NEVADANS FOR ANTIBIOTIC AWARENESS

2004 Partner ConferenceApril 9, 2004

Bill Berliner, MD

THE ANTIBIOTIC

RESISTANCE CRISIS

THE ANTIBIOTIC RESISTANCE CRISIS

• HISTORY OF BACTERIA

• HISTORY OF ANTIBIOTICS

• RESISTANCE

• THE PROBLEM NOW

• NEVADANS FOR ANTIBIOTIC

AWARENESS

HISTORY OF BACTERIA

BACTERIA HAVE BEEN AROUND

LONGER THAN ANY LIVING THING ON

EARTH.

FOSSIL EVIDENCE DATES BACK 3.5

BILLION YEARS.

HISTORY OF BACTERIA

EARTH AS A DAY:

5:00 AM - BACTERIA APPEAR

10:00 PM - DINOSAURS APPEAR

11:59 PM - HUMANS APPEAR

HISTORY OF ANTIBIOTICS

1928 – DR. FLEMING DISCOVERS PENICILLIN FROM BREAD MOLD

1944 – U.S. MILITARY TAKES PENICILLIN TO THE BATTLEFIELD

1945 – BACTERIA WITH RESISTANCE TO PENICILLIN ISOLATED

HISTORY OF ANTIBIOTICS

1960’s: METHICILLIN INTRODUCED

1991: 29% OF STAPH AUREUS

RESISTANT

2001: 62% OF STAPH AUREUS

RESISTANT

RESISTANCE

THE PROBLEM

PSEUDOMAS AEROGINOSA

13 1416

18.516

2326

28

CEFTAZIDIME IMIPENEM

% R

ES

IST

AN

CE

1991 1999 2000 2001 1991 1999 2000 2001

THE PROBLEM

STREPTOCOCCUS PNEUMONIA

32

42

22

29

PENICILLIN CEFOTAXIME

% R

ES

IST

AN

CE

2000 2001 2000 2001

THE PROBLEM

> 50% OF HOSPITAL ACQUIRED BLOODSTREAM INFECTIONS ARE CAUSED BY METHICILLIN-RESISTANT STAPH AUREUS (MRSA)

> 70% OF NURSING HOME STAPH INFECTIONS ARE CAUSED BY MRSA

THE PROBLEM

“THERE ARE PATIENTS TODAY IN HOSPITALS FOR WHOM THERE ARE NO EFFECTIVE THERAPIES.”

Gary DoernDirector of Clinical Microbiology

University of Iowa

NEVADANS FOR ANTIBIOTIC AWARENESS

WHO WE ARE

A STATEWIDE TASK FORCE THAT HAS BEEN IN EXISTENCE SINCE FEBRUARY 2001

3 SUBCOMMITTEES• PUBLIC AWARENESS• PROVIDER EDUCATION• INFECTION CONTROL & SURVEILLANCE

Pharmacist-directed pneumococcal vaccine

protocol increases number of patients receiving

immunization by 1200%

MountainView Hospital - Las Vegas, Nevada

Warren Wood, Pharm.D.

• Criteria checked by admitting nurse

– Over 65

– Hx of COPD,CHF,CAP,Splenectomy, No previous vaccine

• If criteria is met, chart is stamped with an optional order for the physician to check off

• Once ordered, the patient was to receive the vaccine after consent was signed

• Started June 1999

Program Revised in 1999Program Revised in 1999

MountainView HospitalMountainView Hospital

Pneumococcal Vaccine Results after 3 Years# Patients Receiving During Hospitalization

0

5

10

15

20

25

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Total doses administered for all of

2002 = 91

Federal Register Oct 2002CMS modified guidelines, Standing Orders

• Removed requirement for specific physician order• Allowed Medical Staff Approved protocols, in place of specific orders• Approved for Nursing Homes, Clinics, and Hospitals

Pneumococcal Vaccine CriteriaCDC/MMWR 1997

• All immunocompromised persons aged >2yr

• All persons over 5yr

• Persons age 2-64 with:

–Cardiovascular or pulmonary disease

–Diabetes mellitus

–Kidney disease

–Alcoholism, chronic liver disease

–Cerebrospinal fluid leaks

–Functional or anatomic asplenia

–Living in special environments or social settings

Pneumococcal VaccineProcess Revision

• Proposed Protocol:

• Nurse assessment as before, list sent to pharmacy

• Move to a Pharmacist-Directed approach:

– Past success with IVtoPO conversion

– Change in Medicare Regulations

• Pharmacist will write order to administer Vaccine next day

• Physician and/or Patient has over-ride ability

Report of admits from last 24h prints in Pharmacy after midnight. Data

includes: vaccine status, age, diag,

reason for admission

Floor Nurse does usual assessment

which includes vaccine query

Patient is Admitted

Pharmacist reviews data and makes further inquiries if needed, then writes order, and sends sheet

to floor to be placed on chart

Next Day at 2PM, Nurse confirms with patient that they want vaccine, then

administers doseAdministration is recorded in

patient’s chart and nurse gives patient vaccination

pocket card

Pneumococcal Vaccine Process Flowchart

4th Qtr 2003

MountainView =

88%

Pneumococcal Vaccine Results#Patients Receiving During Hospitalization

0

20

40

60

80

100

120

140

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1200% Increase over 2002

Medicare National Voluntary Hospital Reporting Initiative

4th Qtr MountainView was at 88%

0

5

10

15

20

25

30

35

40

45

>90 80-90 70-80 60-70 50-60 40-50 30-40 20-30 10-20 <10

Top 2%

Urgent Care Antibiotic Use

Eugene Somphone MD

Urgent Care Department Chief

Southwest Medical Associates

Introduction

• Reduction of antibiotic use

• Initial assessment of antibiotic use

• Provider and patient education

• Incentives to reduce inappropriate use

• Follow-up studies

• Future reduction

Urgent Care History

• SMA Urgent Cares 100,000 visits a year

• High volume of respiratory infections

• High rate of antibiotic prescriptions

Inappropriate Uses

• Over one-half of all antibiotics written annually are for respiratory infections

• More than 50 million unnecessary prescriptions are written annually

• 17 million prescriptions for antibiotics are written for the common cold

• Antibiotics are given to 75% of patients with sore throat

Initial Study

• Random charts pulled for upper respiratory complaints

• Symptoms of cough, sore throat, runny nose, congestion, sinus pain

• Percentage of patients prescribed an antibiotic

Results of Initial Study

• Overall prescription rate 66.7%

• Fulltime providers 53.5%

• Per diem providers 78.8%

• Range 14-100%

• 3 providers prescribed antibiotics 100% of the time!

Methods to Reduce Inappropriate Use

• Patient education– Handouts– Posters– Discussion

• Provider education• Financial incentives to reduce

inappropriate use

Provider Education• URIs are self-limiting

• Colored secretions are not predictors of bacterial infection

• Bronchitis is viral in nature

• Differentiate sinus symptoms from sinus infection

• Otitis media is oftentimes self-limiting

• Criteria for Strep throat

Financial Incentives

• SMA Bonus

• Antibiotic use as quality measure

• Goal set at less than 45%

Results

• After 3 months rate decreased to 34.2%

• After 6 months rate decreased to 30.5%

Patient Satisfaction

• Overall patient satisfaction rate remains high

• Some disgruntled patients

• Less resistance from patients

Rocephin

• In 2001 Rancho Urgent Care used $70,000

• Provider education and guidelines

• In 2002 all 3 SMA Urgent Cares used $40,000

Choice of Antibiotics

• Generic vs. Branded

• Narrow-spectrum vs. Broad-spectrum

Provider A

• Branded antibiotics prescribed in a 6-month period:

– Augmentin 2

– Cipro 1

– Floxin 1

– Levaquin 1

– Omnicef 1

– Tequin 29

– Z-pak 9

Provider A

• Generic antibiotics prescribed in a 6-month period:

– Amoxicillin 185

– Cefaclor 11

– Cephalexin 87

– Doxycycline 34

– Erythromycin 36

– Penicillin 14

– Tetracycline 3

Provider B

• Branded antibiotics prescribed in a 6-month period:

– Augmentin 6

– Ceftin 2

– Cipro 7

– Levaquin 6

– Tequin 4

– Z-pak 5

Provider B

• Generic antibiotics prescribed in a 6-month period:

– Amoxicillin 75

– Cephalexin 57

– Doxycycline 19

– Erythromycin 20

– Penicillin 38

Future Reductions

• Rapid Strep Testing

• AOM: recent recommendations

Stop Antibiotic Resistance In Washoe

County!

How Can Childcare Providers Help?

Joyce Minter, RN, PHN

www.co.washoe.nv.us/health/cchs

About one-third of Nevada’s children under the age five are in some

form of licensed childcare because their parents

work1

Source: Washoe County Child Care Health Consulting; Trust Fund for Public Health, RFA

2002-2003

Approximately 10,000 children under age six

attend 327 licensed childcare homes and

centers in Washoe County1

Source: Washoe County Child Care Health Consulting; Trust Fund for Public Health, RFA

2002-2003

Childcare providers play a key role in disseminating

information and health education to children and

families

Antimicrobial Resistance (AR) outreach was put into the Child Care Health Consulting (CCHC) grant, a Trust Fund for Public Health (TFPH) grant, to do education and evaluation of efforts

The CCHC is part of Health Child Care Nevada, which is part of the Health Care America campaign

Plan

• Send a survey to all (1250) child care providers

• Educate staff at 3 centers and 9 homes

• Then do a follow-up survey on those selected providers to see if they learned anything

Childcare Consultants Grant

• Printing and postage paid through grant

• PHN time was “in kind” contribution

AR Objective of Grant

• Targeted child care providers will achieve scores at least 10% higher than the entire population of providers in Washoe County on a survey measuring knowledge of antibiotic resistance after an educational session is completed

Child Care Providers• Obtained list of childcare providers

from Social Services-approx. 1250 questionnaires sent out1---------2325---------3910--------3420--------1630--------5

Questionnaire Development

• Made a list of 20 most important messages we wanted to convey

• Put into questionnaire form and data base created (special “Thanks” to Lei Chen)

• Questionnaires coded with identifying information so we could compare pre-test with post test

Survey Packet

• Letter explaining program and instructions to return questionnaire:

If a childcare center - to fax completed questionnairesIf individual childcare provider -

envelope with return postage guaranteed• Questionnaire• Business card • 2 NAA AR bookmarks for each provider as a

“Thank you”

Ideas for Incentives• Totes – NAA• Continuing education credit• Mugs• Water bottles• Purell hand sanitizer• Magnets-able to use some

immunization funding• A drawing/raffle

Activities• Mailed survey to all licensed child

care providers to assess baseline knowledge of antibiotic resistance and entered data for analysis

• Provided educational materials about antibiotic resistance to targeted centers

• Provided survey to targeted centers post intervention to measure change in attitudes

Initial Questionnaire Results

• 346 of 1250 returned = 28% response rate

• Average score was 75.1, standard deviation 13.8. Range of score was 25-100. Full score is 100.

Stop Antibiotic Resistance In Washoe

County!

for more information

www.co.washoe.nv.us/health/cchs

A special thanks to Jane Harper, MS, at Minnesota Department of Health for providing most of the

information in this presentation

Learning Objectives

• List two types of germs that cause common childhood respiratory illnesses

• State what antibiotics cannot do if you are sick with a viral infection

• List comfort measures that can help children with viral infections feel better (hint: an antibiotic is not one of them!)

Learning Objectives

• Name one myth and one fact about antibiotic use

• List 3 steps childcare providers can take to help keep antibiotics working

• Name one bacterial illness which can be prevented by proper immunization

• State the most effective way to prevent the spread of all infections in childcare

Take Home Messages

• Viruses cause most common childhood respiratory illnesses

• Viral illnesses need time to heal - antibiotics cannot help

Take Home Messages• Taking antibiotics for viral illnesses

will not:

– cure the infection

– keep others from getting the illness

– make you feel better

And may lead to antibiotic-resistant bacteria

Take Home Messages

• Comfort measures ease symptoms of viral illnesses (extra fluids, rest, a vaporizer, a smoke-free environment)

• Sick children should stay home until fever-free and able to participate in routine activities without more care than usual from childcare staff

• Always wash your hands - and help children wash theirs!

• Keep immunizations up to date

Bottom Line

• Antibiotics are powerful medicines, but they're not always the answer!

• Misusing antibiotics now means they may not work when needed later to fight a bacterial infection

• Help keep antibiotics working!

Education & Post-Test

• The three centers have completed the education and post-testing

• The nine individual providers will be completed by May

Post-Test Survey Results

• 57 post-tests completed• Average score: 89.5, standard deviation 12.9.

Range of score is 42-100. Full score 100. (pre-test average: 75.1)• Paired comparison result: Fifteen participated

in pre and post test. The average score was improved by 13 before and after the education (statistically significant---P=0.005 by pairing sample T-test).

• 56/57 (98%) participants indicated on their post-tests that the presentation was very useful

THE RURAL EXPERIENCE

LYNN EVANS, LPN

ANTHEM BLUE CROSS & BLUE SHIELD

MY ASSOCIATION WITH THE NAA

• SUB-COMMITTEES• PHYSICIAN OFFICE SITE REVIEWS

ROADBLOCKS ALONG THE WAY

• TRAVELING LITE• WEATHER• WHO IS THE NAA?

WHAT I HAVE ACCOMPLISHED

• GETTING THE INFORMATION OUT• INCREASED AWARENESS

ELKO, WINNEMUCCA, CARLIN, FALLON, YERRINGTON, WELLINGTON, DAYTON,

SILVER SPRINGS, GERLACH, CARSON CITY, GARDNERVILLE, MINDEN, FERNLEY,

STATE LINE, LAKE TAHOE,HAWTHORNE, LAUGHLIN, MESQUITE,

PAHRUMP

MY MOST MEMORABLE RURAL

VISIT

• MOST “FAR OUT” PLACE

FUTURE PLANS

• THE “RURAL SWEEP”

• FROM TONOPAH TO RENO

Measuring the Appropriate Use of Antibiotics

Mary Hothem, R.N.Anthem Blue Cross Blue Shield

April 9, 2004

HEDIS--Who, What & How

• Administered by NCQA

• Used by most HMO’s across the country to measure plan performance

• Standardized methodology and comprehensive audit checks to ensure comparability

• In Nevada, Aetna, Health Plan of Nevada, IHC Health Plans, and Pacificare, already publicly report results

• HMO Nevada does not currently publicly report results due to size, although does collect the data

New to HEDIS 2004

• Appropriate Treatment of Children With Upper Respiratory Infection– Children age 3 months to 18 years– Outpatient visit with diagnosis of URI

(460 or 465) ONLY (no secondary diagnosis

– % with no prescription for antibiotic 30 days before visit date or 3 days after visit date

New to HEDIS 2004

• Appropriate Testing for Children With Pharyngitis– Children age 2 to 18 years– Outpatient visit with diagnosis of

pharyngitis (462, 463, 034.0), ONLY– Received a prescription for antibiotic 3 days

before visit date to 3 days after visit date– % that also had a group A streptococcus test

Considerations for NAA

• This may be a way to measure the effectiveness of FUTURE interventions

• Would allow for benchmarking current Nevada practice patterns with other states / regions

• Would allow for benchmarking across health plans and identify best practices

Antimicrobial Resistance Surveillance Project

Linda Verchick, MSClark County Health District – Office of

EpidemiologyNevadans for Antibiotic Awareness Surveillance

Committee

Antimicrobial Resistance Surveillance Project - 2000

through 2003Initial Surveillance

• Surveillance of six organisms• Data collected from three county facilities

– Major laboratory– Two major hospitals

• Data reported quarterly• Provided some community information

Antimicrobial Resistance Surveillance Project - 2000

through 2003

Initial Surveillance Drawbacks

• Limited number of organisms and antibiotics surveyed

• No elimination of duplicate reports• Limited patient information• Data entry time consuming

Antimicrobial Resistance Surveillance Project - 2000

through 2003Surveillance Organisms

• Streptococcus pneumoniae• Staphylococcus aureus (coag +)• Pseudomonas aeruginosa• Acinetobacter calcoaceticus• Enterococcus faecium• Enterococcus faecalis

Streptococcus pneumoniae Percent Susceptibility to Penicillin - Clark County, NV 2000-2003

0

20

40

60

80

100

2000 2001 2002 2003

Year

Susc

eptib

ility

(%)

Streptococcus pneumoniae Percent Susceptibility to Cefotaxime - Clark County, NV 2000-2003

0

20

40

60

80

100

2000 2001 2002 2003

Year

Susc

eptib

ility (

%)

Antimicrobial Resistance Surveillance Project - 2004

New Surveillance Advantages

• Data electronically received• Elimination of duplicates• Antibiotic susceptibility from all positive

bacterial cultures from all sources• Antibiotic susceptibility reported in

minimum inhibitory concentrations (mics)

Antimicrobial Resistance Surveillance Project - 2004

New Surveillance Advantages

• More patient information available – Inpatient/outpatient– Gender and age

• Ten local hospitals/laboratories have agreed to participate

Nevadans for Antibiotic Awareness Surveillance

Project - 2004New Surveillance Disadvantages

• Computer program design is time consuming

• Technical difficulties obtaining data • HIPAA misinterpretation

Nevadans for Antibiotic Awareness Surveillance Project

2004Goals

• Provide an antibiogram specific to each participating facility

• Provide clinicians with a county wide antibiogram

• Provide rapid reporting on a quarterly basis• Identify emerging resistant organisms

Goals• Follow resistance development within a

sensitivity category (S, I, R)• Identify the development of resistance

within a patient• Provide a better understanding of antibiotic

resistance in both community acquired and nosocomial illness

Nevadans for Antibiotic Awareness Surveillance Project

2004

Nevadans for Antibiotic Awareness

Christine Petersen, MD, MBA

2004 Partner Conference

April 9, 2004

Nevada Antibiotic Usage Trends

• Data collected from 4 health plans• Represents 382,252 members throughout

the state• Includes oral outpatient antibiotic scripts• Excludes antifungals, topical and

antituberculosis medications• Baseline year 2000 and the first 2 quarters

of 2001

Outpatient Antibiotic Scripts

per Member per Month

368,252 Health Plan Members

2000 –2003

0.045

0.050

0.055

0.060

0.065

0.070

0.075

0.080

0.085

Quarter 1 Quarter 2 Quarter 3 Quarter 4

2000200120022003