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Transcript
Presentation Number: 264
Category: A1. Infectious Diseases - Anti-infective Agents
Retrospective Review And
Analysis of the Clinical
Impacts of an Antimicrobial
Stewardship Program
Katie Gordon
PGY1 Pharmacy Resident
Providence Alaska Medical Center
Anchorage, Alaska
Deemed exempt from IRB due to quality improvement project
1
Disclosure Statement
Katie Gordon, Pharm.D.
Potential Conflicts of interest: None
Sponsorship: None
Proprietary information or results of ongoing research may
be subject to different interpretations.
Presentation of this slide indicates my agreement to abide
by the non-commercialism guidelines provided on the CE
Requirements page.
2
Learning Objectives
Describe the components of an antimicrobial
stewardship program
Explain the criteria for health care associated
pneumonia versus community-acquired pneumonia
Target audience: Pharmacists
3
Providence Alaska Medical
Center
Location:
◦ Anchorage, Alaska
◦ Population Estimate: 300,549 as of 2014
◦ 1 of 3 hospitals in Anchorage
◦ Largest hospital in Alaska
◦ Highest level of acuity of care in
Alaska
Demographics:
◦ 394 bed, tertiary care, community
hospital
◦ Level 2 Trauma Center
◦ Level 3 NICU
◦ Safety net hospital
◦ Decentralized pharmacy model
4
Background
IDSA recommended components for Secondary Supplements to AMS
AMS program includes:
Programs
◦ Essential
◦ Infectious disease physician
◦ Clinical pharmacist with infectious disease
training
◦ Optimal
◦
◦
◦
◦
◦
Clinical microbiologist
Information system specialist
Infection control professional
Hospital epidemiologist
Hospital administrative support
Primary Core Strategies
◦ Prospective audit with intervention
and feedback
◦ Formulary restriction and
preauthorization
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Education
Guidelines and clinical pathways
Antimicrobial cycling
Antimicrobial order forms
Combination therapy
Streamlining or de-escalation of
therapy
Dose optimization
Parenteral to oral conversion
EMR, CPOE, and clinical decision
support
Computer based surveillance
Clinical microbiology support
Process measures
5
Background
PAMC’s AMS program was initiated August 26, 2013
The objective of this study is to evaluate clinical outcomes
of patients admitted with community-acquired pneumonia
in relation to the start of an antimicrobial stewardship
program in order to assess:
• Inpatient mortality
• 30-day readmission rate
• Rate of C. difficile infection during admission
• Length of stay
• Duration of antimicrobial agents
6
Methodology
Retrospective analysis
Assessed for non-inferiority
◦ Year prior to AMS program initiation
◦ Year one post-AMS program initiation
Inclusion:
◦ Primary ICD-9 code of 486.0 consistent with CAP
◦ August 26, 2012-August 26, 2014
7
Methodology
Exclusion:
◦ Pregnant
◦ Incarcerated
◦ <18 years of age
◦ Admitted for <24 hours
◦ Concurrent infection
requiring antibiotics
◦ LOS >60 days
◦ Met criteria for HCAP
◦ Immunocompromised
◦ Antibiotics in preceding 90
days
◦ Hospitalization of 5 days or
more
◦ Chronic dialysis within 30 days
◦ Home infusion therapy
◦ Residence in extended care
facility
◦ Hospitalization for ≥2 days in
preceding 90 days
8
Methodology
1180 Patients
(Excluding LOS <1
day, age <18 yo)
Exclusion Criteria
790 Patients
390 Patients
Included
9
Results
Comorbidities
70.00%
p 0.221
60.00%
50.00%
p 0.734
40.00%
p 0.440
p 0.360
30.00%
p 0.784
p 0.229
20.00%
p 0.375
10.00%
0.00%
HTN
COPD
DM
Year Prior
Asthma
HF
A.fib
Tobacco
Year 1 of AMS
10
Results
Clinical Outcomes
14%
12%
10%
p 0.425
8%
6%
p 0.571
p 0.425
4%
p 1.0
2%
0%
Inpt Mortality
Readmit
Readmit PNA/SOB
Rate of C.diff
acquisition
Year Prior
4.05%
6.76%
2.70%
0.90%
Year 1
2.98%
8.93%
4.17%
0.60%
11
Results
Inpatient Mortality (% Yes)
12%
10%
8%
6%
4%
2%
0%
Q3 2012 Q4 2012 Q1 2013 Q2 2013 Pre-AMS Post-AMS Q4 2013 Q1 2014 Q2 2014 Q3 2014
Q3 2013 Q3 2013
12
Results
Readmission within 30 days d/t PNA/SOB (% Yes)
7%
6%
5%
4%
3%
2%
1%
0%
Q3 2012 Q4 2012 Q1 2013 Q2 2013 Pre-AMS Post-AMS Q4 2013 Q1 2014 Q2 2014 Q3 2014
Q3 2013 Q3 2013
13
Results
Clinical Outcomes
10
p 0.054
9
8
p 0.041
7
p 0.129
6
5
4
3
2
1
0
Mean Length of Stay
Mean Days Inpt Abx
Mean Days Total Abx
Year Prior
6.95
5.57
9.48
Year 1
5.86
5.11
8.78
14
Results
Length of Stay (Days)
10
9
8
7
6
5
4
Q3 2012 Q4 2012 Q1 2013 Q2 2013 Pre-AMS Post-AMS Q4 2013 Q1 2014 Q2 2014 Q3 2014
Q3 2013 Q3 2013
15
Results
Common CAP Antibiotics
Total days of inpt abx
5.9
0.6
5.7
0.5
5.5
5.3
p 0.001
p <0.001 p <0.001
0.4
0.3
5.1
4.9
0.2
4.7
0.1
4.5
0
CTX
Azith
PreAMS
LVQ
PostAMS
16
Conclusions
The antimicrobial stewardship (AMS) program at PAMC has not had
negative impacts on clinical outcomes as related to communityacquired pneumonia
Decrease in mean length of stay and duration of antimicrobials
Fluoroquinolone usage has decreased
Ceftriaxone and azithromycin usage has increased
Future directions for continuation of this project include:
◦ Analysis after initiation of the community-acquired pneumonia clinical
pathway
◦ Analysis of other commonly intervened upon disease states
◦ Integration of procalcitonin levels and rapid diagnostics (Biofire® Viral Panel)
17
References
Dellit TH, Owens RC, McGowan JE, et al. Infectious disease society of
America and the society for healthcare epidemiology of America guidelines
for developing an institutional program to enhance antimicrobial
stewardship. CID. 2007;44:159-177.
CDC. Vital signs: Improving antibiotic use among hospitalized patients.
MMWR. March 2014;63(09):194-200.
Ibrahim OM, Polk RE. Antimicrobial use metrics and benchmarking to
improve stewardship outcomes. Infect Dis Clin N Am. 2014;28:195-214.
Schmitt S, McQuillen DP, Nahass R, et al. Infectious disease specialty
intervention is associated with decreased mortality and lower healthcare
costs. CID. 2014;58(1):22-28.
The Joint Commission: Specifications Manual for Joint Commission National
Quality Core Measure (2010B).
https://manual.jointcommission.org/releases/archive/TJC2010B1/Pneumon
ia.html. Accessed August 10, 2014.
18