Download Evidence Based Guidelines at PHD related to Infectious Disease

Evidence Based Guidelines at
PHD related to Infectious
Disease
Edward L. Goodman, MD
Outline
• Standing Orders for Vaccinations
– The problem
– Evidence for guidelines
– Federal Guidelines
• Comprehensive Antimicrobial Management
Program
– Evidence in the literature
– Components of Program
– Outcomes to date
Standing Orders for Influenza
and Pneumonia Vaccine
•
•
•
•
Background
Interventions in the literature
Federal support
Implementation
Background: http://www.cms.hhs.govhealthyaging/2a.asp
• Influenza and pneumonia represent 5th
leading cause of death in elderly
– 20,000 to 40,000 influenza related deaths
annually
– 90% occur in those >65 years old
– Influenza vaccine effective
• Reduces hospitalizations by 27-57%
• Reduces deaths by 27-30%
Underutilization
• Influenza/pneumococcal vaccines are
underutilized for persons >65
– Overall, 66%/35%
– Nursing Homes 68%/38%
• National Center for Health Statistics. Early release of
selected estimates from the 2002 National Health Interview
Surveys.
http://www.cdc.gov/NCHS/about/major/nhis/released2002
09.
Cost effectiveness of Influenza
vaccination. Leavenworth, G. The costly toll of vaccinepreventable disease. Business and Health 1995;(13)(3)16
• Minnesota health plan, three flu seasons
• Vaccinated 45-58% of those >64 years
• Lower hospitalization rates for flu,
pneumonia, CHF
• Average savings of $117 per vaccinated
member
Standing Orders Improve Rates
•
•
Task Force on Community Preventive Services. Recommendations
regarding interventions to improve vaccination coverage in children,
adolescents, and adults. Am J Prev Med 2000;18:92—140
.
Health Care Financing Administration. Evidence report and
evidence-based recommendations: interventions that increase the utilization
of Medicare-funded preventive service for persons age 65 and older.
Baltimore, Maryland: U.S. Department of Health and Human Services, Health
Care Financing Administration, October 1999; HCFA publication no.
HCFA-02151.
•
Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-based
strategies for improving influenza vaccination rates. J Fam Prac 1994;38:
258--61.
•
Stevenson KB, McMahon JW, Harris J, Hilman JR, Helgerson SD.
Increasing pneumococcal vaccination rates among residents of long-term-care
facilities: provider-based improvement strategies implemented by peer-review
organizations in four western states. Infect Control Hosp Epidemiol
2000;21:705--10.
Government Regulations to
Promote Standing Orders
•
Centers for Medicare and Medicaid Services. Medicare and Medicaid
programs: conditions of participation: immunization standards for hospitals,
long-term care facilities, and home health agencies. Washington, DC: U.S.
Department of Health and Human Services, Centers for Medicare and Medicaid
Services, 2002. Available at
http://www.cms.gov/providerupdate/regs/cms3160fc.pdf
<http://www.cms.gov/providerupdate/regs/cms3160fc.pdf> .
Centers for Medicare and Medicaid Services, Center for Medicaid and
State Operations. Program memorandum: change in requirement for signed
physician's order for influenza and pneumonia vaccine. Washington, DC: U.S.
Department of Health and Human Services, Centers for Medicare and Medicaid
Services, 2002; publication no. S&C-03-02.
Comprehensive Antimicrobial
Management Program
Rationale
• Antibiotic use (appropriate or not) leads to
microbial resistance
• Resistance results in increased morbidity,
mortality, and cost of healthcare
• Appropriate antimicrobial stewardship will
prevent or slow the emergence of resistance
among organisms (Clinical Infectious Diseases 1997; 25:584-99.)
• Antibiotics are used as “drugs of fear”
(Kunin et al.Annals 1973;79:555)
Antibiotic Misuse
• Surveys reveal that:
– 25 - 33% of hospitalized patients receive
antibiotics (Arch Intern Med 1997;157:1689-1694)
– 22 - 65% of antibiotic use in hospitalized
patients is inappropriate (Infection Control 1985;6:226-230)
Changes in Resistance Rates at a
University Hospital
• A university hospital had an increase in multidrugresistant K. pneum.
• Physicians were educated about the association
between ceftazidime use and MDR K. pneum.
• Education occurred through grand rounds,
attending rounds and consultations by ID
physicians and clinical pharmacists.
Infect Control Hosp Epidemiol. 2000;21: 455-458.
Changes in Resistance Rates at a
University Hospital
PreIntervention
PostIntervention
Ceftaz (gms)
4,301
1,248
Pip/taz (gms)
12,455
17,464
Imipen (gms)
140
60
Abx tot cost
$68,027
$59,166
Parameter
K. pneumo Resistance
Ceftaz
22%
Pip/taz
36%
Infect Control Hosp Epidemiol. 2000;21: 455-458.
15%
19%
Resistance Changes in a
Community Hospital
• Increase resistance among GNR with C-I beta-lactamases, staph
and enterococcus
• An antimicrobial task force was formed (ID physicians,
pharmacists, microbiologists, and infection-control.)
• Consultations were triggered by 3rd generation cephalosporins,
carbapenems, and vancomycin.
• Extended spectrum penicillins/beta-lactamase inhibitor and
aminogycosides were encouraged.
• Costs were reduced by $650,000/year.
Pharmacotherapy 1999;19(8 pt 2):129S-132S
Resistance Changes in a
Community Hospital
Selected
Bacteria
VRE
E. cloacae*
E. aerogenes*
Acinetobacter sp*
S. marcescens*
MRSA
Pseudomonas sp*
% of Resistance
1994
1998
16
61
63
17
20
34
13
*resistance to pip/tazo
Pharmacotherapy 1999;19(8 pt 2):129S-132S
6
28
11
0
0
23
17
Changes in Resistance at an Urban
Teaching Hospital
• Epidemic in the surgical ICU of bacteremia due to Acinetobacter
sensitive only to imipenem
• Prior-authorization from ID faculty for selected antibiotics
(amikacin, aztreonam, ceftaz, cipro, imipenem, ticar/clav) was
required.
• Acquisition cost for antimicrobial drugs were reduced by
$863,100/year.
• Survival rates, LOS, and length of ICU stay were not impacted.
Clinical Infectious Diseases 1997;25:230-9.
Changes in Resistance at an Urban
Teaching Hospital
Organism Tic/clav
Imipen
Ceftaz
Ceftriax
Pre Post Pre Post Pre Post Pre Post
P. aerug
Inpt
Outpt
ICU
K. pneum
Inpt
Outpt
ICU
17
21
11
13
17
35
5
17
20
16
7
6
16
2
Clinical Infectious Diseases 1997;25:230-9.
24
34
8
12
69
74
88
28
31
36
12
3
Components of PHD Program
• Intravenous (IV) to oral conversion for well
absorbed (highly bioavailable) antimicrobials
• Discontinuation of preoperative antibiotic
prophylaxis at 24h
• Restricted antibiotic therapy
Components of the Program 1
• IV to Oral Conversion for Highly Bioavailable
Antimicrobials
– Patient Criteria
• Able to take oral medications and diet
• No persistent nausea, vomiting, or diarrhea
• No medical condition that could decrease drug absorption
– IV to oral conversions became automatic on July 1,
2001
• Pharmacists consult with nurse about how well the patient
is eating and taking medications
Components of the Program 2
• Discontinuation of Preoperative Surgical
Prophylaxis at 24 Hours
– Strong support in the medical literature
– Undergoing a “clean” procedure
• Open heart
• Artificial joint insertion
• Many others
Components of the Program 3a
• Restricted Antimicrobial Therapy
– Antimicrobial Criteria
• High risk
• High cost
• High potential to select resistance
• Drugs of “last resort”
Components of the Program 3b
• Restricted Antimicrobial Therapy
– Antimicrobials restricted to ID physicians
• Quinupristin/Dalfopristin (Synercid®)
• New Antifungal Agents
– Antimicrobials restricted after 48 hours – require
Infectious Disease consult to continue
•
•
•
•
•
Vancomycin
Imipenem/Meropenem
Cefepime
Ceftazidime
Linezolid
Results of CAMP
• April 2001 inception and partial
implementation
• July 1, 2001 full implementation
Antimicrobial Program Interventions
(April 3, 2001 - December 31, 2002)
IV to PO
Surgical
Restricted
Conversion Prophylaxis Antimicrobials Total
Interventions
291
448
325
1064
Accepted
264
(91%)
261
(58%)
286
(88%)
811
(76%)
Rejected
27
187
39
253
Table 1
Team Activities To Date
Including 2003
• 30 - 60 antimicrobial orders screened daily
• > 1400 antibiotic recommendations have been
made since April 1, 2001
• Recommendations are communicated through
notes on charts and phone calls
• Overall acceptance rate is 79%
Surgical Prophylaxis Antibiotic
Doses / Day
0.35
p=.010
p=.003
0.3
0.25
2000
2001
2002
0.2
0.15
0.1
0.05
0
Doses/Census Day
IV vs. Oral
Total Antibiotic Cost / Day
$14
$12
$10
$8
2000
2001
2002
$6
$4
$2
$0
IV Abx
PO Abx
Cost/Census Day Cost/Census Day
Restricted Antibiotics
Doses / Day
0.2
0.18
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
p=.007
p=.016
2000
2001
2002
Doses/Census Day
Vancomycin
0.1
0.098
0.096
0.094
0.092
0.09
0.088
0.086
0.084
0.082
0.08
0.078
2000
2001
2002
Doses/Census Day
IV and PO
Fluoroquinolones
0.1
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0
1999
2000
2001
2002
IV Dose/Census Day
Oral Doses/Census Day
Total Antibiotic
Doses / Day
2.5
2
p=.001
1.5
p=.000
2000
2001
2002
1
0.5
0
Doses/Census Day
Facility Census Days
180000
175000
170000
165000
160000
155000
2000
2001
2002
Annual Antibiotic Expenditure
$2,500,000
$2,000,000
$1,500,000
$1,000,000
$500,000
$0
2000
2001
2002
Total Antibiotic
Cost / Census Day
$14
$12
$10
$8
$6
2000
2001
2002
$4
$2
$0
Cost/Census Day
Cost Savings for 2001 = $399,238
Cost Savings for 2002 = $659,812
Total Cost Savings = $1,059,050
Changes in Bug/Drug Susceptibility
Patterns
30%
25%
20%
15%
10%
5%
0%
1999
2000
2001
2002
% Bug/Drug combinations having > or = 5% increase in resistance
%Bug/Drug combinations having > or = 5% decrease in resistance