored for adherence and impact Implement consistent methods for assessing the effectiveness of infection prevention activities

CMS Proposed Regulations for Infection Prevention and Control Programs (IPC) Cross-cutting IPC regulations: Facility risk assessment of resident population ( 483.70) Integrating IPC into QAPI activities ( 483.75) Required review and update of IPC program, policies/procedures ( 483.80) Designated IPC Officer with specific training ( 483.80) IPC-specific education and training for all staff ( 483.80) 92

CMS Proposed Regulations for Antibiotic Stewardship Antibiotic stewardship integrated within pharmacy and infection prevention and control (IPC): Expanding pharmacy medication reviews to include antibiotics for monthly review; reviews also occur for all new admissions/re-admissions, ( 483.45) Antibiotic use protocols and monitoring included in IPC ( 483.80) Integrating IPC and stewardship into QAPI activities ( 483.75) Richards et al. JAMDA 2005; 6: 109 112. 93

Accountability Antibiotic stewardship leads can utilize existing resources Infection prevention and control coordinator Tracking antibiotics, monitoring adherence to prescribing practices Consultant Laboratory Alerting facilities if antibiotic resistant organisms are identified Education about differences in diagnostic testing (i.e. different test for C. difficile) Creating antibiograms to help with empiric antibiotic selection and monitor for resistance State and local health departments Educational support and resources on antibiotic stewardship and infection prevention by the Healthcare-Associated Infections prevention programs

Resources for Leadership Education Utilize existing campaigns and resources to make facility staff and residents more aware of safe antibiotic use http://www.cdc.gov/getsmart/healthcare/

Resources for Clinician Education www.cdc.gov/longtermcare/

Education-Residents Develop resources and tools to engage residents and families to in stewardship education efforts, this will reduce barrier of resident and family expectations in improving antibiotic prescribing Start the conversation early with residents and their families http:www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

Resources for Consumer Education www.choosingwisely.org/doctor-patient-lists/

Use Evidence-based Practice Guidelines to Create Management Algorithms Clin Infect Dis 2009; 48:149-171 Infect Control Hosp Epidemiol 2001; 22:120-124

Gap between MD Diagnosis and Surveillance Criteria 146 infections, UTI or pneumonia were diagnosed and treated by clinicians 33/146 (23%) were also identified by applying either McGeer or Loeb minimum criteria Wang L. et al. Eur J Clin Microbiol Infect Dis. 2012. 31(8):1797-804.

Action-Policy Implement at least one policy or practice to improve antibiotic use, ideally in a stepwise fashion Antibiotic prescribing and use policies Documentation of dose, route, duration and indication for every antibiotic course Develop facility specific treatment guidance for common infections based on practice guidelines http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html Ouslander et al, Consensus-Derived Interventions to Reduce Acute Care Transfer (INTERACT)-Compatible Order Sets for Common Conditions Associated with Potentially Avoidable Hospitalizations, JAMDA, 2015

Reporting Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff Monitoring and feedback to providers and staff on the impact of their efforts is critical to sustaining improvements Provider specific feedback is one of the most effective ways to change prescribing behaviors Any measure being tracked as part of monitoring antibiotic use should have a mechanism for reporting the results back to appropriate staff in the facility Having antibiotic use data to share with staff, residents and families especially improvement in clinical outcomes (e. g., decreased CDI) can increase support of stewardship activities

Education Provide educational resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use Education may be one of the first elements implemented to establish support among facility providers and staff Effective and sustained change doesn t happen without education Use educational events as an opportunity to engage providers and staff in identifying ways to improve current practices Address staff concerns and barriers to changing antibiotic use in your facility Work with facility staff to develop resources/tools to educate residents/families on stewardship efforts in your facility