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

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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……

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.

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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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RateDaysPresent alllocations

AU Mean

SHS Mean

Linear (RateDaysPresentall locations)

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RateDaysPresentEtrapenem

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RateDaysPresentcefazolin

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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”

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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Total DOT Inpatient DOT Discharge DOT

CHA UTI Baseline (63) Intervention (110)

0% 2%

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49%

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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

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CHA SSTIBaseline (8) Intervention (25)

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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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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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Cephalosporin Quinolone Nitrofurantoin SMZTMP Abx changes Abx resistant Quinolineordered, ceph

sensitive

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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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RateDaysPresentVancomycin

AU Mean

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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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RateDaysPresentPip/Tazo

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Linear (RateDaysPresentPip/Tazo)

• Increase our efforts to de-escalate antibiotic choice• Increase our education of provider staff on days of

therapy needed to treat

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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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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

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