Post on 20-Jan-2021
Presenter:Marc Meyer, BPharm, RPh, CIC, FAPIC
Clinical Pharmacists, Infection Preventionist,Antibiotic Stewardship Pharmacist
Southwest Health System, Cortez, Colorado
None
How do AU vendors and NHSN AU work to drive stewardship efforts?
Is infection prevention an important part of ASP?
Does ASP save money? Be able to describe stewardship efforts in
hospital, LTC, clinic, and dental settings. Be able to promote the value of community
stewardship efforts.
Pharmacist-led antimicrobial stewardship
SHS serves about 50,000 people in rural southwest Colorado, and in parts of Utah, Arizona, and New Mexico, including the Ute Mountain Ute and Navajo reservations. SHS has 25 inpatient beds and ten clinics.
The Review on Antimicrobial Resistance, 2014
The Review on Antimicrobial Resistance, 2014
CDC. Antibiotic resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/
$20 billion in added direct healthcare costs annually
2011-14 antibiotic prescribingAll ages: decreased 5%
Pediatric: decreased 14%Adults: no change
Asolva Medici ◦ www.asolva.com◦ Medici AU costs $1 per bed per month Pulls three files, MAR, Transfer, Admission Customizable antibiotic usage data Uploads to NHSN AU Free trial period
◦ Medici ASP costs $5 per bed per month Daily antibiotic and lab usage tool Customizable, broad-spectrum, time-outs, DOT Free trial period
NHSN AU◦ Upload CDA files from Medici AU into NHSN◦ Benchmarking, SAAR (standardized antimicrobial administration
ratio), rate days present NHSN LTC UTI and LabID
540 hospitals enrolled46 states and DC46 CAH97 <50 beds
0
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1
1.2
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SHS ALL SAAR MS
<25 beds
SHS Mean
Linear (SHS ALL SAAR MS)
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1.4
SHS ALL SAAR ICU
<25 beds
SHS Mean
Linear (SHS ALL SAAR ICU)
Arjun Srinivasan MDAssociate Director for Healthcare Associated Infection Prevention
Programs at the CDC
“Want to halt the spread of antibiotic resistance? Think infection prevention.”
“Antibiotic stewardship and infection control need to be seen as inseparable sides of the same coin.”
Let’s look at some data……
Effect of antibiotic stewardship on the incidence of infection and colonization with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis The Lancet, June 2017
?I believe ASP’s are patient safety programs and it’s all about
doing what is right for the patient.
But let’s take a look at some data and you decide!
According to the CDC, implementation of infection control and antibiotic stewardship will, in 5 years:◦Reduce MDR HAIs or CDI deaths by
37,000.◦Reduce MDR HAIs or CDI infections by
619,000.
0
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SHS SHS SHS SHS SHS SHS SHS SHS SHS SHS SHS
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 17-Aug 17-Sep 17-Oct 17-Nov
DOT: MS, ICU, ED
DOT
Mean
Linear(DOT)
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700
RateDaysPresent alllocations
AU Mean
SHS Mean
Linear (RateDaysPresentall locations)
-10
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RateDaysPresentEtrapenem
SHS Mean
Linear(RateDaysPresentEtrapenem)
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80
2016
M01
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M11
RateDaysPresentcefazolin
SHS Mean
Linear (RateDaysPresentcefazolin)
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120
140
RateDaysPresentceftriaxone
AU Mean
SHS Mean
Linear(RateDaysPresentceftriaxone)
Community-acquired pneumonia 5 -7 daysNosocomial pneumonia 8-10 daysPyelonephritis 5-7 daysIntra-abdominal infection 4 daysAcute exacerbation
of chronic bronchitis and COPD 5-7 daysAcute bacterial sinusitis 5-7 daysCellulitis 5-7 daysChronic osteomyelitis 45 days
JAMA Internal Medicine September 2016 Volume 176, Number 9 , The New Antibiotic Mantra-“Shorter Is Better”
Yes
Pick your area of concern from your data. Do a search of professional societies for current
guidances that match your area of concern. Pull current papers on your topic since the
guidance was published; if no guidance is available, develop yours based on the studies.
Consider a collaborative effort with another hospital, clinic, LTC, hospital association, LTC association, APIC, or pharmacy groups.
You have a packet with all guidances we have used in the projects being discussed today.
Keep them simple and measureable. Don’t look at too many items in your study. Do your own benchmarking with baseline data or
make sure you can obtain a benchmark. Publish your goals and post your progress to your
providers and staff. Readjust goals and guidance during the project if
needed.
Go slow, be successful! Suggested first projects◦ Form an official stewardship team◦ Antibiogram program◦ UTI, SSTI, URI, CAP/HAP guidance (IDSA, SHEA etc)◦ Guideline-based OR prophylaxis (IDSA, APHA, SHEA,
College of Surgeons)◦ Restrict your formulary◦ Monitor new antibiotic IV starts◦ Monitor antibiotic total monthly costs◦ DOT monitoring if feasible◦ Choose an antibiotic class to monitor◦ Review your handwashing program◦ Antibiotic timeouts◦ Daily patient care rounding as a team
◦ 20% reduction from baseline in duration of treatment◦ 30% reduction in inappropriate antibiotic selection ◦Monitor C. difficile rates using NHSN◦ Education event◦ There will be a paper coming out soon with this data for the combined 28 hospitals
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5
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Total DOT Inpatient DOT Discharge DOT
CHA UTI Baseline (63) Intervention (110)
0% 2%
44%41%
49%
21% 21%
2% 3%
20% 19%
72%
7% 9%
CHA UTIBaseline Intervention
◦ Reduction from baseline in duration of treatment◦ Reduction from baseline in broad gram-negative antibiotic use◦Monitor C. difficile rates using NHSN◦ Education event
11
4
7
9
3
7
Total DOT Inpatient DOT Discharge DOT
CHA SSTIBaseline (8) Intervention (25)
0% 0%
50%
13%
38%
13%
25% 25%
0% 0%
72%
16%12%
20%
12%
24%
CHA SSTIBaseline Intervention
Goals◦ Decrease DOT to 5-7 days adults, 7 to 14
days pediatrics◦ Decrease quinolone use over baseline
Education events◦ Pediatric, Jason Newland, MD◦ Adult, Katherine Fleming-Dutra, MD
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8
6.5 6.6
5.9
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DOT Adult DOT Ped DOT
Baseline UTI DOT
Intervention 1 UTI DOT
30
26
43
29 3028
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RX Rate Adult Rate Ped Rate
Baseline UTI RX RATE
Intervention 1 UTI RX RATE
30
40
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2931
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45
Quinolone Rate Adult Quinolone Rate Ped Quinolone Rate
Baseline UTI Quin Rate
Intervention 1 UTI Quin Rate
Specialty # of RX in millions (%) RX/1000
Family Practice 64.6 (25) 672Pediatrics 33.2 (13) 612Internal Med 32.5 (13) 388Dentistry 25.7 (10) 209Nurse Practitioner 16.9 (7) 154
Hicks L A et al, N Engl J Med 2013 308 1461-1462
Antibiotic #mil % Per 1000Amoxicillin 13.8 56.3 43.6Clindamycin 3.53 14.4 11.2Penicillin 3.24 13.2 10.2Cephalexin 1.19 4.9 3.8Azithromycin 1.14 4.7 3.6Amox/Clav .56 2.3 1.6Doxycycline .43 1.7 1.4Ciprofloxacin .16 .6 .5Erythromycin .09 .4 .3SMZ/TMP .05 .2 .2
Hicks L A et al, N Engl J Med 2013 308 1461-1462
Antibiotic treatment is essential to treat septicemia Clinical signs include pyrexia, trismus, significant
regional lymphadenopathy, gross facial swelling, closure of the eye, dysphagia, tachycardia, and rigors
Historically, antibiotics have been prescribed in courses between 5 and 10 days duration.
It is becoming increasingly evident that long courses of antibiotics are not required and may destroy the homeostasis of the oral micro-flora and lead to colonization resistance
Usually they can be discontinued after 2 to 3 days
Following drainage and removal of the cause of infection, a three-day standard dose antibiotic regime was effective in the management of the acute dentoalveolar abscess in all reviewed patients
The predominant organisms isolated from dentoalveolar abscesses derived from the periodontal tissues are obligate anaerobes
Those derived from periapical tissues are mixed infections
British Dental Journal 2011;211:591-594 S. J. Ellison
Prescribe only when clinical signs and symptoms of infection are present (fever, swelling, etc.)
Use the most narrow-spectrum antibiotic for the shortest duration possible
Revise antibiotic regimens based on patient progress and culture if needed
Collaborate with referring specialist about prescribing protocolsFluent, Jacobson, Hicks: Considerations for Responsible Antibiotic Use in Dentistry, JADA 2016
20% reduction in total UTI’s treated with antibiotics 20% reduction in total antibiotic days Shift the use of primary antibiotic away from
fluoroquinolones to less broad spectrum agents Questions◦ Can guidance and education, along with support, foster a
stewardship environment in LTC?◦ Does guidance have impact on cases meeting NHSN
definition? Education event
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7 7 7
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DOT DOT No culture DOT Culture
Pre-intervention
Intervention
32%
41%
12%
1%
7%9%
20%
39%
33%
11%9%
6%
9%11%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Cephalosporin Quinolone Nitrofurantoin SMZTMP Abx changes Abx resistant Quinolineordered, ceph
sensitive
Pre-intervention
Intervention
320
233
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50
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150
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250
300
350
Pre-intervention Intervention
27% Reduction
UTI DX EMR
◦ Can guidance and education, along with support, foster a stewardship environment in LTC? Yes, reduction in DOT (22%) and UTI Dx (27%)◦ Does guidance increase cases meeting NHSN definition? No, 17% decline in case completion◦ Can you use NHSN to drive stewardship projects? Yes, custom data along with regular fields◦ They will move forward with a Phase Two project
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2017M012017M022017M032017M042017M052017M062017M072017M082017M092017M102017M11
<25 Beds
SHS MS MRSA SAAR
SHS Mean
Linear (SHS MSMRSA SAAR)
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12020
16M
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2017
M11
RateDaysPresentVancomycin
AU Mean
SHS Mean
Linear(RateDaysPresentVancomycin)
41 cases reviewed, mostly cellulitis 15% had a prior MDRO 17% had no culture 24% not de-escalated 58% met stewardship definition MRSA 17%, E faecalis 7% 60% sensitive to cefazolin We recommended that cefazolin be the drug
of choice for cellulitis without history of prior MDRO or complications
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Mean <25 Beds
SHS SAAR MS MDRO
SHS Mean
Linear (SHS SAAR MSMDRO)
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M11
RateDaysPresentPip/Tazo
AU Mean
SHS Mean
Linear (RateDaysPresentPip/Tazo)
• Increase our efforts to de-escalate antibiotic choice• Increase our education of provider staff on days of
therapy needed to treat
21%
60%
37%
60%
0%
10%
20%
30%
40%
50%
60%
70%
MDRO Culture De-escalated Meets Stewardship
Pip/Tazo Audit
Pip/Tazo
Clinic stewardship Hospital stewardship LTC stewardship Dental stewardship
Can they make an impact in small communities? You decide?
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DOT Adult DOT Ped DOT
Baseline UTI DOT
Intervention 1 UTI DOT
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Year 13 Year 14 Year 15 Year 16 Year 17
SSI Infections
Rate per 1000
Linear (SSI Infections)
Linear (Rate per 1000)
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Total DOT Inpatient DOT Discharge DOT
CHA SSTIBaseline (8) Intervention (25)
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Total DOT Inpatient DOT Discharge DOT
CHA UTI Baseline (63) Intervention (110)
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DOT
Mean
Linear (DOT)
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RateDaysPresentEtrapenem
SHS Mean
Linear(RateDaysPresentEtrapenem)
98
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7 7 7
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DOT DOT Noculture
DOTCulture
Pre-intervention
Intervention
320233
050
100150200250300350
27% Reduction UTI DX
UTI DX EMR
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MDR
Mean
LTC project launch
Clinic Project Launch
Stewardship team officially formed
MDR tracking began
SSTI and UTI Hospital project
Stewardship along with infection prevention does save the health system money.
Stewardship is a data-driven quality learning process for all areas of the medical system.
The bulk of antibiotics are prescribed in the community setting, not the hospital. We need to fine-tune antibiotic usage in all care settings.
Marc J. Meyer R.Ph, BPharm, CIC, FAPIC970-564-2194 Officemmeyer@swhealth.org