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Presenter:Marc Meyer, BPharm, RPh, CIC, FAPIC
Clinical Pharmacists, Infection Preventionist,Antibiotic
Stewardship Pharmacist
Southwest Health System, Cortez, Colorado
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None
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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.
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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.
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The Review on Antimicrobial Resistance, 2014
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The Review on Antimicrobial Resistance, 2014
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CDC. Antibiotic resistance threats in the United States, 2013.
www.cdc.gov/drugresistance/threat-report-2013/
$20 billion in added direct healthcare costs annually
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2011-14 antibiotic prescribingAll ages: decreased 5%
Pediatric: decreased 14%Adults: no change
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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
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540 hospitals enrolled46 states and DC46 CAH97
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
SHS ALL SAAR MS
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
SHS ALL SAAR ICU
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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……
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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
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?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!
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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.
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0
50
100
150
200
250
300
350
400
450
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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0
100
200
300
400
500
600
700
RateDaysPresent alllocations
AU Mean
SHS Mean
Linear (RateDaysPresentall locations)
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-10
0
10
20
30
40
50
RateDaysPresentEtrapenem
SHS Mean
Linear(RateDaysPresentEtrapenem)
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0
10
20
30
40
50
60
70
80
2016
M01
2016
M02
2016
M03
2016
M04
2016
M05
2016
M06
2016
M07
2016
M08
2016
M09
2016
M10
2016
M11
2016
M12
2017
M01
2017
M02
2017
M03
2017
M04
2017
M05
2017
M06
2017
m07
2017
M08
2017
M09
2017
M10
2017
M11
RateDaysPresentcefazolin
SHS Mean
Linear (RateDaysPresentcefazolin)
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0
20
40
60
80
100
120
140
RateDaysPresentceftriaxone
AU Mean
SHS Mean
Linear(RateDaysPresentceftriaxone)
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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”
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Yes
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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.
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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.
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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
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◦ 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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9
5
7
9
4
6
Total DOT Inpatient DOT Discharge DOT
CHA UTI Baseline (63) Intervention (110)
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0% 2%
44%41%
49%
21% 21%
2% 3%
20% 19%
72%
7% 9%
CHA UTIBaseline Intervention
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◦ Reduction from baseline in duration of treatment◦ Reduction
from baseline in broad gram-negative antibiotic use◦Monitor C.
difficile rates using NHSN◦ Education event
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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
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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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9 9
8
6.5 6.6
5.9
0
1
2
3
4
5
6
7
8
9
10
DOT Adult DOT Ped DOT
Baseline UTI DOT
Intervention 1 UTI DOT
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30
26
43
29 30 28
0
5
10
15
20
25
30
35
40
45
50
RX Rate Adult Rate Ped Rate
Baseline UTI RX RATE
Intervention 1 UTI RX RATE
-
30
40
9
2931
8
0
5
10
15
20
25
30
35
40
45
Quinolone Rate Adult Quinolone Rate Ped Quinolone Rate
Baseline UTI Quin Rate
Intervention 1 UTI Quin Rate
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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
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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
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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
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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
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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
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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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9
8
10
7 7 7
0
2
4
6
8
10
12
DOT DOT No culture DOT Culture
Pre-intervention
Intervention
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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
0
50
100
150
200
250
300
350
Pre-intervention Intervention
27% Reduction
UTI DX EMR
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◦ 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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0
0.5
1
1.5
2
2.5
2017M012017M022017M032017M042017M052017M062017M072017M082017M092017M102017M11
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0
20
40
60
80
100
12020
16M
01
2016
M02
2016
M03
2016
M04
2016
M05
2016
M06
2016
M07
2016
M08
2016
M09
2016
M10
2016
M11
2016
M12
2017
M01
2017
M02
2017
M03
2017
M04
2017
M05
2017
M06
2017
M07
2017
M08
2017
M09
2017
M10
2017
M11
RateDaysPresentVancomycin
AU Mean
SHS Mean
Linear(RateDaysPresentVancomycin)
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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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0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Mean
-
0
20
40
60
80
100
120
2016
M01
2016
M02
2016
M03
2016
M04
2016
M05
2016
M06
2016
M07
2016
M08
2016
M09
2016
M10
2016
M11
2016
M12
2017
M01
2017
M02
2017
M03
2017
M04
2017
M05
2017
M06
2017
M07
2017
M08
2017
M09
2017
M10
2017
M11
RateDaysPresentPip/Tazo
AU Mean
SHS Mean
Linear (RateDaysPresentPip/Tazo)
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• 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
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Clinic stewardship Hospital stewardship LTC stewardship Dental
stewardship
Can they make an impact in small communities? You decide?
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9 9
8
6.5 6.6
5.9
0
1
2
3
4
5
6
7
8
9
10
DOT Adult DOT Ped DOT
Baseline UTI DOT
Intervention 1 UTI DOT
-
0
2
4
6
8
10
12
14
16
18
20
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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11
4
7
9
3
7
Total DOT Inpatient DOT Discharge DOT
CHA SSTIBaseline (8) Intervention (25)
9
5
7
9
4
6
Total DOT Inpatient DOT Discharge DOT
CHA UTI Baseline (63) Intervention (110)
-
0
100
200
300
400
500
DOT
Mean
Linear (DOT)
-10
0
10
20
30
40
50
RateDaysPresentEtrapenem
SHS Mean
Linear(RateDaysPresentEtrapenem)
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98
10
7 7 7
0
2
4
6
8
10
12
DOT DOT Noculture
DOTCulture
Pre-intervention
Intervention
320233
050
100150200250300350
27% Reduction UTI DX
UTI DX EMR
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0
10
20
30
40
50
60
70
80
90
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
25 26 27 28 29 30 31 32 33 34 35 36
MDR
Mean
LTC project launch
Clinic Project Launch
Stewardship team officially formed
MDR tracking began
SSTI and UTI Hospital project
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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.
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Marc J. Meyer R.Ph, BPharm, CIC, FAPIC970-564-2194
[email protected]
Stewardship: Success and Failures�A Limited-Resources
Approach�DisclosuresObjectivesSouthwest Health SystemGloom and Doom
in 2050!Slide Number 6Antibiotic Resistance TodayHave we made any
progress?Antibiotic CostsAsolva and NHSN ToolsAsolva AUAsolva
AUAsolva Medici ASPNHSN AU Data 12-2017NHSN AUNHSN AUSAARSAARWhy is
ASP and IP Important? Does ASP Save Dollars? Impact of a National
EffortDoes ASP save dollars: DOTDoes ASP save dollars: Rate DaysUse
of EtrapenemUse of CefazolinUse of CeftriaxoneShorter Is BetterDoes
ASP Save Dollars?How to Develop GuidanceProject GoalsFirst
AttemptsCHA UTI Project Goals Slide Number 35CHA SSTI Project
GoalsSlide Number 37Slide Number 38Clinic Project UTIClinic Data
UTIClinic Data UTIClinic Data UTIDental Stewardship�What Are
Dentists Prescribing?British Dental Journal 2009�British Dental
Journal 2011�British Dental Journal 2011�Tips for Responsible
Dental Antibiotic PrescribingCG Healthcare LTC ProjectDays of
TherapyAntibioticUTI’s Qualifying for AntibioticsDid we meet
goals?�What Drives My ASP? MRSA SAAR Vancomycin Rate DaysVancomycin
AuditWhat Drives My ASP? MDR SAAR Rate Days Pip/TazoSlide Number
59Slide Number 60Community stewardship Successful Intervention:
Clinic Successful Intervention: Hospital Successful Intervention:
Hospital Successful Intervention: HospitalSuccessful Intervention:
LTCCommunity Stewardship: MDR Reduction�Conclusions��Feel free to
call or email.�Thanks
