Protecting Patients and Antimicrobials Best Practices in Stewardship Jonathan Hand MD Director, Antimicrobial Stewardship Program Director, Transplant Infectious Diseases Department of Infectious Diseases Assistant Professor University of Queensland School of Medicine Ochsner Clinical School Disclosures I have no financial relationships with commercial interests to disclose My presentation does not include discussion of off label or investigational use diagnostics 1
Objectives Overview of overuse and opportunities Define Antibiotic Stewardship Review strategies to integrate into practice and give updates on old problems recently in literature FDA Quinolone warning Asymptomatic bacteriuria Upper respiratory infection and antibiotics Clostridium difficile diagnostic optimization Penicillin allergy Antibiotic Stewardship Resources Fleming Predicts the Future in 1945 - Alexander Fleming, 1945 2
Antibiotic Overuse is Significant Healthcare Burden More than 250 million outpatient antibiotic prescriptions written in U.S, annually; majority are for acute respiratory tract infections and are largely unnecessary. > 50% of antibiotics prescribed are unnecessary or inappropriate per CDC. Antibiotics are the leading cause of adverse events from drugs, accounting for nearly 24% of ADEs present on admission. Antibiotic resistant bacteria cause > 2 million illnesses and 23,000 deaths/year. Robert Wood Johnson Foundation, Health Affairs, May 2015 Opportunities To Optimize Antibiotic Use Are Everywhere Settings and populations have different needs NO One-size-fits-all approach. Get creative! 3
Aims of Antimicrobial Stewardship Optimize the Drug Broad spectrum agents used for susceptible organisms or community-acquired diseases Optimize the Dose (and route) Doses not adjusted for renal dysfunction, IV used when PO alternative, organisms with higher MICs underdosed, site of infection not considered Optimize the Duration Durations are arbitrary De-escalate/Discontinue Antibiotics used to treat illness that is not infection Minimize adverse events (C. difficile and MDROs) Improve patient outcomes A Coherent Set of Actions Which Promote Using Antimicrobials Responsibly Dyar, O.J. et al.clin Micro and Inf, 2017; 793-798 4
Regulatory Requirements 28 recommendations summarizing data on: Interventions: preauthorization and/or prospective audit and feedback, didactic education, facility-specific clinical practice guidelines for common infectious diseases syndromes, reduce the use of antibiotics associated with a high risk of CDI, prescriber-led review of appropriateness of antibiotic regimens, computerized clinical decision support systems integrated into the electronic health record at the time of prescribing be incorporated as part of asps to improve antibiotic prescribing, Optimization: dedicated PK monitoring for vanco/aminoglycosides, alternative dosing strategies based on PK/PD principles toi improve outcomes and decrease costs for broad-spectrum ß-lactams and vancomycin, IV to PO, PCN skin testing, interventions to reduce antibiotic therapy to the shortest effective duration Microbiology and lab diagnostics: stratified antibiograms (location, age etc), performs elective or cascade reporting of antibiotic susceptibility test results, rapid viral testing for respiratory pathogens, rapid diagnostic testing on blood specimens, PCT in ICU, pts with hematologic malignancy use nonculture-based fungal markers Measurement : DOTs and DDDs overall measures best reflect impact of ASPs and their interventions, costs based on prescriptions or administrations instead of purchasing data Special populations: facility-specific guidelines for fever and neutropenia, ASP interventions to improve NH/skilled nursing facility's, NICUs, terminally ill patients 5
How Can I Prescribe Antibiotics More Appropriately? How Can I Help My Institution Prescribe Antibiotics More Appropriately? 6
25 inpatient VA medical centers, October 2013 September 2014 691/961 = 72% 494/729 = 68% Inappropriate Antibiotic Use for Asymptomatic Bacteriuria 7
Southeastern Performance is Poor 8
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Patient Education Provider Education 10
Physician-specific Feedback Published percentile ranking of each physician in local practice Emailed to each physician every 2 weeks First email was individual ranking with blinding to other physicians Subsequent report cards fully transparent (UNBLINDED) Outpatient Inappropriate Antibiotics for URI West Bank Clinic Pilot 11
Changes in Prescribing After 9-months 69% Other OHS Clinics West Bank Clinic Milani RV, et al. Reducing Inappropriate Antibiotic Prescribing in Clinical Practice: Use of Normative Comparison. submitted 2017 12
System Rollout January 2017: Changes in prescribing after 6-months 40% 26% 13
Clostridium difficile Antibiotic optimization and infection control practices are key strategies to combat C. diff HOWEVER, literature suggests we are: over-testing (low pre-test probability, laxative use) therefore over-diagnosing (high sensitivity of 2-step and PCR testing) leading to over-treatment (metronidazole/po vanco/fidaxomicin are not benign) and unnecessary contact isolation (associated with worse outcomes) Courtesy Sean Fox Kwon et al J. Clin. Microbiol. February 2017 vol. 55 no. 2 596-605 Lab must be/feel supported to discard specimens 3 watery stools in 24 hours NO testing if laxative in prior 48 hours Minimal (no) increase in diagnostic yield if repeated within 7 days > 50% of patients will remain asymptomatically colonized Work with institution to create policy/letter for care facilities Clinical Infectious Diseases 2013;57(8):117 81 14
Leveraging the Electronic Medical Record to Reduce HO-Cdiff -Decreased test volume by 39% -Reduced inappropriate repeat testing by 80% -Achieved SIR 4 quarter average 0.78, better than national goal Gregson et al BMJ Qual Saf 2016 25: 1015-1016 OMC EMR Support 15
Inappropriate C. difficile Testing at OMC Avoidance of repeat tests within 7 days Discard of non-liquid stool (Bristol 6 + 7) 849 (7day) + 742 (lab discard) = 1591 over ~ 8 month period Will this decrease overall HO-CDI rate? Implementation of testing initiatives Confounded by significant rise in hand hygiene compliance??? 16
The Penicillin Allergy Has Had Its Day 10% of the population reports a penicillin allergy BUT <1% of population is truly allergic (true Type 1, IgEmediated reactions) 80% of patients with IgE-mediated penicillin allergy lose sensitivity after 10 years Less-effective and broad-spectrum antibiotics are used as alternatives Solensky et al Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010 Oct;105(4):259-273. β-lactam Allergy Label Associated With Poor Outcomes Observational studies suggest worse clinical outcomes among patients with β-lactam allergy Increased in-hospital mortality 1 Increased odds of C. diff, MRSA and VRE 2 Prolonged length of stay 2 Adverse drug reactions 3 Readmission for same infection 3 1. Charneski L et al. Pharmacotherapy 2011; 31:742 7 2. Macy E et al. Journal of Allergy and Clinical Immunology 2014, 790-796 3. MacFadden DR et al. Clin Infect Dis 2016;63:904 10 17
SSI: substantial morbidity/mortality >$25,000 per case influence perceptions of hospital quality publicly reported β-lactam s preferred peri-operatively cefazolin skin flora (staph, strep), -cidal, PK Retrospective cohort: HPRO, KPRO, HYST, COLO, CABG 2010-2014, 8385 patients, 922 (11%) reported PCN allergy Patients with Listed PCN Allergy Get Suboptimal Drug Perioperatively Blumenthal K et al Clin Infec Dis 2017; 1058-4838 18
Reported PCN Allergy: 50% Increased Odds of SSI Mediated through receipt of β-lactam alternative Implementation Significant published literature on skin testing inpatient floor, ICU, ED, perioperative Skin testing negative ~ 90% Can be performed by: Allergists Pharmacists Fellows Non-allergy physicians 19
OMC ASP Website Other Institutional Education ASP Resources and Education Goff DA, Kullar R, Bauer KA, File TM, Jr. Eight Habits of Highly Effective Antimicrobial Stewardship Programs to Meet the Joint Commission Standards for Hospitals. Clin Infect Dis. 2017;64(8):1134-1139. 20
Summary Opportunities to optimize use across settings and populations Avoid quinolones for non-severe infections Avoid treating asymptomatic bacteriruia (outside of recommended populations) Avoid routinely treating URIs with antibiotics Use (micro) lab, infection control, EMR and nurse/provider education to curb inappropriate C. difficile testing Dig deeper into PCN allergy, try to test when possible Use colleagues (admin, MD, non-md - lab, nursing, IC, IT) to accomplish goals = Your incentives are aligned! Appropriate antibiotic use is not an ID issue, it is a quality and patient safety issue and is EVERYONE S issue Questions? Jonathan.Hand@ochsner.org 21