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NationalCenterforEmergingandZoonoticInfectiousDiseases

CoreElementsofOutpatientAntibioticStewardship:

ImplementingAntibioticStewardshipIntoYourOutpatientPractice

MelindaNeuhauser,PharmD,MPH

OfficeofAntibioticStewardshipDivisionofHealthcareQualityPromotionNationalCenterforEmergingandZoonoticInfectiousDiseasesCentersforDiseaseControlandPrevention

May16,2016

Objectives

§ Defineantibioticstewardship.

§ Describeoutpatientantibioticuse.

§ Discussopportunitiesforpharmaciststoplayaroleinimprovingantibioticuseintheoutpatientsetting.

Life-SavingBenefitsofAntibiotics§ Oncedeadlyinfectiousbacterialdiseasesaretreatable,

substantiallyreducingdeathscomparedtopre-antibioticera

§ Importantadjuncttomodernmedicaladvances– Surgeries– Transplants– Cancertherapies

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AntibioticResistance

CDC.AntibioticresistancethreatsintheUnitedStates,2013.www.cdc.gov/drugresistance/threat-report-2013/

$20billioninexcessdirecthealthcarecostsannually

AntibioticUseDrivesResistance

http://www.cdc.gov/drugresistance/about.html

Dateofantibioticintroduction

Penicillin1943

Methicillin1960

Vancomycin1972

Levofloxacin1996

Ceftaroline2010

Dateofresistanceidentified

1940Penicillin-R

Staphylococcus

1962Methicillin-R

Staphylococcus

1988Vancomycin-REnterococcus

1996Levofloxacin-RStreptococcus

2011Ceftaroline-RStaphylococcus

It’saMatterofPatientSafety

§ Adverseeventsfromantibioticsrangefromminortosevere

– Sideeffectslikerashorantibiotic-associateddiarrhea

– Allergicreactions,includinganaphylaxis(life-threatening)

§ 1in1000antibioticprescriptionsleadstoanemergencydepartment(ER)visitforanadverseevent

– 142,000ERvisitsperyearforantibiotic-associatedadverseevents

– Antibioticsaremostcommoncauseofdrug-relatedemergencydepartmentvisitsforchildren

§ Long-termconsequences:growingevidencethatantibioticsassociatedwithchronicdiseasethroughdisruptionofthemicrobiotaandmicrobiome

Shehab,etal.ClinInfectDis.2008Sep15;47(6):735-43.Bourgeois,etal.Pediatrics. 2009;124(4):e744-50.Linder.ClinInfectDis.2008Sep15;47(6):744-6.Vangay,etal.Cellhost&microbe2015;17(5):553-564.

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It’saMatterofPatientSafety:Clostridiumdifficile

Morerecentestimate:453,000infectionsandcaused15,000deathsintheUSannually

CDC.AntibioticresistancethreatsintheUnitedStates,2013.www.cdc.gov/drugresistance/threat-report-2013/LessaNEJM2015;372(9):825-34

AntibioticExpendituresinUnitedStatesbyTreatmentSetting

Sudaetal.JAntimicrobChemother2013;68:715–718https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_Report_2014__3_.pdf.https://www.folkhalsomyndigheten.se/pagefiles/20281/Swedres-Svarm-2014-14027.pdf.

Estimate80-90%ofantibioticuseoccurringinoutpatientsetting

Fleming-Dutraetal.JAMA2016;315(17):1864-1873.http://www.pewtrusts.org/~/media/assets/2016/05/antibioticuseinoutpatientsettings.pdf;

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WhatisAntibioticStewardship?§ Antibioticstewardshipistheeffortto:

– Measureantibioticprescribing– Improveantibioticprescribingsothatantibioticsare

onlyprescribedandusedwhenneeded– Minimizemisdiagnosesordelayeddiagnosesleading

tounderuseofantibiotics– Ensurethattherightdrug,dose,anddurationare

selectedwhenanantibioticisneeded

It’saboutpatientsafetyanddeliveringhigh-qualityhealthcare.

CDC’sCoreElementsofAntibioticStewardshipforHospitalsandNursingHomes

SanchezGV,Fleming-DutraKE,RobertsRM,HicksLA.CoreElementsofOutpatientAntibioticStewardship.MMWRRecommRep2016;65(No.RR-6):1-12.https://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e

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Who are the Core Elements of Outpatient Antibiotic Stewardship intended for?

InitialStepsforOutpatientAntibioticStewardship

– Conditionsforwhichantibioticsareoverprescribed– Conditionswhichareoverdiagnosed– Conditionsforwhichthewrongdose,durationoragentoftenis

selected– Conditionsforwhichwatchfulwaitingordelayedprescribingis

underused– Conditionsforwhichantibioticsareunderusedortheneedfor

timelyantibioticsisn’trecognized


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TheCoreElementsofOutpatientAntibioticStewardship§ Commitment:demonstratededicationtoand

accountabilityforoptimizingantibioticprescribingandpatientsafety

§ Actionforpolicyandpractice:implementatleastonepolicyorpracticetoimproveantibioticprescribing,assesswhetheritisworking,andmodifyasneeded

§ TrackingandReporting:monitorantibioticprescribingpracticesandofferregularfeedbacktocliniciansorhavecliniciansassesstheirownantibioticuse

§ EducationandExpertise: Provideeducationalresourcestocliniciansandpatientsonantibioticprescribingandensureaccesstoneededexpertiseonantibioticprescribing

https://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.html

Commitment§ Demonstratededicationtoandaccountabilityforoptimizingantibioticprescribing

andpatientsafetybydoingoneofthefollowing:

Clinicians Organizational Leadership

• Write and display public commitments in support of antibiotic stewardship

• Identify a single leader to direct antibiotic stewardship activities within a facility

• Include stewardship-related duties in position descriptions or job evaluation criteria

• Communicate with all clinic staff to set patient expectations

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PublicCommitmentPosters§ Simpleintervention:poster-placedinexamroomswithclinicianpictureandcommitmenttouse

antibioticsappropriately§ Randomized-controlledtrial§ Principleofbehavioralscience:desiretobeconsistentwithpreviouscommitments§ “Behavioralnudge”tomaketherightchoice

“Asyourdoctors,wepromisetotreatyourillnessinthebestwaypossible.Wearealsodedicatedtoavoidprescribingantibioticswhentheyarelikelydotomoreharmthangood.”

§ Adjustedabsolutereductionininappropriateantibioticprescribing:-20%comparedtocontrols,p=0.02

Meekeretal.JAMAInternMed.2014;174(3):425-31.

CommitmentPostersinIllinois,TexasandNewYork

http://blogs.cdc.gov/safehealthcare/?p=5900

PutaCommitmentPosterinYourClinic!§ CDCworkedwiththeauthorsofthestudytocreatea

postertemplatefordownload§ WillbecominginSpanish§ Addyourpictureandsignature§ Placeinyourexaminationrooms

§ Availableat:https://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/index.html

Addyourpictureandsignaturehere

Meekeretal.JAMAInternMed.2014;174(3):425-31.

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Commitment§ Demonstratededicationtoandaccountabilityforoptimizingantibioticprescribing

andpatientsafetybydoingoneofthefollowing:


• Write and display public commitments in support of antibiotic stewardship

• Identify a single leader to direct antibiotic stewardship activities within a facility

• Include stewardship-related duties in position descriptions or job evaluation criteria

• Communicate with all clinic staff to set patient expectations

Action§ Implementatleastonepolicyorpracticetoimproveantibioticprescribing,assess

whetheritisworking,andmodifyasneeded


• Use evidence-based diagnostic criteria and treatment recommendations

• Use delayed prescribing practices or watchful waiting, when appropriate

• Provide communications skills training for clinicians

• Require explicit written justification in the medical record for nonrecommended antibiotic prescribing

• Provide support for clinical decisions

• Use call centers, nurse hotlines, or pharmacist consultations as triage systems to prevent unnecessary visits

http://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/index.html

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Action§ Implementatleastonepolicyorpracticetoimproveantibioticprescribing,assess

whetheritisworking,andmodifyasneeded


• Use evidence-based diagnostic criteria and treatment recommendations

• Use delayed prescribing practices or watchful waiting, when appropriate

• Provide communications skills training for clinicians

• Require explicit written justification in the medical record for nonrecommended antibiotic prescribing

• Provide support for clinical decisions

• Use call centers, nurse hotlines, or pharmacist consultations as triage systems to prevent unnecessary visits

CommunicationTrainingasanAntibioticStewardshipIntervention§ Enhancedcommunicationtrainingreducesantibioticprescribingforrespiratoryinfectionsinallages

whilemaintainingpatientsatisfaction

§ Communicationgoals– Understandingthepatient’sexpectations– Explainingwhyantibioticswill/willnothelp– Providingsymptomaticrecommendations– Discussingwhentoreturnifthepatientisnotbetter

§ Effectappearstobesustainableovertime

Calsetal.AnnFamilyMed2013;11(2)157-64.Littleetal.Lancet 2013:382(9899)1175-82.

TrackingandReporting§ Monitorantibioticprescribingpracticesandofferregularfeedbacktocliniciansor

havecliniciansassesstheirownantibioticprescribingpracticesthemselves


• Self-evaluate antibiotic prescribing practices

• Participate in continuing medical education and quality improvement activities to track and improve antibiotic prescribing

• Implement at least one antibiotic prescribing tracking and reporting system

• Assess and share performance on quality measures and established reduction goals addressing appropriate antibiotic prescribing from health care plans and payers

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TrackingandReporting§ Monitorantibioticprescribingpracticesandofferregularfeedbacktocliniciansor

havecliniciansassesstheirownantibioticprescribingpracticesthemselves


• Self-evaluate antibiotic prescribing practices

• Participate in continuing medical education and quality improvement activities to track and improve antibiotic prescribing

• Implement at least one antibiotic prescribing tracking and reporting system

• Assess and share performance on quality measures and established reduction goals addressing appropriate antibiotic prescribing

WhatShouldYouTrackandReportinYourOutpatientFacility?§ Decisionsshouldbemadeineachpracticeorfacilitybasedonyouropportunitiesforimprovement§ Options:

– Antibioticprescribingforoneormorehigh-priorityconditions(e.g.acutebronchitis)– Percentageofallvisitsleadingtoantibioticprescriptions– Atthelevelofahealthcaresystem

• Complicationsofantibioticuse(e.g.adversedrugevents,C.difficile infections)• Antibioticresistancetrendsamongcommonoutpatientbacterialpathogens

TrackingandReportingwithPeerComparisons§ Effectivefeedbackinterventionsoftenincludepeerperformancecomparisons

– Comparingclinician’santibioticselectionpatternsforrespiratoryconditionstocolleagues’performance1

• Ledtoincreaseduseofguidelinerecommendedagents

– Comparingclinician’spercentageofinappropriateantibioticprescribingforacuterespiratoryconditionsto“top-performers”intheirpractice 2

• Ledtodecreasedinappropriateantibioticprescribingforacuterespiratoryinfectionsthatshouldnotbetreatedwithantibiotics(e.g.coldsandacutebronchitis)

– Notifyingcliniciansthattheyprescribemoreantibioticsthan80%oftheirpeers,basedonthepercentageallvisitsleadingtoantibioticprescriptions3

• Ledtodecreasedoverallantibioticprescribingandcost-savings

1.Gerber.JAMA 2013;309(22):2345-2352.2.Meekeretal.JAMA 2016;315(6): 562-570.3.Hallsworthetal.Lancet 2016;387(10029):1743-1752.

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EducationandExpertise§ Provideeducationalresourcestocliniciansandpatientsonantibioticprescribing

andensureaccesstoneededexpertiseonoptimizingantibioticprescribing.


• Use effective communications strategies to educate patients about when antibiotics are and are not needed

• Educate about the potential harms of antibiotic treatment

• Provide patient education materials

• Provide face-to-face educational training (academic detailing)

• Provide continuing education activities for clinicians

• Ensure timely access to persons with expertise

EducatingPatientsThroughEffectiveCommunication§ Clinicianscitepatientdemandforantibioticsasareasontheyprescribeinappropriately1

– Cliniciansarenotverygoodatcorrectlydeterminingwhichpatientswantantibiotics2

– Cliniciansaremorelikelytoprescribeantibioticswhentheythinkthatthepatientwantsthem2

§ Patientscanbesatisfiedwithoutantibiotics,eveniftheyexpectthem,witheffectivecommunication– Combiningexplanationsofwhyantibioticsarenotneededwithrecommendationsformanaging

symptomshavebeenassociatedwithincreasedvisitsatisfaction3

– Providingrecommendationsofwhentoseekmedicalcareifthepatientworsensordoesn’timprove(i.e.acontingencyplan)hasbeenassociatedwithincreasedsatisfactionforpatientswhoexpectedantibioticsbutdidnotreceivethem4

1.Sanchez,EID;2014;20(12);2041-7.2.Mangione-SmithPediatrics 1999;103(4):711-8.3.Mangione-SmithAnnFamilyMed2015;13(3)221-7.4.Mangione-SmithArchPediatrAdolescMed2001;155:800-6.

EducationandExpertise§ Provideeducationalresourcestocliniciansandpatientsonantibioticprescribing

andensureaccesstoneededexpertiseonoptimizingantibioticprescribing§ Inappropriateantibioticprescribingisrarelyduetoclinicalknowledgegapsalone


• Use effective communications strategies to educate patients about when antibiotics are and are not needed

• Educate about the potential harms of antibiotic treatment

• Provide patient education materials

• Provide face-to-face educational training (academic detailing)

• Provide continuing education activities for clinicians

• Ensure timely access to persons with expertise

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www.cdc.gov/getsmart

http://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.htmlMedscapevideo:http://www.medscape.com/viewarticle/871205?src=par_cdc_stm_mscpedt&faf=1

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https://www.whitehouse.gov/the-press-office/2016/11/10/presidential-proclamation-get-smart-about-antibiotics-week-2016

Summary§ Antibioticstewardshipisoneofthemostimportantstrategiestocombatantibioticresistanceand

keepourpatientssafe

§ TheCoreElementsofOutpatientStewardshipprovidesaframeworkforimprovingoutpatientantibioticprescribing

§ TheCoreElementsofOutpatientStewardshipincludethefollowing:– Commitment– ActionforPolicyandPractice– TrackingandReporting– EducationandExpertise

§ Wecanallbeantibioticstewards— pleaseimplementtheCoreElementsinyourpractice!

Formoreinformation,contactCDC1-800-CDC-INFO(232-4636)TTY:1-888-232-6348www.cdc.gov

ThefindingsandconclusionsinthisreportarethoseoftheauthorsanddonotnecessarilyrepresenttheofficialpositionoftheCentersforDiseaseControlandPrevention.

www.cdc.gov/[email protected]

Acknowledgements:MemoSanchez,RebeccaRoberts,LauriHicks

JonathanA.Finkelstein,JeffreyS.Gerber,AdamL.Hersh,DavidY.Hyun,JeffreyA.Linder,LarissaS.May,DanielMerenstein,KatieJ.Suda,RachelZetts,KellyO’Neill,AustynDukes,RachelRobb,MeredithReagan