An Update on National Stewardship Activities 2019 · in improving antibiotic use in outpatient settings, but there is limited experience with these reports for hospital-based providers

National Center for Emerging and Zoonotic Infectious Diseases

An Update on National Stewardship Activities2019

CAPT Arjun Srinivasan, MD

Associate Director for Healthcare Associated Infection

Prevention Programs

Division of Healthcare Quality Promotion

[email protected]

Disclosures

No financial disclosures

I’m going to focus on developments in hospital stewardship. I’ll say a bit about outpatient settings.

“Core Elements of Antibiotic Stewardship” Leadership commitment from administration

Single leader responsible for outcomes

Single pharmacy leader

Antibiotic use tracking

Regular reporting on antibiotic use and resistance

Educating providers on use and resistance

Specific improvement interventions

73.2%

79.9%

88.5%91.9%

75.4%

88.6%93.9%

81.1%

91.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Critical

access

Surgical General

acute care

Children's ≤50 beds 51 - 200

beds

>200 beds None,

undergrad

Graduate,

major

Facility Type Bed Size Teaching Status

Percentage of hospitals meeting all 7 core elements,

by hospital characteristic, 2018

What’s Next For The Hospital Core Elements

A lot has changed since 2014.

The 2019 update of the Core Elements tries to reflect:

– Growth in use measurement

– New data on interventions

Some Details on the Elements From the Upcoming 2019 Update of The Hospital Core Elements

Hospital leadership commitment- dedicating necessary human, financial

and information technology resources

Recognizes that hospital leadership plays a critical role in making sure the

stewardship program has the resources it needs to do its job and that the

program is supported by all groups in the hospital.

– A lack of needed resources remains the most common barrier to

success cited by stewardship programs.

Suggests that the hospital designate a senior executive leader as a point of

contact or “champion” for the stewardship program. The hospital should create a reporting structure that ensures information

on stewardship activities and outcomes is shared with senior leadership

and the hospital board on a regular basis.


Accountability: Appointing a leader or co-leaders responsible for program

management and outcomes.

The 2019 document will highlight the effectiveness physician and

pharmacist co-leadership.

– 59% of US hospitals have a co-lead stewardship program

If the program is led by a pharmacist, there should be a physician who

supports the pharmacist

– 26% of US hospitals have pharmacist led stewardship programs

Leaders of stewardship programs need good communications skills and

must be able to collaborate well with others!


Pharmacy Expertise (previously “Drug Expertise”): Appointing a pharmacist to lead implementation efforts to improve antibiotic use.

Ideally, as the co-leader of the stewardship program.

The name of this element was changed to better emphasize the critical

role of pharmacists in hospital stewardship programs.

Most US hospitals do not have access to pharmacists trained in infectious

diseases, so general clinical pharmacists are most often involved in

stewardship programs.

– They can be highly effective if they are properly supported

– There are a variety of stewardship training programs and resources for

general clinical pharmacists.


Action: Implementing interventions to improve antibiotic use.

The 2019 update specifies three “priority interventions”:– Prospective audit and feedback

– Preauthorization

– Facility specific treatment guidelines

Prospective audit and feedback and preauthorization are the best

established hospital stewardship interventions.

Treatment guidelines can be important in enhancing the effectiveness of

prospective audit and feedback and preauthorization.


Action: Implementing interventions to improve antibiotic use.

Hospital stewardship programs should consider focusing on the three

conditions that comprise about two-thirds of all hospital antibiotic use:

– Lower respiratory tract infections

– Urinary tract infections

– Skin and soft tissue infections

Treatment guidelines are available for all three and there are several

published improvement examples:

– Optimizing duration of therapy, including post-discharge

– Improving urine culturing practices

– Narrow spectrum therapy for skin and soft tissue infections


Reporting: Reporting information on antibiotic use and resistance to

prescribers, pharmacists, nurses and hospital leadership on a regular

basis.

Sharing facility-specific information on antibiotic use is a tool to motivate

improved prescribing, particularly if wide variations in the patterns of use

exist among similar patient care locations.

Provider specific reports with peer comparisons have been quite effective

in improving antibiotic use in outpatient settings, but there is limited

experience with these reports for hospital-based providers.

Summary information on antibiotic use and resistance and on the work of

the antibiotic stewardship program should be shared regularly with

hospital leadership and the hospital board.


Education: Educating prescribers, pharmacists, and nurses about adverse

reactions from antibiotics, antibiotic resistance and optimal prescribing.

Case-based education can be especially powerful

– Prospective audit with feedback and preauthorization are both good

methods to provide education on antibiotic use. This can be especially

effective when the feedback is provided in person, sometimes called

“handshake stewardship”. Education should be tailored to the specific provider group.

Patients should also be educated, especially about potential adverse

reactions to antibiotics- what should they be sure to tell healthcare

providers about?


Tracking: Monitoring antibiotic prescribing, impact of interventions, and

other important outcomes like Clostridioides difficile infection and

resistance patterns.

Outcome measures like C. difficile.

Process measures like adherence to treatment guidelines and

recommendations.

Hospitals should report data on antibiotic use into the CDC’s National Healthcare Safety Network Antibiotic Use Option so they can benchmark

their use.

Information on Program Leadership and Actions-2019 NHSN Hospital Survey

59% of programs are co-lead by MD and PharmD

– 12% physician only

– 26% pharmacist only

41% of programs do prior authorization

65% of programs do prospective audit with feedback

Percent Effort for Stewardship in Job Description: MD and PharmD

0

10

20

30

40

50

60

70

1-25% 26-50% 51-75% 76-100% Not specified

MD PharmD

Time Spent on Stewardship: MD and PharmD

0

10

20

30

40

50

60

70

80

1-25% 26-50% 51-75% 76-100% Not specified

MD PharmD

Focus of Prior Authorization vs Prospective Audit

Prior Authorization Prospective Audit

Daptomycin, Linezolid 33 51

New anti-gram negative

(e.g. anti-CRE agents)

31 46

Carbapenem 26 56

Vancomycin 5 53

Quinolone 7 45

Pip/tazo, cefepime 7 49

Colistin 22 36

Echinocandin 20 37

Next Steps in Assessing Stewardship Programs

Now that we have reached such high levels of reported implementation,

should we begin to raise the bar on what’s considered to meet specific elements?

For example:

– Should action require prior authorization or post-prescription review?

– Should accountability specify some amount of dedicated time?

Yearly Submission into the NSHN Antibiotic Use Option*

0

200

400

600

800

1000

1200

1400

1600

2012 2013 2014 2015 2016 2017 2018 2019

No. of

Facilities

Reporting or

that have

Reported

AU Data

*As of Sept 1, 2019

Standardized Antimicrobial Administration Ratio (SAAR)

A ratio of actual use to predicted use.

Predicted use is modeled based on all data submitted and is risk adjusted

based on a variety of hospital characteristics (e.g., number of ICU beds in

the hospital), but not on any patient level factors.

The measure was endorsed by The National Quality Forum, in 2016.

SAARs for different groups of antibiotics.

SAARs for adult and pediatric locations.

SAARs for ICU and non-ICU locations.

SAARs can be calculated at the individual unit level or hospital wide.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ICU

Wa

rd

Ste

p-d

ow

n

He

m-O

nc

ICU

Wa

rd

Ste

p-d

ow

n

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nc

ICU

Wa

rd

Ste

p-d

ow

n

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ICU

Wa

rd

Ste

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ICU

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ow

n

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nc

ICU

Wa

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Ste

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ow

n

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m-O

nc

Broad spectrum

antibacterial agents

predominantly used

for hospital-onset

infections

Broad spectrum

antibacterial agents

predominantly used

for community-

acquired infections

Antibacterial agents

predominantly used

for resistant Gram-

positive infections

(e.g., MRSA)

Narrow spectrum

beta-lactam agents

All Antibacterial

Agents

Antibacterial agents

posing the highest risk

for CDI

Antifungal agents

predominantly

used for invasive

candidiasis

Percentage of Adult 2017-baseline SAARs significantly less than 1, not significantly different

from 1, and significantly greater than 1, by agent category and location type,

2018 data reported to the NHSN AU Option from adult SAAR locations

Percentage of SAARs statistically significantly <1 Percentage of SAARs not statistically different from 1 Percentage of SAARs statistically significantly >1

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

1/1

/20

17

2/1

/20

17

3/1

/20

17

4/1

/20

17

5/1

/20

17

6/1

/20

17

7/1

/20

17

8/1

/20

17

9/1

/20

17

10/1

/201

7

11/1

/201

7

12/1

/201

7

1/1

/20

18

2/1

/20

18

3/1

/20

18

4/1

/20

18

5/1

/20

18

6/1

/20

18

7/1

/20

18

8/1

/20

18

9/1

/20

18

10/1

/201

8

11/1

/201

8

12/1

/201

8

1/1

/20

19

2/1

/20

19

3/1

/20

19

4/1

/20

19

5/1

/20

19

6/1

/20

19

SA

AR

Valu

es

NSBL and BSCA SAARs for Medical Wards, 2017-2019*

NSBL SAAR BSCA SAAR Linear (NSBL SAAR) Linear (BSCA SAAR)

Some Interesting Points

Most pooled mean values are around 1.

~25% of locations are using an excess of 20% or more antibiotics than

predicted across all locations types and agent classes.

More wards than critical care units have SAARs significantly greater than

1, though medical critical care units have generally higher percentages

greater than 1 than other ICU types.

Antifungal agents have the lowest median but the widest range of SAARs.

Medical Critical Care Units had a particularly high distribution for the CDI

agent class.

What’s Next Can we combine SAAR data with hospital survey data and C. difficile data

to try and gain insights into which structures and processes might be more

effective?

We’d love to be able to point to the “highest yield” items in the core elements.

Do SAAR values correlate with opportunities to improve use?

– VA is assessing this through their electronic MUE work

Do SAARs move in expected directions with stewardship interventions?

– DASON wrapping a multi-year project exploring this

How would additional data (e.g. ICD) impact risk adjustment?

– DASON finishing work on an analysis and University of Maryland

starting a project.

How Can We Drive Change In Stewardship?

Direct the rider

– Follow the bright spots

Motivate the elephant

– Find the feeling

Shape the path

– Tweak the environment

Follow The Bright Spots

What can we learn from the top performers?

All of them do prior authorization and/or post prescription review.

Antibiotic Resistance Won’t Motivate The Elephant. We need to emphasize the fact that avoiding unnecessary antibiotics can

help protect against serious and near-term potential harms:

C. difficile

Adverse drug reactions- which land people in the ED 200,000 times per

year.

Disruption of the microbiome- which can cause diarrhea and yeast

infections and which can increase the risk of sepsis

Patients who got antibiotics for asthma exacerbations had longer lengths

of stay than patients who did not and no reduction in treatment failure

(JAMA Intern Med. 2019;179(3):333-339)

Motivate the Elephant- The “Ikea Effect” Perhaps stewardship interventions would be more effective if

they were designed in collaboration with providers.

Maybe especially with the providers who are the worst

offenders.

This approach has been effective in improving prescribing in

hospitals Europe and the US.

And had added benefits:

– Stewardship interventions became a partnership

– Stewardship programs could refer outliers and complainers

to someone in their own department

Haas MK et al. Open Forum Infectious Diseases. 2016

Sikkens et al. JAMA Intern Med, 2017

Shape The Path. How To Put New Ideas Into Practice?

Max Planck:

A scientific truth does not triumph by convincing its opponents and

making them see the light, but rather because its opponents eventually

die and a new generation grows up that is familiar with it.

Thaler and Sunstein:

You find ways to nudge them forward.

CMS Hospital Conditions of Participation Final Rule-9/30/2019

Condition of Participation- Infection Control and Antibiotic Stewardship Programs

“An implementation date that is six months from this final rule” End of March, 2020

A Standard Is Only As Good As Its Enforcement

Box checking enforcement will drive box checking behavior.

But, enforcement that is aware of advances, informed by experts and

adapts to input has the power to educate and drive implementation of

best practices.

Using Accreditation To Drive Improvement

What are key things surveyors can look for and questions they can ask that

would:

– Help get the best sense of how good the stewardship program is- how

do we make sure people aren’t just “checking the boxes”?– Direct stewardship programs to policies and practices that are most

effective?

How can we embed this work into the existing survey process?

More to come on this . . .

We Need More Riders: Critical Role of Bedside Nurses in Stewardship

Nurses can play a critical role when they know the process and can watch

for omissions.

Nurses are key in prompting the provider/team to perform key actions

that might get overlooked.

Nurses are critical in patient and family education.

CDC partnering with Johns Hopkins on a project to engage nurses in

stewardship.

The project is focused on:

– Collection of urine cultures- why and how

– Collection of respiratory cultures- why and how

– Assessment of penicillin allergy

De-escalate Anti-MRSA Coverage

Avoid Treatment of ASB

Limit Antibiotic Duration

Avoid Duplicative Anaerobic Coverage

Verify Penicillin Allergy Stewardship Pharmacy

Posters to be launched soon:

Engage all pharmacists in

stewardship

Suggestions for hospital

stewardship

implementation and/or

quality improvement

projects

Antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses (ARIs)* by outpatient setting — MarketScan, 2014

*Antibiotic-inappropriate ARIs include: Viral URI, bronchitis, bronchiolitis; influenza; nonsuppurative otitis media; viral pneumonia; asthma/allergy. Visits

with additional diagnoses of concomitant bacterial infections (e.g. pneumonia, urinary tract infections, acute otitis media, sinusitis) were excluded.

Palms D, Hicks L, Hersh AL, et al. JAMA Int Med. E-Publish Ahead of print July 16, 2018.

45.7%

24.6%17.0% 14.4%201,682

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500,000

1,000,000

1,500,000

2,000,000

Urgent Care Emergency

Department

Office Retail Health

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% Antibiotic-Inappropriate ARIs with Antibiotics

No. Antibiotic-Inappropriate ARIs with Antibiotics

Respiratory infections are major drivers of antibiotic use in outpatient settings.

2%

5%

5%

7%

8%

9%

9%

11%SinusitisAcute otitis media

Pharyngitis

Skin and soft tissue infections

Urinary tract infections

Bronchitis

Viral upper respiratory infection

Pneumonia

Top diagnoses leading to antibiotic prescriptions in US doctors’ offices and emergency departments, 2010-2011

Fleming-Dutra et al. JAMA. 2016;315(17):1864-1873.

Interventions resulted in decreases in antibiotic prescription rates for all ARIs.

0.58

0.87

0.59

0.40

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2

URI &

Prevalence rate ratio for antibiotic prescribing for ARI post versus

Pharyngitis

Sinusitis

All

uncomplicated

ARIs

Madaras-Kelly et al. IDWeek 2018

Kabbani et al. J Am Geriatr Soc. 2018 Oct;66(10):1998-2002.

Among older adults, fluoroquinolones account for 22%

of all antibiotics prescribed.

Next Steps in Outpatient Stewardship

IQVIA is allowing every state to access data on top antibiotic prescribers

for multiple specialties.

CDC is working with state health departments on efforts to send letters to

top prescribers.

– Letting them know that they are an outlier

– Offering resources to assess and potentially improve prescribing

CDC also working with the urgent care community.

– Assessing ways to improve antibiotic prescribing in urgent care

– Working on an accreditation standard for stewardship in urgent care.


Working with the Health Services Resource Administration (HRSA) on ways

to expand outpatient stewardship in federally qualified rural health

centers.

– There are thousands of these clinics around the country

Working with the National Center for Quality Assurance on expanding

Health Effectiveness Data Information Set (HEDIS) measures for outpatient

prescribing.

– We’re trying to develop a composite measure for outpatient antibiotic prescribing.


Collaborating with CDC opioid to explore opportunities for synergy

between efforts to improve opioid and antibiotic prescribing.

– Bottle of amoxicillin directions: “Take as needed for pain”

Conclusions

We know that real progress in improving use comes from the work that

you do every day.

Our goal is to support you.

Please tell us what we can do to help!

Self assessment question

The revised CDC Core Elements for Hospital Antibiotic Stewardship

Programs will emphasize which of these as the two most important

priorities for stewardship actions:

– Time outs and penicillin allergy testing

– Prospective audit with feedback and prior authorization

– Automatic stop orders and order sets

– Community acquired pneumonia and urinary tract infections

treatment guidelines

Self assessment question

The revised CDC Core Elements for Hospital Antibiotic Stewardship

Programs will emphasize which of these as the two most important

priorities for stewardship actions:

– Time outs and penicillin allergy testing

– Prospective audit with feedback and prior authorization

– Automatic stop orders and order sets

– Community acquired pneumonia and urinary tract infections

treatment guidelines

Documents

An Update on National Stewardship Activities 2019 · in improving antibiotic use in outpatient settings, but there is limited experience with these reports for hospital-based providers