Preventing and Responding to Antibiotic Resistant Infections in New Hampshire

Preventing and Responding to Antibiotic Resistant Infections in New Hampshire Benjamin P. Chan, MD, MPH NH Dept. of Health & Human Services Division of Public Health Services May 23, 2017

To bring a greater awareness and understanding of the antimicrobial stewardship work in NH, and to invite you to join us in our on-going work

Antibiotic resistance is a problem Antibiotic use contributes to antibiotic resistance There is a large amount of inappropriate antibiotic use or prescribing that occurs It is not the responsibility of any single person, group of individuals, or organization to address

Coordinated interventions to improve the way we prescribe and use antibiotics in order to: Improve patient outcomes Prevent antimicrobial resistance Reduces cost Antibiotic use includes: Type of antibiotic (or no antibiotics) Dose Duration Route of administration Fishman N. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012; 33(4):322 7.

Knowledge of Infectious Diseases Knowledge of Patient Knowledge of Antibiotics Healthcare Provider(s) Attitude Decision to Use Antibiotics Patient s Attitude and Desires Availability of Antibiotics Choice of Antibiotics Refine Choice of Antibiotics & Determine Treatment Course Culture Results Adapted from: Fishman. Am J Med 2006;34(5):S55-63.

Where do we begin addressing the problem? How big of a problem is antibiotic use and resistance in NH? How do we engage facilities and healthcare providers on this issue? How do we develop a coordinated and consistent approach to antibiotic stewardship and infection prevention? (not just human medicine) Can we leverage the benefits of being a small state with a close working relationship with healthcare facilities?

~ 50 members from various specialties Physician Veterinarian Nurse (ARPN and RN) Pharmacist Dentist NH Dental Society Microbiology/laboratory Infection Control Preventionist Urgent care Medical Director Chief Medical Officer Foundations for Healthy Communities Health Facilities Surveyor Public Health

1. Engage leadership to build commitment across NH to prevent and respond to AR infections 2. Engage stakeholders to inform, support, and coordinate AS activities 3. Enhance AR surveillance 4. Coordinate a consistent approach to collect antibiotic use data from healthcare facilities 5. Promote and coordinate stewardship activities and prevent spread of resistant infections

There did not exist a comprehensive system of AR surveillance in New Hampshire November 2016: Hospital antibiogram data was made reportable to NH DHHS We collected 2016 AR data from most hospitals in NH and created a state-wide antibiogram

Tool for clinicians to choose appropriate empiric antibiotics for common infectious syndromes: Uncomplicated UTI s Community Acquired Pneumonia Skin and Soft Tissue infections Intra-abdominal infections Healthcare-associated Gram Negative aerobic infections Analyze temporal trends and geographic patterns of antibiotic resistance in NH Guide antibiotic stewardship efforts at the local, regional, and state level

Surveillance Infection Prevention Antibiotic Stewardship Public Messaging Antibiotic susceptibility CRE Assess health facility capacity Targeted patient messaging Antibiotic use & prescribing Gonorrhea Clinician education Generalized public messaging High priority organisms General prevention guidance Develop AS guidance & resources Engage Leadership & Stakeholders

CRE was made reportable in NH at end of 2016 Total # of confirmed CRE cases (2017): 47 3 isolates had the KPC plasmid K. oxytoca: 2 E. cloacae: 1 Organism # of Cases Enterobacter cloacae 22 Enterobacter aerogenes 10 Klebsiella pneumoniae 5 Escherichia coli 4 Klebsiella oxytoca 2 Serratia marcescens 1 Other 3 Total 47

26% not initially treated according to STD guidelines

Always Dual Therapy to prevent emergence of resistance Azithromycin is used to prevent gonorrhea resistance, not just to treat chlamydia CDC. STD Treatment Guidelines, 2015. MMWR Jun 2015;64(3).

CDC. Antibiotic Resistance Threats in the United States, 2013.

Future Direction of Antimicrobial Stewardship in New Hampshire

Assess AS capabilities at NH healthcare facilities through coordination with local AS leadership Track antibiotic prescribing patterns in both the inpatient and outpatient settings Implement AS initiatives (including targeted messaging and resources to outpatient triage nurses) Promote a protocol for assessing penicillin allergies in patients (a driver of broad spectrum antibiotic use) Develop and disseminate targeted patient messaging about antibiotic use and AR (and C. difficile)

The NH public health agency works closely with federal and local partners (including both human and veterinary medicine) to develop and implement a shared strategy to improve antibiotic use and prevent the spread of antimicrobial resistant pathogens

NH DHHS general AR/AS webpage: https://www.dhhs.nh.gov/dphs/cdcs/hai/ar-providers.htm NH antibiogram and clinical summary: https://www.dhhs.nh.gov/dphs/cdcs/hai/publications.htm CRE guidance: https://www.dhhs.nh.gov/dphs/cdcs/hai/publications.htm