Download IDSA 2012 Poster - ABSSSI Project - PasqualeT

Evaluation of the Impact of an Antimicrobial Stewardship Program
in Patients with Acute Bacterial Skin and Skin Structure Infections
(ABSSSI) at a Teaching Hospital
Poster Number 744
IDSA 2012
TR
1
Pasquale ;
1Department
Abstract (Revised)
Background: ABSSSIs are often associated with unnecessary use of
broad-spectrum antibiotics; this use is a potential target for
Antimicrobial Stewardship. In 2011, the average length of stay (LOS) at
Summa Health System for ABSSSIs (ICD9 code 681-682.9) was 6.2
days, and 30-day ABSSSI readmission rate was 6.2%. Incorporating a
key hospital initiative of reducing LOS, a decision was made to have
Antimicrobial Stewardship Program (ASP) evaluate all patients
admitted with ABSSSI for appropriateness of therapy. The primary
objective of this study was to observe the impact of ASP on LOS, 30day ABSSSI readmission rate, and antimicrobial use.
Methods: In February 2012, the ASP began to evaluate patients
admitted with ABSSSI. Patients are identified via Emergency
Department admission list of the previous 24 hours. Clinical Pharmacist
and ID physician prospectively review patient’s clinical status and
antimicrobial therapy regimen and provided feedback to attending
physicians.
Results: In this ongoing study, ASP intervened on 62 patients. Patient
average age was 56 (range 19-90); 33 (53%) were male; 22 (35%) had
diabetes mellitus. Lower extremity (52%) was the most common site.
The intervention group LOS was 4.4 days compared to 6.2 days for
historical data (p < 0.001). The 30-day ABSSSI readmission rate was
3% compared to 6.2% for historical data (p = 0.483). The ABSSSI
subtype and interventions include:
ABSSSI Subtype:
Cellulitis
Major or deep abscess
Surgical Site Infection
Diabetic Wound
Intervention Type:
No. (%) of patients
(n = 62)
47 (76%)
16 (26%)
5 (8%)
2 (3%)
Total Number of Interventions
(n = 85)
Antibiotic Regimen Change
20 (24%)
De-escalation
23 (37%)
Dose Change
27 (44%)
ID Consult
6 (7%)
Other
9 (11%)
Interventions Accepted
81 (95%)
The most common appropriate antimicrobial recommendation was
change from an anti-MRSA agent to beta-lactam for methicillinsusceptible S. aureus. Most common de-escalation recommendation was
reducing anti-pseudomonal broad-spectrum beta-lactam plus
vancomycin to monotherapy with non-antipseudomonal beta-lactam.
Conclusion: We have observed a reduction in the average LOS and 30
day ABSSSI readmission rate as a result of intervention
recommendations by ASP compared with historical control. ABSSSI
patient populations offer ASP a potential target population to
significantly reduce costs.
1
TL Trienski ;
DE
1
Olexia ;
JP
2
Myers ;
MJ
2
Tan ; AK
2
Leung ;
JE
2
Poblete ;
TM File
Timothy R. Pasquale, PharmD
Summa Health System
525 E. Market Street
Akron, OH
Phone: 330-375-7020
Fax: 330-375-7622
[email protected]
2
Jr
of Pharmacy, Summa Health System, Akron, OH; 2Department of Medicine, Summa Health System, Akron, OH.
Introduction
Table 1
• Although acute bacterial skin and skin structure infections
(ABSSSIs) are among the most common infections requiring
hospitalizations, there is currently a of lack data regarding their
management and outcomes. Jenkins et al recently reported one
center’s experience of adult patients hospitalized with
complicated skin and soft-tissue infections1. The authors
concluded there was frequent use of potentially unnecessary
diagnostic studies, broad-spectrum antibiotic therapy, and
prolonged treatment courses in these patients1. In a matched
cohort study, Hatoum et al. reported that patients with
complicated skin and skin structure infections incurred on
average 3.81 additional days and $14,794 excess hospitalization
charges2.These findings are suggestive of potentially important
targets for Antimicrobial Stewardship Program (ASP).
• In 2011, the historical data from Summa Health System for
patients with ABSSSIs (ICD9 code 681-682.9) revealed an
average length of stay of 6.2 days and a 30-day ABSSSI
readmission rate of 6.2%.
• The primary objective of this study was to observe the impact
of AST on LOS, 30-day ABSSSI readmission rate, and
antimicrobial use.
Patient Characteristics
Variable
Avg Age
55.87 (range 19-90)
Male Gender
33 (53%)
White Race
58 (94%)
Avg Charlson Co-morbidity Index
(with Age)
De-escalation
Dose Change
44%
Diabetes mellitus
22 (35%)
Congestive Heart Failure
7 (11%)
Peripheral Vascular Disease
2 (3%)
Cerebrovascular Disease
6 (10%)
Myocardial Infarction
4 (6%)
Renal Disease
7 (11%)
Malignancy
7 (11%)
ID Consult
• Of the 23 de-escalation interventions:
• 14 (61%) were anti-MRSA agent plus a beta-lactam to
beta-lactam monotherapy.
• 4 (17%) were beta-lactam plus anti-MRSA agent to antiMRSA agent monotherapy.
• ID consults recommendations were for extensive cellulitis,
orbital cellulitis, infected hardware, and osteomyelitis.
10%
Lower Extremity
52%
Upper Extremity
Groin or Buttock
15%
Trunk or Back
Face, Head or Neck
11%
• ABSSSI offer a great opportunity for ASP as hospitals have
experienced a 71% increase in the rate of hospitalizations due to
skin and soft-tissue infections1.
• The most common interventions were dosage change, deescalation, and antibiotic regimen change. The most common
de-escalation recommendation was from
piperacillin/tazobactam plus vancomycin to monotherapy with
cefazolin or ampicillin/sulbactam.
• Prospective evaluation by ASP resulted in a significant
reduction in the average length of stay of patients admitted with
ABSSSI (ICD-9 codes 681-682.9) and readmission rates.
• Study limitations include single center, observational, nonrandomized and small sample size.
Outcomes of Patients Intervened by ASP
Variable
15%
• The primary goal of antimicrobial stewardship programs (ASP)
is to optimize clinical outcomes while minimizing unintended
consequences of antimicrobial use, including toxicity, the
selection of pathogenic organisms, and the emergence of
resistance3.
• This observational study illustrated the positive impact of an
ASP program on patients with ABSSSI. A total of 85
interventions on 62 patients from February 2012 to August 2012
were recommended with a 95% acceptance rate.
Other
Table 2
Primary Location of ABSSSI
Average LOS,
mean (days)
ASP Group
(n = 62)
Historical Data
(n = 1149)
P – value*
4.4 days
6.2 days
< 0.001
30 day All cause
readmission rate
6.5%
30 day ABSSSI
readmission rate
3.33%
16.71%
6.27%
* Chi square analysis was performed. #95% CIs(0.00098, 5.024)
• In this ongoing study, ASP has intervened on 62 patients admitted
with an ABSSSI (ICD9 681-682.9).
Figure 4
ABSSSI Subtype
0.050
0.483#
Conclusions
• ASP intervention demonstrated a significant reduction in the
average LOS compared to historical controls.
• We also observed a reduction in the 30 day all cause
readmission rate as well as 30 ABSSSI readmission rate
compared to historical controls.
• ABSSSI patient populations offer ASP a potential target
population to improve outcomes and decrease costs.
References
3% 2%
• Patient characteristics are listed in Table 1.
8%
Cellulitis
26%
Major or Deep Abscess
Surgical Site Infection
76%
Diabetic Wound
Decubitus Ulcer
• Outcomes are listed in Table 2.
37%
12 (19%)
Figure 2
• ASP recommended 85 interventions and 81 (95%) were accepted.
The interventions types are displayed in Figure 3.
24%
Co-morbidities:
• ID physician prospectively reviewed patient’s clinical status and
antimicrobial therapy regimen and provided feedback to attending
physician.
• ABSSSI characteristics including location and subtype are
displayed in Figures 1 and 2.
11%
Antibiotic Regimen
Change
20 (32%)
Polymicrobial Infection
• Patients are identified via Emergency Department admission list
of the previous 24 hours.
Results
7%
3 (range 0-7)
Surgical Intervention
• In February 2012, the Antimicrobial Stewardship Program (ASP)
began to evaluate patients admitted with ABSSSI.
• Patients without an Infectious Disease (ID) Consult on admission
were further evaluated by a Clinical Pharmacist and ID physician.
ASP Intervention Type (n = 85)
No. (%) of Patients
(n = 62)
Figure 1
Methods
Discussion
Figure 3
• Example of cellulitis ASP intervened on is pictured in figure 4.
SUMMA AKRON CITY HOSPITAL
1. Jenkins TC, Sabel AL, Sarcone EE, Price CS, Mehler PS, Burman WJ. Skin
and Soft-Tissue Infections Requiring Hospitalization at an Academic Medical
Center Opportunities for Antimicrobial Stewardship. Clin Infect Dis 2010;
51(8):895-903.
2. Hatoum HT, Akhras KS, Lin SJ. The attributable clinical and economic
burden of skin and skin structure infections in hospitalized patients: a matched
cohort study. Diagn Microbiol Infect Dis 2009;64:305-310.
3. Dellit T.H., Owens R.C., McGowan J.E. Jr., Gerding D.N., et al. Infectious
Disease Society of American and The Society of Healthcare Epidemiology of
America Guidelines for Developing an Institutional Program to Enhance
Antimicrobial Stewardship. Clin Infect Dis 2007;44:159-77.