Download Antibiotic Stewardship

Antibiotic Stewardship
The Increased Scrutiny of Antibiotic Use
Jennifer L. Hardesty, PharmD, FASCP
Chief Clinical Officer
Corporate Compliance Officer
Remedi SeniorCare
William Vaughan RN, BSN
Vice President, Education and Clinical Affairs
Remedi SeniorCare
Disclosure / Contact
• Jennifer Hardesty is a shareholder at Remedi
SeniorCare
• William Vaughan is a shareholder at Remedi
SeniorCare, a contractor to CMS (QAPI) and a
member of the Institute for Safe Medication
Practices clinical advisory board (Long-Term Care
Advise ERR)
• Contact :
– [email protected]
– [email protected]
Objectives
• Discuss current and proposed federal regulations
which impact the use of antibiotics in nursing
homes.
• Identify three clinical practices which maximize
the benefits and minimize the risks associated
with the use of antibiotics in long term care
residents.
• Describe the concept of antibiotic stewardship
and identify four core elements of an antibiotic
stewardship program.
Regulatory “Priorities”
Antibiotics
“However, with the recent emergence of
resistant organisms, pediatric organizations
have strongly recommended initial antibiotics
only for certain children”
- Merck Manual
“Ninety–98% of rhinosinusitis cases are viral,
and antibiotics are not guaranteed to help
even if the causative agent is bacterial.”
- CDC
“Although warranted in some cases, antibiotics
are greatly overused.”
- American Academy of Family Physicians
Nursing Homes
• ~ 4 million admissions / year
• ABT use common (up to 70% / year)
• Inappropriate prescribing (up to 75%)
– Unnecessary
– Wrong drug, dose or duration
• Colonization common
Source: CDC (http://www.cdc.gov/media/releases/2015/p0915-nursing-home-antibiotics.html)
In the Crosshairs:
Urinary Tract “Infections”
• Generalized change in condition (falls, mental
status, etc.)
– Adverse drug reaction ("Any symptom in an
elderly patient should be considered a drug side
effect until proven otherwise.”– Gurwitz et al)
– Fluid / electrolyte imbalance
– Infection
• + urine culture  Antibiotics
colonization
In the Crosshairs:
Urinary Tract “Infections”
• “Don’t obtain a urine culture unless there are
clear signs and symptoms that localize to the
urinary tract.”
– AMDA
• “Don’t use antimicrobials to treat bacteriuria
in older adults unless specific urinary tract
symptoms are present.”
– AGS
In the Crosshairs:
Urinary Tract “Infections”
• A patient with advanced dementia may be
unable to report urinary symptoms … In this
situation, it is reasonable to obtain a urine
culture if there are signs of systemic infection
such as fever … leukocytosis, or a left shift or
chills in the absence of additional symptoms
(e.g., new cough) to suggest an alternative
source of infection.
– AMDA
Other High Risk Areas
Current Regulations
• F 281 (Profession standards of quality)
– “Standards published by professional
organizations”
• F 329 (Unnecessary Drugs)
– Indication
– Dose
– Duration
– Monitoring
– Adverse consequences (c. diff)
No Absolutes
Rationale for Care Based on:
• Evidence
• Thoughtful risk / benefit analysis
• Resident / surrogate involvement
 Document especially in high risk situations
Actions to Consider
• Engage Medical Directors / Consultant
Pharmacists
• Educate
– Prescribers
– Nursing staff
– Residents / surrogates /families
• Discuss / document goals of care
Actions to Consider
• Don’t succumb to perceived regulatory
pressure to “do something”
– Watchful waiting
– Antibiotic “time out”
• Quality assurance
– Consistency of prescribing practices
– Type of antibiotic (broad spectrum)
– Duration of therapy
• Choosing Wisely (www.choosingwisely.org)
Proposed Regulations
• Infection and Prevention Control Officer
• Infection Prevention and Control Program
– Antibiotic stewardship
• Quality Assurance Performance Improvement
Antibiotics- Some Facts
Each Year in the US:
• ~2 million people become infected with resistant bacteria
• At least 23,000 people die each year as a direct result of these
infections
• 250,000 patients (hospitalization) get Clostridium difficile each
year,
• C. difficile kills at least 14,000 people each year
Resistance Develops….Survival of the Fittest
Antibiotic Resistance Spreads…..
Fast-paced resistance
Resistance develops quickly:
• Methicillin:
o developed in 1960
o resistance by 1962
• Linezolid
o developed in 2000
o resistance by 2001
Adverse Drug Reactions:
Antibiotic Overuse
Systemic Adverse Effects of Common Antibiotics
Antibiotic Class
• Adverse Drug Events





N/V/D
Myalgias
Blood dyscrasias
Candidiasis
C. Difficile
Most Common Side Effects
Penicillins
rash, diarrhea, abdominal pain, nausea/vomiting, hypersensitivity reactions
Cephalosporins
rash, diarrhea, nausea/vomiting (rare), hypersensitivity reactions, vaginal
candidiasis
Aminoglycosides
renal toxicity, ototoxicity, dizziness, nausea/vomiting, nystagmus
Carbapenems
diarrhea, nausea/vomiting, headache, rash, liver toxicity, eosinophilia
Vancomycin
flushing, hypotension, itching, phlebitis, taste alteration, nausea/vomiting,
headache, dizziness
Macrolides
abdominal pain, diarrhea, anorexia, nausea/vomiting, taste alterations
Sulfonamides
nausea/vomiting, diarrhea, anorexia, abdominal pain, rash, photosensitivity,
headache, dizziness
Tetracyclines
nausea/vomiting, diarrhea, anorexia, abdominal pain, liver toxicity
Quinolones
myalgias, tendonitis, nausea/vomiting, diarrhea, abdominal pain, headache,
lethargy, insomnia, photosensitivity
Lincosamide
colitis,diarrhea, nausea/vomiting, rash, hypersensitivity, jaundice
Additional Problems:
Clostridium Difficile
Clostridium Difficile
C.Difficile - Treatment
Drug Treatment:
• Metronidazole $
• Vancomycin $$-$$$
• Fidaxomicin (Dificid) $$$$
Recurrence -can occur in up to 25% of patients (another episode
of C. difficile within 8 weeks)
• Relapse of the initial infection
• Re-infection with a new strain
Recurrence Treatment:
• First recurrence- the same medication
• Second recurrence, a tapered or pulsed oral vancomycin
• Third recurrence fecal transplant should be considered
Long-term care facility residents are particularly at risk for C. Difficile complications
CDC: What Can the Health Care Community Do?
CDC: What Can the Health Care Community Do?
Antimicrobial Stewardship
Coordinated interventions designed to improve and measure the
appropriate use of antimicrobial agents by promoting the
selection of the optimal antimicrobial drug regimen
Patients receive the right antibiotic, at the right dose, at the right
time, and for the right duration
Antibiotic Stewardship Programs are a
“win‐win” for all involved!
Antibiotic Stewardship will:
–
–
–
–
Decrease antibiotic resistance
Decrease C. difficile infections
Decrease costs
Increase good patient outcomes
http://www.cdc.gov/getsmart/healthcare/factsheets/antibiotic-use.html
LTC Core Elements for Antibiotic
Stewardship
http://www.cdc.gov/longtermcare/prevention/antibi
otic-stewardship.html
Leadership Commitment
• Write statements in support of improving antibiotic use to be
shared with staff, residents and families
• Include stewardship-related duties in position descriptions:
o
o
o
Medical Director
Clinical nurse leads, DON
Consultant pharmacist
• Communicate with nursing staff ,prescribing clinicians
o Expectations about use of antibiotics
o Monitoring and enforcement of stewardship policies
• Create a culture which promotes antibiotic stewardship
o
o
o
Messaging
Education
Celebrating improvement
Accountability
• Medical Director: set standards for antibiotic prescribing practices for all
clinical providers
• Director of Nursing: set the practice standards for assessing, monitoring and
communicating changes in a resident’s condition by front-line nursing staff.
• Infection prevention program coordinator:
o Track antibiotic starts
o Monitor adherence to evidence-based published criteria
o Review antibiotic resistance patterns in the facility
• Consultant pharmacist : support antibiotic stewardship oversight through
quality assurance activities
• Laboratory Services:
o Alerting facility if certain antibiotic-resistant organisms are identified,
o Educate staff on the differences in diagnostic tests available
o Antibiogram
Drug Expertise
• Partner with antibiotic stewardship program leads at
the hospitals within your referral network
• Infectious Disease practitioners and consultants in
your community
• Consultant Pharmacists
Action Through Policy/Practice Change
Policies that support optimal antibiotic use
o Require dose, duration, indication for every order
o Viewing culture data
Broad interventions to improve antibiotic use
o Improving the evaluation and communication of clinical signs/symptoms
o “Communication Tool”
o INTERACT Tools
o “Antibiotic time-out”
o Developing antibiotic monitoring and infection management guidance
Infection and syndrome specific interventions to improve
antibiotic use
o Asymptomatic bacteriuria (ASB)
o Urinary tract infection prophylaxis
o Lower Respiratory Tract Infections (Viral vs Bacterial)
Tools and Protocols:
INTERACT Programs
https://interact2.net/tools_v4.html
Tracking/Reporting: Use and Outcomes
• Process Measures:
o Completeness of clinical assessment documentation at the time of the
antibiotic prescription
o Completeness of antibiotic prescribing documentation
o Antibiotic selection is consistent with recommended agents for
specific indications
o Point prevalence of antibiotic use
o Antibiotic days of therapy (DOT)
o Post-prescription review of appropriateness
• Outcome Measures:
o
o
o
o
Track C. difficile and resistant organisms
Track adverse drug events related to antibiotic use
Antibiotic resistance
Track costs related to antibiotic use
Tools and Protocols:
Antibiotic Appropriateness Assessment - G+ Infections
Tools and Protocols:
Antibiotic Appropriateness Assessment- UTI
http://www.remedirx.com/site/wp-content/uploads/2016/02/2016-02-M.R.-UTI-Assess-Tool.pdf
Education
• Provide antibiotic stewardship education to clinicians, nursing staff,
residents and families
• Linking education with feedback on physician prescribing practices
• Interactive academic detailing (e.g., face-to-face interactive
workshops) has the strongest evidence for improving medication
prescribing practices
• Providing feedback on individual physician prescribing practices and
adherence to the guidelines over 12 months
Tools and Protocols:
Appropriate Antibiotic Use Summary
http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/adult-approp-summary.pdf
The First Steps:
• Ensure all orders have dose, duration, and indications
• Get cultures before starting antibiotics
• Take an “antibiotic timeout,” reassessing antibiotics after 48–72
hours
• Implement policies that encourage best practices
o Establishment of minimum criteria for prescribing antibiotics
o Review of antibiotic appropriateness/resistance patterns
o Nursing protocols for monitoring patients’ status for an evolving
condition if there is no specific indication for antibiotics
Small, Sustainable Changes
• Facility should not attempt to implement all of the
interventions at once.
• Interventions to implement should be tailored to the
areas that most need improvement at your facility
• Essential to monitor and measure
o Measurement Framework- various measures of antibiotic
use to assess effectiveness of improvements
http://www.remedirx.com/news-events/news/
Changing Prescribing Behaviors
Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing
Among Prescribers; Leeker et al.
Interventions Resulting in Decreased Inapproporate Prescribing
Triggers a pop-up in the EHR - presentes electronic
order sets suggesting nonantibiotic treatments
Requires clinicians to enter free-text justifications for
Accountable justification prescribing antibiotics into EHR. "No justification"
populates if left blank.
Sent emails to prescribers that compar their antibiotic
Peer comparison
prescribing rates with those of "top performers" (those
with the lowest inappropriate prescribing rates).
Suggested alternatives
Inappropriate prescribing decreased
from 22% to 6%
Inappropriate prescribing decreased
from 23% to 5%
Inappropriate prescribing decreased
from 20% to 4%
JAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275
Antibiotic Stewardship:
Are You Ready?
LTC Antibiotic Stewardship Tool
Core Elements Checklist
LTC Antibiotic Stewardship Tool
Core Elements Checklist
LTC Antibiotic Stewardship Tool
Core Elements Checklist
LTC Antibiotic Stewardship Tool
Core Elements Checklist
Thank You
Questions?