IMPACT OF ANTIMICROBIAL STEWARDSHIP INTERVENTIONS ON ANTIBIOTIC PRESCRIBING BY EMERGENCY DEPARTMENT PHYSICIANS FOR THE OUTPATIENT MANAGEMENT OF URINARY TRACT

INFECTIONS

Mariah Cadavos

PGY1 Pharmacy Practice Resident

Providence Alaska Medical Center – Anchorage, AK

IRB Status: Approved

Disclosure

• Speaker: Mariah Cadavos• Potential conflicts of interest – none

• Financial support – none

• The research presented is subject to different interpretation

• This presentation is educational in nature and abides by non-commercial guidelines

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Abbreviations

• AMS = antimicrobial stewardship program

• ED = emergency department

• FQ = fluoroquinolone

• PAMC = Providence Alaska Medical Center

• UTI = urinary tract infection

• SMX-TMP = sulfamethoxazole-trimethoprim

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Learning Objectives

• Identify the most common pathogen known to cause UTIs

• Describe possible effects of local guideline on prescribing patterns for outpatient management of UTIs

• Identify potential areas for pharmacy intervention to improve prescribing practices

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Pre-Assessment

1. The most common pathogen known to cause UTIs is:A. Coagulase-negative StaphylococcusB. Enterococcus faecalisC. Escherichia coli

2. Utilization of ____ decreased in patients w/ acute cystitis after implementation of the UTI guideline.A. LevofloxacinB. CephalexinC. Sulfamethoxazole-Trimethoprim

3. What is an intervention pharmacists can make when managing antibiotics for UTIs? Select all that apply.A. Optimizing duration of antibioticsB. Tailoring antibiotic choice based on patient specific factors (allergies, administration preference)C. Implementing an AMS guideline

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Providence Alaska Medical Center

• Tertiary, non-profit, community medical center

• Level II trauma center

• Largest hospital in Alaska• 402 beds

• 62 emergency department beds

• AMS program• Implemented August 2013

• PharmD – Full Time

• MD – Part Time

• ED pharmacy service• Implemented October 2018

• Pharmacist coverage from 0700 - 0200

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Anchorage, AK

https://www.architectsalaska.com/project/providence-hospital/

Background

• In 2015, CDC reported that UTIs are amongst the twenty leading primary diagnosis groups in the ED• 2.2 million visits/year

• 1.8 million females

• UTIs most commonly caused by Escherichia coli (E.coli)• PAMC susceptibility rates

• 79% SMX-TMP

• 81% Cefazolin

• 85% Ciprofloxacin/Levofloxacin

• Effective antibiotic selection is imperative to reduce resistance and promote high quality, cost effective care

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Methodology• Retrospective pre-/post guideline implementation chart review of patients diagnosed w/

acute cystitis or acute pyelonephritis

• Time period: April 1, 2016 – August 31, 2018

• AMS ”PAMC Adult Emergency Department UTI Treatment Guidelines” were implemented April 1, 2017• Reviewed patients 1 year prior to and after guideline• Reviewed patients a brief time period after ED pharmacy service implementation

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Primary ObjectiveEmpiric antibiotic, dose, frequency, and duration

vs. “PAMC Adult Emergency Department UTI Treatment Guideline” recommendations

Empiric Antibiotic Recommendations

Acute Cystitis

First Line:

1. Nitrofurantoin 100 mg BID x 5 d

2. Cephalexin 500 mg BID x 7 d

3. *Ciprofloxacin 250 mg BID x 3 d

Acute Pyelonephritis

Consider administration of initial single dose IM antibiotic:

1. Ceftriaxone 1 gm IM/IV

2. Gentamicin 3 mg/kg IM

Followed by:

1. Cephalexin 1 g TID x 14 d

2. Levofloxacin 750 mg daily x 5 d

3. Ciprofloxacin 500 mg BID x 7 d

9*only use when no other alternatives exist

Methodology

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Inclusion Criteria Exclusion Criteria

• > 18 years of age• Admitted and discharged directly from

the ED• Primary/secondary diagnosis of

uncomplicated cystitis or pyelonephritis (ICD 10 codes)

• < 18 years of age• Known structural/functional abnormalities of the

genitourinary system• Immunocompromised (i.e. kidney transplant

recipients)• Urinary tract instrumentation within the

preceding 7 days• Currently on suppressive antibiotic therapy for

UTI prophylaxis• Concomitant infections• Boarded in the ED > 48 hrs• Pregnant• Catheterized• Incarcerated

Baseline Characteristics

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Pre-Guideline(n = 71)

Post-Guideline(n=143)

P-value(X2)

Age (range) 41 (18-92) + 20 43 (19-91) + 20 0.54

Male, n (%) 6 (8) 21 (14.7) 0.20

Female, n (%) 65 (92) 122 (85.3)

Acute Cystitis 37 (52) 93 (65)0.07

Acute Pyelonephritis 34 (48) 50 (35)

CrCl < 60 ml/min, n (%) 7 (9.8) 12 (8.3) 0.13

Known diabetes, n (%) 11 (15.4) 24 (16.8) 0.06

Antibiotics in past 90 days, n (%) 8 (11.3) 19 (13.3) 0.16

History of recurrent UTI, n (%) 9 (12.7) 7 (4.9) 0.04

Urine culture E. coli, (100k CFUs), n (%)

22 (31%) 29 (20%) 0.09

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Pre-Guideline(n = 71)

Post-Guideline(n=143)

P-value(X2)

Guideline antibiotic at discharge, n (%) 47 (66) 86 (60) 0.39

Guideline antibiotic regimen at discharge, n (%) 2 (2.8) 25 (17.4) 0.002

• Acute cystitis 1 (1.4) 19 (13.2)--

• Acute pyelonephritis 1 (1.4) 6 (4.2)

Bug-drug mismatch 5 (7.0) 5 (3.4) 0.25

Results

*Applies to patients requiring new prescription after susceptibility report resulted

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Antibiotic Utilization Acute Cystitis

PRE AND POST GUIDELINE

Levofloxacin prescribing (p<0.02)

14%

46%

14%

8%

19%

24%

57%

12%

0%

8%

0%

10%

20%

30%

40%

50%

60%

NITROFURANTOIN CEPHALEXIN CIPROFLOXACIN LEVOFLOXACIN SMX-TMP

% U

SAG

E

ANTIBIOTIC

PRE-GUIDELINE POST-GUIDELINE

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Antibiotic UtilizationAcute Pyelonephritis

PRE AND POST GUIDELINE

SMX-TMP prescribing (p<0.003)

Cephalexin prescribing (p<0.002)

3%

29%

24%

9%

24%

2%

66%

14%

8%

2%

0%

10%

20%

30%

40%

50%

60%

70%

NITROFURANTOIN CEPHALEXIN CIPROFLOXACIN LEVOFLOXACIN SMX-TMP

% U

SAG

E

ANTIBIOTIC

PRE-GUIDELINE POST-GUIDELINE

Antibiotic Utilization

• Acute Cystitis• Empiric levofloxacin use decreased (p<0.02)

• Acute Pyelonephritis• Empiric SMX-TMP use decreased in patients diagnosed w/ acute pyelonephritis

(p<0.003)

• Not recommended in guideline, in response to resistance rates

• Empiric cephalexin use increased after guideline implementation

• Appropriate

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ResultsClinical Outcomes

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Pre-Guideline(n=71)

Post-Guideline(n=143)

P-value(X2)

30 day UTI readmission rate, n (%) 1 (1.4) 5 (3.5) 0.38

90 day UTI readmission rate, n (%) 0 1 (0.7) --

Conclusion

• Implementation of an AMS guideline for outpatient management of UTIs led to increased adherence to appropriate to antibiotic regimen

• Implementation of an AMS guideline did not show any difference in 30 and 90 day readmission rates for UTIs

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Discussion

• Future Directions• ED pharmacy urine culture callbacks

• Limitations• Retrospective chart review

• Small sample size

• Single institution

• Only included patients with acute cystitis and acute pyelonephritis

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Post-Assessment

1. The most common pathogen known to cause UTIs is:A. Coagulase-negative StaphylococcusB. Enterococcus faecalisC. Escherichia coli

2. Utilization of ____ decreased in patients w/ acute cystitis after implementation of the UTI guideline.A. LevofloxacinB. CephalexinC. Sulfamethoxazole-Trimethoprim

3. What is an intervention pharmacists can make when managing antibiotics for UTIs? Select all that apply.A. Optimizing duration of antibioticsB. Tailoring antibiotic choice based on patient specific factors (allergies, administration preference)C. Implementing an AMS guideline

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Acknowledgements

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Ali Pryne, PharmD

• Clinical Pharmacist – Emergency Department

Elaine Reale, PharmD

• Pharmacy Clinical Manager

• PGY1 Residency Program Director

References1. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta GA: US Department of Health and

Human Services, CDC; 2014. Available at https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed July 12th, 2018.

2. Dumkow LE, Kenney RM, MacDonald NC, et al. Impact of a multidisciplinary culture follow-up program of antimicrobial therapy in the emergency department. Infect Dis Ther 2014; 3:45–53.

3. Frazee BW, Trivedi T, Montgomery M, Petrovic DF, Yamaji R, Riley L. Emergency Department Urinary Tract Infections Caused by Extended-Spectrum B-Lactamase-Producing Enterobacteriaceae: Many Patients Have No Identifiable Risk Factor and Discordant Empiric Therapy is Common. Ann Emerg Med 2018; pii: S0196-0644(18)30415-3.

4. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf. Accessed 13 July 2018.

5. Shlaes DM, Gerding DN, John JF Jr, Craig WA, Bornstein DL, Duncan RA, et al. Society for Health Care Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals. Clin Infect Dis. 1997 Sep; 25(3):584-99.

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