Advisor Live: Antimicrobial Stewardship - Why Now and How?

Advisor Live®

Antimicrobial stewardship – Why now and how?

November 19, 2015

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Faculty

MODERATOR

Gina Pugliese, RN, MS, FSHEAVice President

Premier Safety Institute®

CAPT Arjun Srinivasan, MDAssociate Director,

Healthcare associated infection

prevention programs, CDC

Michael Postelnick, RPh BCPS

AQ Infectious DiseasesSenior Infectious Diseases Pharmacist

Northwestern Memorial Hospital, Chicago

Craig Barrett PharmD,BCPSDirector, Safety Solutions, Premier Inc.

@PremierHA

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CAPT Arjun Srinivasan, MD,

Associate Director

Healthcare Associated Infection Prevention Programs

Division of Healthcare Quality Promotion, CDC

@PremierHA

#AdvisorLive

#GetSmartWeek

CAPT Arjun Srinivasan, MD

Associate Director for Healthcare Associated

Infection Prevention Programs

Division of Healthcare Quality Promotion

[email protected]

Improving Antibiotic Stewardship in Hospitals-Why Now?

Why Antibiotic Stewardship?

• In hospitals, antibiotic stewardship programs

have been proven to:

– Improve antibiotic use

– Reduce antibiotic resistance

– Reduce complications of antibiotic use- especially

Clostridium difficile

– Improve patient outcomes

– Save money

•IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs

http://www.journals.uchicago.edu/doi/pdf/10.1086/510393

77HAI Regional Training HAI Training Requirements is sponsored by SHEA and the CDC

Most Common Reasons for

Unnecessary Days of Therapy

192 187

94

0

50

100

150

200

250

Duration of Therapy

Longer than Necessary

Noninfectious or

Nonbacterial Syndrome

Treatment of Colonization

or Contamination

Da

ys

of

Th

era

py

576 (30%) of 1941 days of antimicrobial therapy deemed unnecessary

Hecker MT et al. Arch Intern Med. 2003;163:972-978.

Susceptibility Profile of KPC-Producing K.

pneumoniaeAntimicrobial Interpretation Antimicrobial Interpretation

Amikacin I Chloramphenicol R

Amox/clav R Ciprofloxacin R

Ampicillin R Ertapenem R

Aztreonam R Gentamicin R

Cefazolin R Imipenem R

Cefpodoxime R Meropenem R

Cefotaxime R Pipercillin/Tazo R

Cetotetan R Tobramycin R

Cefoxitin R Trimeth/Sulfa R

Ceftazidime R Polymyxin B MIC >4mg/ml

Ceftriaxone R Colistin MIC >4mg/ml

Cefepime R Tigecycline R

C. difficile• Data from population-based surveillance in

2011.

• ~453,000 total annual C. difficile infections.

• ~15,000 attributable deaths

– 80% of deaths in patients >65 years old

– 66% of cases were healthcare associated.

– About $1 billion in excess healthcare costs and re-

admissions

• C difficile infections are now part of the

inpatient quality reporting program• N Engl J Med 2015; 372:825-834

Antibiotic Stewardship to Combat

C. difficile

• 2014 meta-analysis on the impact of stewardship

on C. difficile included 16 studies.

• Stewardship programs were significantly

protective against C. difficile

– Pooled risk ratio 0.48; 95% CI: 0.38, 0.62

• Restrictive interventions were most effective.

• Protection especially strong in geriatric settings.

Feazel LM et al. J Antimicrob Chemother, March 2014

1212

Impact of Reductions in Antibiotic Prescribing

on C. difficile in England

0

10000

20000

30000

40000

50000

60000

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

2004 2005 2006 2007 2008 2009 2010 2011

Cephalosporin doses Fluoroquinolone doses C. difficile in > 65 y.o.

70% reduction in C. difficile

infections over 7 years

Year

De

fin

ed

da

ily d

ose

s in

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sp

ita

l in

pa

tie

nts

Num

ber

of all

(HA

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CD

I cases in >

65 y

o

Ashiru-Oredope et al. J Antimicrob Chemother 2012; 67 Suppl 1: i51–i63

Wilcox MH et al. Clinical Infectious Diseases 2012;55(8):1056–63

http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1179745282388

P. aeruginosa susceptibilities before and after

implementation of antibiotic restrictions (CID 1997;25:230)

0

20

40

60

80

100

Ticar/clav Imipenem Aztreonam Ceftaz Cipro

Perc

en

t su

scep

tib

le

Before After

P<0.01 for all increases

Clinical outcomes better with

antimicrobial stewardship program

0102030405060708090

100

Appropriate Cure Failure

AMP

UP

RR 2.8 (2.1-3.8) RR 1.7 (1.3-2.1) RR 0.2 (0.1-0.4)

Perc

en

t

AMP = Antibiotic Management Program

UP = Usual PracticeFishman N. Am J Med. 2006;119:S53.


Michael Postelnick, RPh BCPS AQ Infectious Diseases

Senior Infectious Diseases Pharmacist

Northwestern Memorial Hospital

Chicago, IL

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Michael Postelnick, RPh BCPS AQ Infectious DiseasesSenior Infectious Diseases PharmacistNorthwestern Memorial HospitalChicago, IL

Measuring the Impact of Antimicrobial Stewardship Interventions on Antimicrobial Resistance

Source: Penicillin finder assays its future. New York Times. 26 June 1945: 21

Call to Antimicrobial Stewardship

“….the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out…… In such cases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism.”

- Sir Alexander Fleming, June 26, 1945

Davey P et al. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD003543

Do Antimicrobial Stewardship Interventions Effect Resistance?

Presentation Overview

•Measuring Antimicrobial Use

•Measuring Antimicrobial Resistance

•Overview of Antimicrobial Stewardship at Northwestern Memorial Hospital

•Representative Stewardship Initiatives

•Current Stewardship Focus at NMH

•Future Directions

Measuring Antimicrobial UseIt is widely believed that you cannot manage what you cannot measure. It is also true that you cannot measure what you cannot define 1

1. Ibrahim OM and Polk RE. Infect Dis Clin N Am 28; 2014: 195-214

Measuring Antimicrobial Use

Measure Calculation Advantages Disadvantages Use?

DOT/1000 PD DOT/(PD/1000) More accurate than DDD

Requires pt. level data

Becoming standardmetric

DOT/1000 admissions

DOT/(admissions/1000)

Not a function of LOS

Requires riskadjustment (RA)

Secondary measure

DDD/1000 PD http://www.whocc.no/ddd/definition_and_general_considera/

Easily calculated, does not require pt level data

Less accurate and consistent

Comparison across countries

LOT/discharge Total LOT/discharge Provides average duration of tx

Not normalized forLOS, needs RA

Identify excessive tx durations

DOT/LOT ratio DOT/LOT Measures agg-regate combo tx

Pt level data needed

Identify un-necessary combo

Proportion receiving abx

Treatedpts/admissions

Needs risk adjustment

Identify unnecessary tx

Interpreting Antimicrobial Use Data

•Benchmarking•Use data must be risk adjusted

•Internal – ICU vs general care floor

•External – Academic medical center vs small rural hospital

•Identify Outliers

•Perform DUE to determine intervention strategies (if needed)

• Unnecessary therapy

• Prolonged durations

• Unusual resistance patterns

Benchmarking by Unit

Fridkin S et al. Clin Infect Dis 1999; 29:245-252

Risk-adjusted Benchmarking

Polk RE et al. Clin Infect Dis 2011; 53:1100-1110

Measuring Antimicrobial Resistance

The Hospital Antibiogram

•Most widely available measure of resistant organisms

•Measures proportion of susceptible organisms over time

•Designed for:•Assisting empiric antimicrobial selection

•Guidance on formulary choices

•CLSI sets guidance for construction

Schulz LT et al. Pharmacotherapy 2012;32(8):668–676

Antibiograms to Assess Stewardship Interventions

Schulz LT et al. Pharmacotherapy 2012;32(8):668–676

What Factors Effect the Ability to Demonstrate Interventional Impact on Resistance?

•Magnitude of Change•Time-series analysis to forecast resistance changes related to antibiotic use

•Ceftazidime/gram negative bacilli and imipenem/Pseudomonas examined

•Complex mathematical model designed for analysis

• Lag-time accounted for

•Impact of changes in antimicrobial use significant but small

• 6% of variation in Pseudomonas susceptibility predicted by imipenem use variation

Lopez-Lozano JM et al. International Journal of Antimicrobial Agents 14 (2000) 21–31

What Factors Effect the Ability to Demonstrate Interventional Impact on Resistance?

•Dynamics of Resistance are Complex•Bacterial resistance mechanisms effect multiple antibiotics

•Stewardship interventions local-resistance is global

•Unintended consequences (“squeezing the balloon”)

•Multiple simultaneous interventions

• Stewardship

• Infection Control

•Regression to the mean

Antimicrobial Stewardship at Northwestern Memorial Hospital

• 894-bed Academic Medical Center

• Primary teaching affiliate of

Northwestern University Feinberg

School of Medicine

• Ranked as the No. 10 hospital in the

nation by U.S. News & World Report

for 2014-15 with 13 specialties

nationally ranked. No. 1 in Illinois and

the Chicago metro area.

• Fiscal Year 2014

• 47,139 Inpatient Admissions

• 598,553 Outpatient visits

• 12,497 Live Births

• 83,245 Emergency Department

Visits

• 12,794 Inpatient Surgeries

• 21,452 Outpatient Surgeries

Northwestern Memorial Hospital

Feinberg and Galter Pavilions Prentice Women’s Hospital

Evolution of Antimicrobial Stewardship NMH 1987-2015

• 1987-1990: Implement Antimicrobial Formulary and Pharmacokinetic Dosing Service

• 1990-1993: Implement Empiric Antimicrobial Guidelines

• 1993-2002: Prospective audit and feedback

• 2002-2003: Initiate “Formal” Stewardship Program

• 2003: Implement Clinical Decision Support

• 2013: CDC-AUR participation

Current Stewardship Structure at NMH• Stewardship physician (0.5 FTE)

Daily TAM review and intervention

Design and support educational initiatives

Provide MD support for all stewardship activities

• Stewardship pharmacists (5 co-funded faculty, approximately 1.4 FTE)

Daily restricted antimicrobial review

72 hour review

MALDI-TOF intervention

Support clinical pharmacist stewardship activities

• Unit-based Clinical Pharmacist

Antimicrobial dosing

IV to PO recommendations

Guideline-based recommendations

72 hour review

Antimicrobial de-escalation

What Have We Accomplished

•Continued control of antimicrobial costs•2014 cost savings = $120,000

•Empiric Antimicrobial Use Guidelines and Incorporation into Order Sets•Optimized Dosing of Antimicrobials

•Comprehensive dosing protocols

•Prolonged infusion protocols for beta-lactams•Leveraging Clinical Decision Support for Bug-drug Mismatches and Restricted Antimicrobials•Expansion of Training Programs for Infectious Diseases Pharmacists

Where Have We Struggled

•Measurement of Impact on Utilization and Resistance•Systematic metrics

•Benchmarking

•Antimicrobial Stewardship Outcomes Research

Representative Stewardship Interventions

Order Sets

Antimicrobial Indications

TAM Alerts

• Identify patients with susceptibility results without active antimicrobial therapy

• Evaluated daily by stewardship physician

• Small minority require clinical intervention

• An average of 4 “critical interventions” identified monthly

TAM Alert Screenshot

TAM Documentation

TAM Alerts by Disposition

142

251

165154

122

32

56 56

2819

9 1121

13 8

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250

300

MAR-MAY 09 JUN-AUG 09 SEPT-NOV 09 DEC 09-FEB 10 MAR-MAY 10

Total

No Intervention

Overtreatment

Undertreatment

Critical Alerts

Examples of Critical Alert Interventions

• Patient with methicillin-resistant S. aureus (MRSA) frombursa fluid On clindamycin (isolate R)

ASP notified hospitalist

Patient was discharged with seven days of PO linezolid

• Patient with growth of P. aeruginosa from cerebrospinal fluid in a patient with lumbar drain History of spine surgery with pseudomeningocele formation + CSF

leak

ASP notified neurosurgery

Infectious disease consulted, ceftazidime initiated

Restricted Antimicrobial Alerts

• Reviewed daily by stewardship pharmacist

• Evaluated against P&T approved criteria

• Interventions coordinated with unit-based clinical pharmacist

Example Restriction Criteria

Linezolid

• Use should be restricted to patients with one of the following:

Documented or strongly suspected VRE infections that are also ampicillin resistant, or VRE infections that are ampicillin-susceptible in patients with penicillin allergy

Documented or suspected hospital acquired pneumonia, ventilator associated pneumonia, or healthcare associated pneumonia with gram positive cocci obtained from a lower respiratory tract sample. Subsequent documentation of MRSA from culture is required for linezolid continuation beyond 72 hours.

Culture-documented methicillin-resistant staphylococcal pneumonia

MRSA infections in patients who exhibit a true allergic reaction to vancomycin

Critically ill patients for whom respiratory sample gram stain results are unavailable or deemed unreliable and MRSA is strongly suspected. Subsequent documentation of MRSA from culture is required for linezolid continuation beyond 72 hours.

Restricted Alert Screenshot

Restricted Drug Alert Documentation

Restricted Antimicrobial Disposition

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1-08 Q2-08 Q3-08 Q4-08 Q1-09 Q2-09 Q3-09 Q4-09 Q1-10 Q2-10 Q3-10 Q4-10

% o

rde

rs o

uts

ide

cri

teri

a

Restricted Antimicrobial Report

% Orders remainingoutside of criteria

% Orders changedby AST

% Orders approvedby ID service

Target = 90%

Custom Alert Capability

•User generated

•Flexible

•Focused

•Simple for end user to design

De-escalation Alert Screenshot

De-escalation Documentation

Pip-tazo De-escalation Results

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23

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61

8683

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9188 89

8386 86

64 %

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Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10

% A

pp

rop

riat

ely

De

-esc

alat

ed

% appropriately deescalated

Goal

Patel J et al. Am J Health-Syst Pharm 2012;69: 1543-44.

Ciprofloxacin MIC Alert

System Generated Antibiograms

• Simple, rapid generation

• Allows for unit and site specific evaluations

• Enhances ability to customize local guidelines

• Increases probability of active initial empiric therapy

• Can help minimize overly broad empiric treatment

Hospital-wide Antibiogram

Unit-specific AntibiogramMICU 2014 Gram negative rods

Site-specific AntibiogramBAL 2014 Gram negative rods

Pharmacist Interventions by Category

0

5

10

15

20

25

30

Dosin

g

CP

OE

Err

or

Unnecessary

tx

AD

E-n

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Rec

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ec

Anticoagula

tion

Antim

icro

bia

l

Ste

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Oth

er

# o

f in

terv

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tio

ns/d

ay

Jan '08

Feb '08

Mar '08

Apr '08

NMH Pharmacist Antimicrobial Stewardship Interventions

Current Stewardship Focus

Clostridium difficile Reduction Initiative

• Hospital C. diff rates are a publicly reported metric

• Partnership with Infection Prevention

• Initiative components:

Education to ensure appropriate testing

Continued strong infection prevention efforts

10% reduction in overall antibiotic use

Patient and family outreach

10% Reduction Interventions and Metric

• Interventions

72 hour structured antibiotic timeout• EMR-triggered review of antibiotics at 72 hours

Mandated end to prolonged post-operative surgical drain prophylaxis

End treatment of asymptomatic bacteriuria

Rapid Diagnostics• Stewardship-driven implementation of MALDI-TOF on blood and respiratory

samples

• Metric

CDC AU DOT data for identified antibiotics

Future Directions

Leveraging the EMR

• Switching from Cerner to Epic offers opportunities

Better use of clinical pathways and order sets

Better use of Point of Ordering Clinical Decision Support• Structured Antibiotic Timeout

New EMR System provides opportunities to change practice habits

• Switching from Cerner to Epic offers risks

Adequate resources

Time and energy devoted to switch can sap momentum from initiatives

Benchmarking

• CDC AUR program provides opportunities for risk adjusted benchmarking

Potential to identify areas to focus improvements

AUR may better define association of use and development of resistance

• Improved TheraDoc Reporting Tools

May provide for closer monitoring and local benchmarking

May provide the ability to focus interventions

Conclusions

• Identifying and reporting relevant metrics to demonstrate the impact of a stewardship program are often challenging

• The EMR and Clinical Decision Support Software such as TheraDoc can be leveraged to facilitate meaningful stewardship interventions

• Progress is being made in developing useful and potentially meaningful stewardship benchmarking methods

• The expanded threats posed by antimicrobial resistance has made antimicrobial stewardship more recognized and important than ever


CAPT Arjun Srinivasan, MD,

Associate Director

Healthcare Associated Infection Prevention Programs

Division of Healthcare Quality Promotion, CDC

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CAPT Arjun Srinivasan, MD

The National Perspective on Antibiotic Stewardship

Implementing Antibiotic Stewardship

Hospitals don’t all look the same, and neither

do stewardship programs.

There must be flexibility in how programs are

implemented.

But, there are certain key elements that have

been strongly associated with success.

Core Elements for Antibiotic Stewardship Programs

Leadership commitment from administration

Single leader responsible for outcomes

Single pharmacy leader

Antibiotic use tracking

Regular reporting on antibiotic use and

resistance

Educating providers on use and resistance

Specific improvement interventionshttp://www.cdc.gov/getsmart/healthcare/implementation/core-

elements.html

Where We Are Now: NHSN Annual Facility

Survey of ~4000 US Hospitals

In 2014, 39.2% of US hospitals reported having

a stewardship program that meets all 7 CDC

core elements for hospital stewardship programs.

Factors associated with meeting all Core

Elements

Larger bed size

Teaching status

Leadership support (written > salary)

Preliminary findings from NHSN 2015 Annual Facility Survey - Not for distribution

Key Next Steps on Implementing

Stewardship Programs• CDC is working with many organizations

through the National Quality Partnership to

develop a “playbook” to provide more specific

suggestions on implementing stewardship

programs.

• Working to connect with smaller hospitals that

have implemented all of the core elements to

get key lessons learned.

National Healthcare Safety Network Antibiotic Use Option

Captures electronic data on antibiotics

administered, along with

admission/discharge/transfer data.

Calculates rates of administration for use:

By facilities to monitor interventions on single

units or facility wide

To collect aggregate information on antibiotic use

at a regional and national level

Eventually, to create antibiotic use benchmarks.

Standardized Antibiotic Administration Ratio (SAAR)

CDC’s 1st attempt at developing a

benchmarking measure for antibiotic use.

Similar in principle to the Standardized

Infection Ration (SIR).

SAAR expresses observed antibiotic use

compared to predicted use.

CDC worked with many partners to develop

the SAAR measure to try and make it most

useful for stewardship.

Standardized Antibiotic Administration Ratio (SAAR)

Experts in stewardship suggested that a variety

of different SAARs would be useful.

SAARs for a variety of different patient

populations.

SAARs for a variety of different groups of

antibiotics.

An Update on the Antibiotic Use Option of NHSN

The Standardized Antibiotic Administration

Ratio was approved for endorsement by the

Patient Safety Committee of the National

Quality Forum in June.

Requested approval was for public health

surveillance and quality improvement only.

A final vote is expected later 2015 or early

2016.

Key Points About the SAAR

The SAAR is risk adjusted based only on

facility characteristics (e.g. presence of ICUs,

hospital size).

The SAAR only helps directs stewardship

efforts to locations and antibiotics where use

appears to deviate from expected.

High use might be perfectly justified, low use

might be harming patients.

Measuring Appropriate Use

We all agree that the ultimate goal of

stewardship is to improve appropriate use of

antibiotics.

It will be hard to measure progress towards

that goal if we don’t have measures of

appropriate use.

CDC is collaborating with partners to try and

help with ways to assess this.

Assessing Appropriate Use

CDC collaborated with partners to create

assessment tools for appropriate use that

hospitals can use for quality improvement.

Available on Get Smart for Healthcare website.

The 2015-15 national antibiotic use point

prevalence survey will include an assessment

of appropriate use for 2 agents (vancomycin

and quinolones) and 2 conditions (community

acquired pneumonia and urinary tract

infections)

Antibiotic Use in US Hospitals-

Key Areas for Attention• In a 2011 survey in ~180 hospitals, CDC and

state collaborators reviewed charts of patients

who got antibiotics to determine the reason for

use, the top three were:

– Lower respiratory tract infections: 34.6%

– Urinary tract infections: 22.3%

– Skin and soft tissue infections: 15.4%

• These 3 infections accounted for more than

half of all in-patient antibiotic use.

JAMA. 2014;312(14):1438-1446

Stewardship in CAP

• Prospective intervention for patients being

treated for CAP.

• Treatment duration reduced from 10 d to 7 d

(p<0.001) with 148 fewer antibiotic days.

• Antibiotics more frequently narrowed based on

culture results (67% v. 19%).

• Fewer patients got duplicate therapy (10% vs

45%).

CID 2012;54:1581-7

“Kicking CAUTI”

• Quality improvement effort in two VA

hospitals in Texas.

• Developed a simple algorithm to improve

sending of urine cultures.

– Defined specific criteria when urine cultures were

indicated.

• Monitored impact on urine cultures and

treatment of UTI in intervention and control

hospitals.

JAMA Intern Med. 2015 Jul;175(7):1120-7.

“Kicking CAUTI”

• Rate of urine culture ordering in interventions

hospitals decreased during the intervention

period:

– From 41.2 to 23.3 per 1000 bed-days; (incidence

rate ratio [IRR], 0.57; 95% CI, 0.53-0.61)

– To 12.0 per 1000 bed-days; (IRR, 0.29; 95% CI,

0.26-0.32) during the maintenance period

– P < .001 for both.

• No change in control hospitals

Skin and Soft Tissue Infections

• Have become common reasons for admission

for antibiotics.

• Are overwhelmingly caused by gram positive

pathogens.

• Despite this, patients are often treated with

agents active against gram negatives and

anaerobes.

Improving Treatment of Skin and

Soft Tissue Infections (SSTI)• Facility implemented a SSTI diagnosis and

treatment guideline.

• Intervention resulted in:

– 3 day reduction in antibiotic treatment (13 v 10d)

– Less use of agents with gram negative and

anaerobic activity

– Better use of diagnostic studies and consults

Jenkins TC Arch Intern Med 2011;171(12):1072-

1079.

Regulatory Requirements?

• Presidential advisors have called for CMS to

make antibiotic stewardship a requirement in

acute and long term care facilities through the

Conditions of Participation.

• CMS has already proposed such a requirement

in long term care.

• They have indicated that they are considering

this for acute care as well.

Accreditation Standards

• The Joint Commission has developed a draft

standard on antimicrobial stewardship that has

been reviewed by several stakeholders and was

recently approved by the Standards and Survey

Procedures Committee.

– It will now go for broader review before being

finalized.

• The standard aligns with and draws from the

CDC core elements.

Conclusion

• This is a critical time for our efforts to

implement antibiotic stewardship programs to

improve antibiotic use.

• We need to continue to build on this

momentum.

• Please tell me what we can do (or do more of)

to support your important work.


Craig Barrett PharmD, BCPS

Director, Safety Solutions, Premier Inc.

Former roles: Pharmacy clinical specialist for surgery and director of

pharmacy residency program at Carolinas HealthCare in Charlotte

@PremierHA

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Impacting the National Action Plan for CARB

PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.

Goal 1: ASP and biosurveillanceSlow the Emergence of Resistant Bacteria and Prevent the

Spread of Resistant Infections

Reducing inappropriate antibiotic use by 20 percent in inpatient

settings and 50% in outpatient settings

Goal 2: Increase AU and AR reportingStrengthen National One-Health Surveillance Efforts to Combat

Resistance

Goal 3: Development of diagnostic testsAdvance Development and Use of Rapid and Innovative

Diagnostic Tests for Identification and Characterization of

Resistant Bacteria

Goal 4: Pharmaceutical developmentAccelerate Basic and Applied Research and Development for

New Antibiotics, Other Therapeutics, and Vaccines

Goal 5: International engagementImprove International Collaboration and Capacities for

Antibiotic-resistance Prevention, Surveillance, Control, and

Antibiotic Research and Development


Economic impact of redundant antimicrobial therapy in US hospitals. Schultz L, Lower TJ, Srinivasan A, Nielson D, Pugliese G. Infect Control Hosp Epidemiol 2014;35(10):1229-1235

Premier, in collaboration with the CDC,

conducted a study of potentially

redundant antimicrobials.

Objective: This study explored the

incidence and economic impact of

potentially redundant antimicrobial

therapy.

Methods:

• Design: Retrospective analysis

• Study Population: All inpatient

discharges in 505 non-federal facilities

in Premier’s hospital database

• Study Period: January 1, 2008 to

December 31, 2011

• Evaluation: Potentially redundant

antimicrobial therapy defined as

overlapping antibiotic spectra for 2 or

more consecutive days. The study

evaluated 23 IV antimicrobial

combinations.


78% (394) hospitals had at least 1 of the 23 unnecessary drug combinations prescribed for 2 or

more days across 32,507 cases.

70% of cases represented 3 specific drug combinations for anaerobic infections. Metronidazole and piperacillin-tazobactam made up 53% of cases.

Nearly 150,000 days of potentially inappropriate antibiotic therapy, resulting in nearly $13 million in

potentially avoidable healthcare costs.

If these cases were representative of all U.S. hospitals over that same period of time, more than

$163 million could have been saved.

Economic impact of redundant antimicrobial therapy in US hospitals. Schultz L, Lower TJ, Srinivasan A, Nielson D, Pugliese G. Infect Control Hosp Epidemiol 2014;35(10):1229-1235.

78%

70%

150,000

$163M


Economic impact of redundant antimicrobial therapy in US hospitals. Schultz L, Lower TJ, Srinivasan A, Nielson D, Pugliese G. Infect Control Hosp Epidemiol 2014;35(10):1229-1235.

53% of all

patients received

redundant metronidazole

and piperacillin-

tazobactam therapy

5% of all patients

received redundant IV

linezolid and vancomycin

therapy

5% of all patients

with dual therapies

received dual beta-

lactam combinations

3 to 6 days was

the mean dose days with

the redundant

combinations


Antimicrobial stewardship is an effective strategy in

reducing overutilization and redundant therapy,

antimicrobial resistance, patient harm, and wasteful

spending.

Based on the study findings of metronidazole used with

piperacillin-tazobactam as the most common

inappropriate or redundant combination, this single

combination should be considered a possible initial target

for antimicrobial stewardship programs.

One successful approach that has been recommended is

for healthcare organizations to develop a list of “never”

combinations of antibiotics or redundant combinations

and provide alerts to providers when these combinations

are ordered.

Applying Lessons Learned


Launch of QUEST mini collaborative of 50 healthcare

organizations as part of White House commitment

September 2015 to June 2016.

Goals:

• Implement CDC Core Elements for hospital antibiotic stewardship

programs

• Reduce potentially inappropriate use of redundant combinations

of intravenous anti-anaerobic antibiotics

Results and learnings will be shared widely

More info at premierinc.com/antibiotics

Premier Collaborative on Antimicrobial Stewardship

http://www.premierinc.com/antibiotics


Premier Research Institute

• Publication with the CDC in September 2014

• 78% of hospital patients treated received unnecessary or

duplicative IV antibiotics

• 70% of the inappropriate use was related to three specific

combinations of IV antibiotics used to treat anaerobic infections

Premier QUEST and PFP Hospitals

• QUEST sprint webinar series on AMS w/CDC

• Participate in performance improvement initiatives to drive AMS

techniques into patient safety practices

PremierConnect Quality

• Developed redundant/duplicative antibiotic usage reports

• Shared reports with member hospitals in October 2014

Premier Activities to Improve Antimicrobial Stewardship


PremierConnect Safety

• 1000 facilities use Premier’s CDSS to support ASP initiatives

• 27 facilities (~25% of all facilities) have submitted data to NHSN

Antimicrobial Use (AU) module

Premier Advocacy

• Participant in White House Forum on Antibiotic Stewardship

• Participant in Stakeholder Forum on Antimicrobial Resistance (S-

FAR)

• CDC White House Partner for “Get Smart Week 2015”

• Participant in National Quality Partners Antibiotic Stewardship

Action Team

• Participant in NQF initiative to develop a practical playbook to

advance effective antibiotic stewardship

Premier Activities to Improve Antimicrobial Stewardship


Premier’s Impact on the National Action Plan for CARB

PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.

Goal 1: ASP and biosurveillance• Premier Research Institute

• PremierConnect Quality

• Premier QUEST and PFP Hospitals

• PremierConnect Safety

• Premier Advocacy

Goal 2: Increase AU and AR reporting• PremierConnect Safety


Premier resources on antimicrobial stewardship on

Premier Safety Institute® website

Tools, resources, solutions,

blogs on measurement, and

e-surveillance for antimicrobial

stewardship from Premier at

premierinc.com/antibiotics

Thank [email protected]


Your questions

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or Tweet@PremierHA

#AdvisorLive


Faculty

MODERATOR

Gina Pugliese, RN, MS, FSHEAVice President

Premier Safety Institute®

CAPT Arjun Srinivasan, MDAssociate Director,

Healthcare associated infection

prevention programs, CDC

Michael Postelnick, RPh BCPS

AQ Infectious DiseasesSenior Infectious Diseases Pharmacist

Northwestern Memorial Hospital, Chicago

Craig Barrett PharmD,BCPSDirector, Safety Solutions, Premier Inc.

@PremierHA

#AdvisorLive

#GetSmartWeek


Visit the Premier Safety Institute for tools,

resources, and e-surveillance solutions

www.premierinc.com/antibiotics

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Date post:	13-Jan-2017
Category:	Healthcare
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