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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