Evidence Based Guidelines at PHD related to Infectious
DiseaseEdward 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/released200209.
Cost effectiveness of Influenza vaccination. Leavenworth, G. The costly toll of vaccine-
preventable 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 andevidence-based recommendations: interventions that increase the utilizationof Medicare-funded preventive service for persons age 65 and older.Baltimore, Maryland: U.S. Department of Health and Human Services, HealthCare Financing Administration, October 1999; HCFA publication no.HCFA-02151.
• Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-basedstrategies 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-carefacilities: provider-based improvement strategies implemented by peer-revieworganizations in four western states. Infect Control Hosp Epidemiol2000;21:705--10.
Government Regulations to Promote Standing Orders
• Centers for Medicare and Medicaid Services. Medicare and Medicaidprograms: 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 MedicaidServices, 2002. Available athttp://www.cms.gov/providerupdate/regs/cms3160fc.pdf<http://www.cms.gov/providerupdate/regs/cms3160fc.pdf> .
Centers for Medicare and Medicaid Services, Center for Medicaid andState Operations. Program memorandum: change in requirement for signedphysician's order for influenza and pneumonia vaccine. Washington, DC: U.S.Department of Health and Human Services, Centers for Medicare and MedicaidServices, 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 multidrug-resistant 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
Parameter Pre- Intervention Post- Intervention Ceftaz ( gms)4,3011,248Pip/ taz (gms)12,45517,464 Imipen ( gms)14060Abx tot cost $68,027 $59,166 K. pneumo Resistance Ceftaz Pip/ taz22%36%15%19% Infect Control Hosp Epidemiol. 2000;21: 455-458.
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
% of Resistance 1994 1998
VRE E. cloacae*
16 61
6 28
E. aerogenes* Acinetobacter sp*
63 17
11 0
S. marcescens* MRSA
20 34
0 23
Pseudomonas sp* 13 17 *resistance to pip/tazo Pharmacotherapy 1999;19(8 pt 2):129S-132S
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 Pre Post Imipen Pre Post Ceftaz Pre Post Ceftriax Pre Post P. aerug Inpt Outpt ICU 1721111317355172434812697488283136K. pneum Inpt Outpt ICU 201676162123Clinical Infectious Diseases 1997;25:230-9.
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 Conversion Surgical Prophylaxis Restricted Antimicrobials Total Interventions 2914483251064Accepted 264(91%)261(58%)286(88%)811(76%)Rejected 2718739253
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
p=.010 p=.003
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Doses/Census Day
200020012002
IV vs. OralTotal Antibiotic Cost / Day
$0
$2
$4
$6
$8
$10
$12
$14
IV AbxCost/Census Day
PO AbxCost/Census Day
200020012002
Restricted Antibiotics Doses / Day
p=.007p=.016
00.020.040.060.08
0.10.120.140.160.18
0.2
Doses/Census Day
200020012002
Vancomycin
0.0780.08
0.0820.0840.0860.088
0.090.0920.0940.0960.098
0.1
Doses/Census Day
200020012002
IV and PO Fluoroquinolones
00.010.020.030.040.050.060.070.080.09
0.1
IV Dose/Census Day Oral Doses/Census Day
1999200020012002
Total Antibiotic Doses / Day
p=.001p=.000
0
0.5
1
1.5
2
2.5
Doses/Census Day
200020012002
Facility Census Days
155000
160000
165000
170000
175000
180000
200020012002
Annual Antibiotic Expenditure
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
200020012002
Total Antibiotic Cost / Census Day
$0
$2
$4
$6
$8
$10
$12
$14
Cost/Census Day
Cost Savings for 2001 = $399,238Cost Savings for 2002 = $659,812Total Cost Savings = $1,059,050
200020012002
Changes in Bug/Drug Susceptibility Patterns
0%
5%
10%
15%
20%
25%
30%
1999 2000 2001 2002% Bug/Drug combinations having > or = 5% increase in resistance%Bug/Drug combinations having > or = 5% decrease in resistance