Optimizing Antimicrobial Stewardship Opportunities

Julie Harting, PharmD, BCIDP

Associate Professor

Sullivan University College of Pharmacy, Louisville, KY

Clinical Pharmacist Specialist, Infectious Disease

University Hospital, Louisville, KY

Objectives

1. Discuss nursing’s role in promoting antimicrobial stewardship

2. Review advances in diagnostics to facilitate antimicrobial prescribing

3. Identify pharmacotherapy options to optimize antimicrobial stewardship for common infections

Kentucky Outpatient Antibiotic Prescribing

2nd Highest Outpatient Prescription Rates in the US

https://arpsp.cdc.gov/https://chfs.ky.gov/agencies/dph/dehp/idb/Documents/StateAntibioticReport.pdf

Kentucky Medicaid Data (2013 – 2014)Statewide: SeniorsStatewide: Dematology, Family Medicine, Urology, Pediatrics

Highest Region: Southeastern KY Patients: PediatricsProviders: Nurse PractitionersAntibiotic: Amoxicillin

This is SCARY! Why?

Consequences of Antibiotic Overuse

Overuse of

Antibiotics

Increase in adverse effects• Allergic reactions• Superinfection• Toxicities

Increase in cost

Increase in antimicrobial resistance

CDC. 2019. “Antibiotic Resistance Threats In the United States, 2019”

Impact of Antibiotic Use on Resistance

http://cddep.org/publications/state_worlds_antibiotics_2015#sthash.hJXzQ0fu.dpbshttp://gis.cdc.gov/grasp/PSA/Downloads/AR-Summary.pdf

http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm500665.htm

MRSA RatesCommunity Antibiotic Prescription Rates

CDC. 2013. “Antibiotic Resistance Threats In the United States, 2013”

Antibiotic Resistance Threats in the U.S.

CDC. 2019. “Antibiotic Resistance Threats In the United States, 2019”

Urgent Serious Concerning

• Clostridium difficile• Drug-resistant

Neisseria gonorrhoeae• Carbapenem-resistant

Enterobacteriaceae (CRE)• Carbapenem-resistant

Acinetobacter sp.• Candida auris

• MDR Pseudomonas• ESBL-Producing

Enterobacteriaceae• Vancomycin-resistant

Enterococcus faecium• MRSA• Drug-resistant Streptococcus

pneumoniae• Drug-resistant Candida sp.• Drug-resistant TB• Drug-resistant Salmonella,

Shigella, Campylobacter

• Erythromycin-Resistant Group A Streptococcus

• Clindamycin-resistant Group B Streptococcus

What is Antimicrobial Stewardship?

• “Optimize patient clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, selection of pathogenic organisms, and the emergence of resistance”

• “Coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration”

• “An activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy”

• “A secondary goal to reduce health care costs without adversely impacting quality of care”

Dellit T, et al. Clin Infect Dis. 2007;44:159-177Barlam T, et al. Clin Infect Dis. 2016;62(10);e51-e77

CDC. 2019. “Antibiotic Resistance Threats In the United States, 2019”

Antimicrobial Stewardship Programs (ASPs)

Acute Care Hospitals

Required: January 2017

Outpatient & Ambulatory Care Settings

Long Term Care Facilities

Required: November 2017

Critical Access Hospitals

Required: 2017, but Extended: March 2020

Goal in progress: March 2020 - presenthttps://www.cdc.gov/antibiotic-use/core-elements/index.html

Core Elements of ASPs & IDSA Guidelines

• 30-50% inappropriate or unnecessary antibiotic use

• CDC Seven Core Elements1. Leadership Support

2. Accountability

3. Drug expertise

4. Actions to support optimal antibiotic use

5. Tracking and monitoring

6. Reporting

7. Education

• IDSA Antimicrobial Stewardship Guidelines (2007, 2016)

http://www.cdc.gov/getsmart/healthcare/evidence.htmlhttps://www.cdc.gov/antibiotic-use/core-elements/index.html

Antimicrobial Stewardship

Team

Physician Specialist

Clinical Pharmacist Specialist

Information Technology

Staff/Clinical PharmacistsNursing

Microbiology

Infection Control

Antimicrobial Stewardship

is a multidisciplinary

effort

Dellit T, et al. Clin Infect Dis. 2007;44:159-177

2017 CDC & ANA: Nurses & Antimicrobial Stewardship

ANA & CDC. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf. 2017. Accessed 5/11/21

2017 CDC & ANA: Nurses’ Role• Obtain appropriate cultures

• Collect prior to starting antibiotics• Use correct specimen collection technique• Understand how the lab processes those samples and when to anticipate results• Use infection prevention strategies (CAUTI, CLABSI, hand hygiene)

• Communicate with providers and inform decisions• Use microbiology results to guide optimal antimicrobial selection and duration• Use microbiology results to interpret colonization versus infection• Encourage antibiotic de-escalation (or narrowing antimicrobial spectrum)• Avoid duplication of therapy• Recommend IV to PO switches

ANA & CDC. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf. 2017. Accessed 5/11/21

2017 CDC & ANA: Nurses’ Role (cont..)

• Patient Allergies• Clarify medication allergies

• Educate patients and families about accurate allergy histories

• Monitor for adverse reactions• Recognize antimicrobial toxicities including allergic reactions

• Symptoms of Clostridioides difficile

Articles on Nurses & ASPs

• Olans RN, et al. The critical role of the staff nurse in antimicrobial stewardship – unrecognized, but already there. Clin Infect Dis. 2016;62(1):84-9

• Carter EJ, et al. Exploring the nurses’ role in antibiotic stewardship: a multisite qualitative study of nurses and infection preventionists. Am J Infect Control. 2018;46(5):492-497

• Ha D, et al. A multidisciplinary approach to incorporate bedside nurses into antimicrobial stewardship and infection prevention. Joint Comm J Qual Pat Safety. 2019;45:600-605

• Kirby E, et al. Reconsidering the nursing role in antimicrobial stewardship: a multisite, qualitative interview study. BMJ Open. 2020;10:e042321

• Wong LH, et al. Empowerment of nurses in antibiotic stewardship: a social ecological qualitative analysis. J Hosp Infect. 2020;106:473-82

• Olans RD, et al. Nurses and Antimicrobial Stewardship: past, present, and future. Infect Dis Clin N Am. 2020;34:67-82

Article Common Themes

Olans RD, et al. Nurses and Antimicrobial Stewardship: past, present, and future. Infect Dis Clin N Am. 2020;34:67-82

•Nurses are:• Communicators• Collaborators• Patient advocates

Article Common Themes: Barriers to Success

Olans RD, et al. Nurses and Antimicrobial Stewardship: past, present, and future. Infect Dis Clin N Am. 2020;34:67-82

• Practice Guidelines lack nurse-defined ASP role• Inclusion and Integration into ASP initiatives, while not increasing

workload

• Provider pushback and power relations

• ASP education and training• Specimen collection techniques

• Drug information

• Allergy clarification

• Infectious disease treatment guidelines

Ha D, et al.

• Hospital administration support for 2 trained nurse ASP leaders• 2x-weekly nursing unit rounds (pharmacist, nurse leaders, floor nurses)• Recommendations were communicated to providers

• Clinical Outcomes• Decreased total antibiotic days, particularly for CAP• Decreased acid suppressants• Decreased urinary and central venous catheter days• Decreased unit length of stay• Decreased hospital-onset Clostridium difficile infections

• Nurses’ feedback• Ownership of ASP initiatives (via integration into the program)• Empowerment and confidence• Improved nursing patient care

Ha D, et al. Joint Comm J Qual Pat Safety. 2019;45:600-605

Antimicrobial Stewardship Resources(National and Statewide)

• Antimicrobial Stewardship Training Modules & CE• https://www.train.org/cdctrain/training_plan/3697• https://www.cdc.gov/antibiotic-use/community/for-hcp/continuing-education.html

• IDSA Antimicrobial Stewardship Guidelines (www.idsociety.org)• 2007: IDSA/SHEA Guidelines for developing an institutional program to enhance antimicrobial

stewardship• 2016: IDSA/SHEA Guidelines for implementing an antimicrobial stewardship program

• Patient Education Resources• https://www.cdc.gov/antibiotic-use/materials-references/index.html• https://louisville.edu/medicine/departments/pediatrics/research/cahrds/KYAbxAwareness

• https://louisville.edu/medicine/departments/pediatrics/research/cahrds/KYAbxAwareness/kentucky-antibiotic-awareness-sick-child-handout

• Healthcare Professional Education Resources• https://www.cdc.gov/antibiotic-use/training/materials.html

Penicillin Allergy Resources

• CDC• https://www.cdc.gov/std/tg2015/pen-allergy.htm• https://www.cdc.gov/antibiotic-use/community/pdfs/penicillin-factsheet.pdf

• Johns Hopkins Medicine• https://www.hopkinsmedicine.org/antimicrobial-stewardship/nursing-

toolkit/_docs/penicillin-allergy-101-nurses-slide-deck.pdf

• Shenoy ES, et al. Evaluation and management of penicillin allergy. JAMA. 2019;32(1):188-199• Useful supplements/toolkits

• Blumenthal KG, et al. Antibiotic allergy. Lancet. 2019;393:183-98

• Castells M, et al. Penicillin allergy. N Engl J Med. 2019;381:2338-51

Microbiology Rapid Diagnostics

& Antimicrobial Stewardship

Miller JM, et al. Clin Infect Dis. 2018;67(6):e1-94

Advantages

• Quicker, often more accurate, information

• New methodologies for identifying pathogens

• Improved clinical outcomes• Length of stay, time to antibiotic

de-escalation, time to effective therapy, cost, mortality

• Adult and pediatric uses

Microbiology Rapid Diagnostics

Disadvantages• Appropriate ordering and

interpretation requires education• Couple with ASP specialist

• May not be able to distinguish colonizers vs. pathogens• Respiratory and gastrointestinal

panels• Surveillance testing can lead to

over-prescribing• Variable sensitivity & specificity

• May not replace simultaneous traditional culture methods

Miller JM, et al. Clin Infect Dis. 2018;67(6):e1-94

Sepsis & Bloodstream Infections

Sample Collection

24 hours 48 hours 72 hours

TraditionalTesting

Pathogen Identification

(25-40% positivity)

Antimicrobial Susceptibility

Rapid Diagnostics

• Pathogen Identification• Possible Resistance

Antimicrobial Susceptibility

Respiratory Tract Infections

Rapid Diagnostic Test Specimen Turn Around Time

Influenza A/B onlyRSV onlyInfluenza A/B + RSVParainfluenza only

Nasal SwabNasopharyngeal Swab

< 1 hour

Multiple viruses plus atypical bacteria Nasopharyngeal Swab Up to 5 hours

MRSA Nasal Swab 1 day

Group A Streptococcus Oropharyngeal swab < 30 minutes

Multiple bacteria with resistance Endotracheal Aspirate 4-5 hours

Multiple viruses and bacteria with resistance SputumEndotracheal AspirateBronchoscopy

1-2 days

Hanson KE, et al. Molecular Testing for Respiratory Tract Infections: Clinical and Diagnostic Recommendations from IDSA. Clin Infect Dis. 2021;71(10):2744-51

Outpatient Respiratory Tract Infections

Infection Type Pathogens Recommendation

Sinusitis Mostly Viral (90%) Avoid antibacterial therapy unless:• Severe (worsening >3-4 days, fever, purulent discharge• Persistent (> 10 days)• If bacterial, “watchful waiting” or amoxicillin/clavulanic acid

Acute Bronchitis Mostly Viral (90%) Avoid antibacterial therapyUse symptomatic and supportive agents (decongestants, cough suppressants, antihistamines)

Common Cold Mostly Viral Use symptomatic and supportive agents (decongestants, NSAIDs)

Pharyngitis Mostly Viral Consider bacterial if:• Fever, tonsillar exudate, swollen lymph nodes, absence of cough• Group A Streptococcus: 20-30% of pediatric cases, 5-10% of

adult cases. amoxicillin, penicillin, cephalosporins, clindamycin, azithromycin, clarithromycin

https://www.cdc.gov/antibiotic-use/clinicians/adult-treatment-rec.html

Respiratory: Bacterial vs Viral

• Rapid testing panels• Highly sensitive = good for ruling out bacterial or viral infection• Bacterial panels: interpretation challenges

• Unable to distinguish colonizers vs pathogens

• MRSA nasal screening• 95-98% NPV rule out MRSA pneumonia

• Procalcitonin (pro-inflammatory bio-marker)• Controversial evidence with sepsis and respiratory infections• Cutoff value not well understood• Often ordered incorrectly

Moradi T, et al. Clin Infect Dis. 2020;71(7):1684-9, Parente DM, et al. Clin Infect Dis. 2018;67(1):1-7, Self WH, et al. Clin Infect Dis. 2017;65(2):183-190, Kamat IS, et al. Clin Infect Dis. 70(3):538-542, Lee CC, et al. J Am Med Dir Assoc. 2020;21(1):1690-2

Gastrointestinal Infections

• Potential for inappropriate ordering and misinterpretation• Perform on loose stool only!

• Assess recent laxative or enteral nutrition use, and frequency of diarrhea

• Gastroenteritis (Infectious Diarrhea)• Mixed bacteria and viral panels (up to 22 pathogens)

• Clostridioides difficile• PCR assays: risk of false positives

• Unable to differentiate colonization from true infection

• Must couple with toxin testingO’Neal M, et al. Ther Adv Infect Dis. 2020;7:1-10, Pollock NR, et al. Clin Infect Dis. 2019;68(1):78-86

www.idsociety.org: 2018 IDSA C. difficile Guideline Update, 2017 IDSA Infectious Diarrhea

Infections, Other

• Central nervous system• Meningitis panel (14 pathogens, bacterial and viral)

• High potential in pediatrics

• Sexually transmitted infections

• HIV

• Hepatitis

Miller JM, et al. Clin Infect Dis. 2018;67(6):e1-94

Summary

• Nurses can improve patient outcomes by collaborating and communicating information with ASPs• Allergies, PO switches, microbiology results and antibiotic de-escalation

• ASP training and education is needed to optimize nurses’ contribution and impact• Pharmacology information (antimicrobials and allergies)

• Nurses should be aware that microbiology information for a variety of infections is rapidly evolving• Trained providers are needed for appropriate ordering and interpreting of

results