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NEVADANS FOR ANTIBIOTIC AWARENESS 2004 Partner Conference April 9, 2004 Bill Berliner, MD THE ANTIBIOTIC RESISTANCE CRISIS THE ANTIBIOTIC RESISTANCE CRISIS • HISTORY OF BACTERIA • HISTORY OF ANTIBIOTICS • RESISTANCE • THE PROBLEM NOW • NEVADANS FOR ANTIBIOTIC AWARENESS HISTORY OF BACTERIA BACTERIA HAVE BEEN AROUND LONGER THAN ANY LIVING THING ON EARTH. FOSSIL EVIDENCE DATES BACK 3.5 BILLION YEARS. HISTORY OF BACTERIA EARTH AS A DAY: 5:00 AM - BACTERIA APPEAR 10:00 PM - DINOSAURS APPEAR 11:59 PM - HUMANS APPEAR HISTORY OF ANTIBIOTICS 1928 – DR. FLEMING DISCOVERS PENICILLIN FROM BREAD MOLD 1944 – U.S. MILITARY TAKES PENICILLIN TO THE BATTLEFIELD 1945 – BACTERIA WITH RESISTANCE TO PENICILLIN ISOLATED HISTORY OF ANTIBIOTICS RESISTANCE 1960’s: METHICILLIN INTRODUCED 1991: 29% OF STAPH AUREUS RESISTANT 2001: 62% OF STAPH AUREUS RESISTANT THE PROBLEM PSEUDOMAS AEROGINOSA % RESISTANCE 26 28 23 13 1991 14 1999 16 18.5 2000 CEFTAZIDIME 2001 16 1991 1999 2000 2001 IMIPENEM THE PROBLEM % RESISTANCE STREPTOCOCCUS PNEUMONIA 42 32 29 22 2000 2001 PENICILLIN 2000 CEFOTAXIME 2001 THE PROBLEM > 50% OF HOSPITAL ACQUIRED BLOODSTREAM INFECTIONS ARE CAUSED BY METHICILLIN-RESISTANT STAPH AUREUS (MRSA) > 70% OF NURSING HOME STAPH INFECTIONS ARE CAUSED BY MRSA THE PROBLEM “THERE ARE PATIENTS TODAY IN HOSPITALS FOR WHOM THERE ARE NO EFFECTIVE THERAPIES.” Gary Doern Director of Clinical Microbiology University of Iowa NEVADANS FOR ANTIBIOTIC AWARENESS WHO WE ARE A STATEWIDE TASK FORCE THAT HAS BEEN IN EXISTENCE SINCE FEBRUARY 2001 3 SUBCOMMITTEES • PUBLIC AWARENESS • PROVIDER EDUCATION • INFECTION CONTROL & SURVEILLANCE Pharmacist-directed pneumococcal vaccine protocol increases number of patients receiving immunization by 1200% MountainView Hospital - Las Vegas, Nevada Warren Wood, Pharm.D. Program Revised in 1999 MountainView Hospital • Criteria checked by admitting nurse – Over 65 – Hx of COPD,CHF,CAP,Splenectomy, No previous vaccine • If criteria is met, chart is stamped with an optional order for the physician to check off • Once ordered, the patient was to receive the vaccine after consent was signed • Started June 1999 Pneumococcal Vaccine Results after 3 Years # Patients Receiving During Hospitalization 25 20 15 Total doses administered for all of 2002 = 91 10 5 0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Federal Register Oct 2002 CMS modified guidelines, Standing Orders • Removed requirement for specific physician order • Allowed Medical Staff Approved protocols, in place of specific orders • Approved for Nursing Homes, Clinics, and Hospitals Pneumococcal Vaccine Criteria CDC/MMWR 1997 • All immunocompromised persons aged >2yr • All persons over 5yr • Persons age 2-64 with: –Cardiovascular or pulmonary disease –Diabetes mellitus –Kidney disease –Alcoholism, chronic liver disease –Cerebrospinal fluid leaks –Functional or anatomic asplenia –Living in special environments or social settings Pneumococcal Vaccine Process Revision • Proposed Protocol: • Nurse assessment as before, list sent to pharmacy • Move to a Pharmacist-Directed approach: – Past success with IVtoPO conversion – Change in Medicare Regulations • Pharmacist will write order to administer Vaccine next day • Physician and/or Patient has over-ride ability Pneumococcal Vaccine Process Flowchart Patient is Admitted Report of admits from last 24h prints in Pharmacy after midnight. Data includes: vaccine status, age, diag, reason for admission Administration is recorded in patient’s chart and nurse gives patient vaccination pocket card Floor Nurse does usual assessment which includes vaccine query Pharmacist reviews data and makes further inquiries if needed, then writes order, and sends sheet to floor to be placed on chart Next Day at 2PM, Nurse confirms with patient that they want vaccine, then administers dose 4th Qtr 2003 Mountain View = 88% Pneumococcal Vaccine Results #Patients Receiving During Hospitalization 140 120 1200% Increase over 2002 100 80 60 40 20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Medicare National Voluntary Hospital Reporting Initiative 4th Qtr MountainView was at 88% 45 40 35 30 25 20 Top 2% 15 10 5 0 >90 80-90 70-80 60-70 50-60 40-50 30-40 20-30 10-20 <10 Urgent Care Antibiotic Use Eugene Somphone MD Urgent Care Department Chief Southwest Medical Associates Introduction • • • • • • Reduction of antibiotic use Initial assessment of antibiotic use Provider and patient education Incentives to reduce inappropriate use Follow-up studies Future reduction Urgent Care History • SMA Urgent Cares 100,000 visits a year • High volume of respiratory infections • High rate of antibiotic prescriptions Inappropriate Uses • Over one-half of all antibiotics written annually are for respiratory infections • More than 50 million unnecessary prescriptions are written annually • 17 million prescriptions for antibiotics are written for the common cold • Antibiotics are given to 75% of patients with sore throat Initial Study • Random charts pulled for upper respiratory complaints • Symptoms of cough, sore throat, runny nose, congestion, sinus pain • Percentage of patients prescribed an antibiotic Results of Initial Study • • • • • Overall prescription rate 66.7% Fulltime providers 53.5% Per diem providers 78.8% Range 14-100% 3 providers prescribed antibiotics 100% of the time! Methods to Reduce Inappropriate Use • Patient education – Handouts – Posters – Discussion • Provider education • Financial incentives to reduce inappropriate use Provider Education • URIs are self-limiting • Colored secretions are not predictors of bacterial infection • Bronchitis is viral in nature • Differentiate sinus symptoms from sinus infection • Otitis media is oftentimes selflimiting • Criteria for Strep throat Financial Incentives • SMA Bonus • Antibiotic use as quality measure • Goal set at less than 45% Results • After 3 months rate decreased to 34.2% • After 6 months rate decreased to 30.5% Patient Satisfaction • Overall patient satisfaction rate remains high • Some disgruntled patients • Less resistance from patients Rocephin • In 2001 Rancho Urgent Care used $70,000 • Provider education and guidelines • In 2002 all 3 SMA Urgent Cares used $40,000 Choice of Antibiotics • Generic vs. Branded • Narrow-spectrum vs. Broad-spectrum Provider A • Branded antibiotics prescribed in a 6-month period: – Augmentin 2 – Cipro 1 – Floxin 1 – Levaquin 1 – Omnicef 1 – Tequin 29 – Z-pak 9 Provider A • Generic antibiotics prescribed in a 6-month period: – Amoxicillin 185 – Cefaclor 11 – Cephalexin 87 – Doxycycline 34 – Erythromycin 36 – Penicillin 14 – Tetracycline 3 Provider B • Branded antibiotics prescribed in a 6-month period: – Augmentin 6 – Ceftin 2 – Cipro 7 – Levaquin 6 – Tequin 4 – Z-pak 5 Provider B • Generic antibiotics prescribed in a 6-month period: – Amoxicillin 75 – Cephalexin 57 – Doxycycline 19 – Erythromycin 20 – Penicillin 38 Future Reductions • Rapid Strep Testing • AOM: recent recommendations Stop Antibiotic Resistance In Washoe County! How Can Childcare Providers Help? Joyce Minter, RN, PHN www.co.washoe.nv.us/health/cchs About one-third of Nevada’s children under the age five are in some form of licensed childcare because their parents 1 work Source: Washoe County Child Care Health Consulting; Trust Fund for Public Health, RFA 2002-2003 Approximately 10,000 children under age six attend 327 licensed childcare homes and 1 centers in Washoe County Source: Washoe County Child Care Health Consulting; Trust Fund for Public Health, RFA 2002-2003 Childcare providers play a key role in disseminating information and health education to children and families Antimicrobial Resistance (AR) outreach was put into the Child Care Health Consulting (CCHC) grant, a Trust Fund for Public Health (TFPH) grant, to do education and evaluation of efforts The CCHC is part of Health Child Care Nevada, which is part of the Health Care America campaign Plan • Send a survey to all (1250) child care providers • Educate staff at 3 centers and 9 homes • Then do a follow-up survey on those selected providers to see if they learned anything Childcare Consultants Grant • Printing and postage paid through grant • PHN time was “in kind” contribution AR Objective of Grant • Targeted child care providers will achieve scores at least 10% higher than the entire population of providers in Washoe County on a survey measuring knowledge of antibiotic resistance after an educational session is completed Child Care Providers • Obtained list of childcare providers from Social Services-approx. 1250 questionnaires sent out 1---------232 5---------39 10--------34 20--------16 30--------5 Questionnaire Development • Made a list of 20 most important messages we wanted to convey • Put into questionnaire form and data base created (special “Thanks” to Lei Chen) • Questionnaires coded with identifying information so we could compare pretest with post test Survey Packet • Letter explaining program and instructions to return questionnaire: If a childcare center - to fax completed questionnaires If individual childcare provider envelope with return postage guaranteed • Questionnaire • Business card • 2 NAA AR bookmarks for each provider as a “Thank you” Ideas for Incentives • • • • • • Totes – NAA Continuing education credit Mugs Water bottles Purell hand sanitizer Magnets-able to use some immunization funding • A drawing/raffle Activities • Mailed survey to all licensed child care providers to assess baseline knowledge of antibiotic resistance and entered data for analysis • Provided educational materials about antibiotic resistance to targeted centers • Provided survey to targeted centers post intervention to measure change in attitudes Initial Questionnaire Results • 346 of 1250 returned = 28% response rate • Average score was 75.1, standard deviation 13.8. Range of score was 25-100. Full score is 100. Stop Antibiotic Resistance In Washoe County! for more information www.co.washoe.nv.us/health/cchs A special thanks to Jane Harper, MS, at Minnesota Department of Health for providing most of the information in this presentation Learning Objectives • List two types of germs that cause common childhood respiratory illnesses • State what antibiotics cannot do if you are sick with a viral infection • List comfort measures that can help children with viral infections feel better (hint: an antibiotic is not one of them!) Learning Objectives • Name one myth and one fact about antibiotic use • List 3 steps childcare providers can take to help keep antibiotics working • Name one bacterial illness which can be prevented by proper immunization • State the most effective way to prevent the spread of all infections in childcare Take Home Messages • Viruses cause most common childhood respiratory illnesses • Viral illnesses need time to heal antibiotics cannot help Take Home Messages • Taking antibiotics for viral illnesses will not: – cure the infection – keep others from getting the illness – make you feel better And may lead to antibiotic-resistant bacteria Take Home Messages • Comfort measures ease symptoms of viral illnesses (extra fluids, rest, a vaporizer, a smoke-free environment) • Sick children should stay home until fever-free and able to participate in routine activities without more care than usual from childcare staff • Always wash your hands - and help children wash theirs! • Keep immunizations up to date Bottom Line • Antibiotics are powerful medicines, but they're not always the answer! • Misusing antibiotics now means they may not work when needed later to fight a bacterial infection • Help keep antibiotics working! Education & Post-Test • The three centers have completed the education and post-testing • The nine individual providers will be completed by May Post-Test Survey Results • 57 post-tests completed • Average score: 89.5, standard deviation 12.9. Range of score is 42-100. Full score 100. (pre-test average: 75.1) • Paired comparison result: Fifteen participated in pre and post test. The average score was improved by 13 before and after the education (statistically significant---P=0.005 by pairing sample T-test). • 56/57 (98%) participants indicated on their post-tests that the presentation was very useful THE RURAL EXPERIENCE LYNN EVANS, LPN ANTHEM BLUE CROSS & BLUE SHIELD MY ASSOCIATION WITH THE NAA • SUB-COMMITTEES • PHYSICIAN OFFICE SITE REVIEWS ROADBLOCKS ALONG THE WAY • TRAVELING LITE • WEATHER • WHO IS THE NAA? WHAT I HAVE ACCOMPLISHED • GETTING THE INFORMATION OUT • INCREASED AWARENESS ELKO, WINNEMUCCA, CARLIN, FALLON, YERRINGTON, WELLINGTON, DAYTON, SILVER SPRINGS, GERLACH, CARSON CITY, GARDNERVILLE, MINDEN, FERNLEY, STATE LINE, LAKE TAHOE, HAWTHORNE, LAUGHLIN, MESQUITE, PAHRUMP MY MOST MEMORABLE RURAL VISIT • MOST “FAR OUT” PLACE FUTURE PLANS • THE “RURAL SWEEP” • FROM TONOPAH TO RENO Measuring the Appropriate Use of Antibiotics Mary Hothem, R.N. Anthem Blue Cross Blue Shield April 9, 2004 HEDIS--Who, What & How • Administered by NCQA • Used by most HMO’s across the country to measure plan performance • Standardized methodology and comprehensive audit checks to ensure comparability • In Nevada, Aetna, Health Plan of Nevada, IHC Health Plans, and Pacificare, already publicly report results • HMO Nevada does not currently publicly report results due to size, although does collect the data New to HEDIS 2004 • Appropriate Treatment of Children With Upper Respiratory Infection – Children age 3 months to 18 years – Outpatient visit with diagnosis of URI (460 or 465) ONLY (no secondary diagnosis – % with no prescription for antibiotic 30 days before visit date or 3 days after visit date New to HEDIS 2004 • Appropriate Testing for Children With Pharyngitis – Children age 2 to 18 years – Outpatient visit with diagnosis of pharyngitis (462, 463, 034.0), ONLY – Received a prescription for antibiotic 3 days before visit date to 3 days after visit date – % that also had a group A streptococcus test Considerations for NAA • This may be a way to measure the effectiveness of FUTURE interventions • Would allow for benchmarking current Nevada practice patterns with other states / regions • Would allow for benchmarking across health plans and identify best practices Antimicrobial Resistance Surveillance Project Linda Verchick, MS Clark County Health District – Office of Epidemiology Nevadans for Antibiotic Awareness Surveillance Committee Antimicrobial Resistance Surveillance Project - 2000 through 2003 • • • • Initial Surveillance Surveillance of six organisms Data collected from three county facilities – Major laboratory – Two major hospitals Data reported quarterly Provided some community information Antimicrobial Resistance Surveillance Project - 2000 through 2003 Initial Surveillance Drawbacks • Limited number of organisms and antibiotics surveyed • No elimination of duplicate reports • Limited patient information • Data entry time consuming Antimicrobial Resistance Surveillance Project - 2000 through 2003 Surveillance Organisms • • • • • • Streptococcus pneumoniae Staphylococcus aureus (coag +) Pseudomonas aeruginosa Acinetobacter calcoaceticus Enterococcus faecium Enterococcus faecalis Streptococcus pneumoniae Percent Susceptibility to Penicillin - Clark County, NV 2000-2003 Susceptibility (%) 100 80 60 40 20 0 2000 2001 2002 Year 2003 Susceptibility (%) Streptococcus pneumoniae Percent Susceptibility to Cefotaxime - Clark County, NV 2000-2003 100 80 60 40 20 0 2000 2001 2002 Year 2003 Antimicrobial Resistance Surveillance Project - 2004 New Surveillance Advantages • Data electronically received • Elimination of duplicates • Antibiotic susceptibility from all positive bacterial cultures from all sources • Antibiotic susceptibility reported in minimum inhibitory concentrations (mics) Antimicrobial Resistance Surveillance Project - 2004 New Surveillance Advantages • More patient information available – Inpatient/outpatient – Gender and age • Ten local hospitals/laboratories have agreed to participate Nevadans for Antibiotic Awareness Surveillance Project - 2004 New Surveillance Disadvantages • Computer program design is time consuming • Technical difficulties obtaining data • HIPAA misinterpretation Nevadans for Antibiotic Awareness Surveillance Project 2004 Goals • Provide an antibiogram specific to each participating facility • Provide clinicians with a county wide antibiogram • Provide rapid reporting on a quarterly basis • Identify emerging resistant organisms Nevadans for Antibiotic Awareness Surveillance Project 2004 Goals • Follow resistance development within a sensitivity category (S, I, R) • Identify the development of resistance within a patient • Provide a better understanding of antibiotic resistance in both community acquired and nosocomial illness Nevadans for Antibiotic Awareness Christine Petersen, MD, MBA 2004 Partner Conference April 9, 2004 Nevada Antibiotic Usage Trends • Data collected from 4 health plans • Represents 382,252 members throughout the state • Includes oral outpatient antibiotic scripts • Excludes antifungals, topical and antituberculosis medications • Baseline year 2000 and the first 2 quarters of 2001 Outpatient Antibiotic Scripts per Member per Month 368,252 Health Plan Members 2000 –2003 2000 2001 2002 2003 0.085 0.080 0.075 0.070 0.065 0.060 0.055 0.050 0.045 Quarter 1 Quarter 2 Quarter 3 Quarter 4