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ANTIBIOTICS IN THE ER: EXPLORING THE ROLE OF ANTIMICROBIAL STEWARDSHIP IN THE EMERGENCY DEPARTMENT

ANGELINA DAVIS, PHARMD, MS, BCPS (AQ-ID)LIAISON CLINICAL PHARMACISTDUKE ANTIMICROBIAL STEWARDSHIP OUTREACHNETWORK

Financial Disclosures

There are no financial disclosures

ObjectivesReview trends in antimicrobial prescribing in the emergency department (ED) and consider the opportunity for optimization of patient care through antimicrobial stewardshipDiscuss challenges to implementation of antimicrobial stewardship efforts in the EDIdentify key strategies for antimicrobial stewardship in the ED to optimize patient care, reduce the risk for antibiotic resistance and decrease healthcare costsExplore the potential role of rapid diagnostics in the ED for optimization of antimicrobial prescribing

“Antibiotic resistance costs an estimated $20 billion annually to the U.S. healthcare system and increases patient hospital stays by more than eight million days.”

-Infectious Diseases Society of America

Antibiotic Resistance Threats in the United States, 2013

http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11

Four Core Actions to Prevent Antibiotic Resistance1. Preventing infections,

preventing the spread of resistance

2. Tracking3. Improving antibiotic

prescribing/stewardship4. Developing new dugs and

diagnostic tests

http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11

Clinical Outcomes: ASP versus Usual Practice

Fishman N. Antimicrobial stewardship. Am J Med 2006;119(6) Suppl 1:S53‐S61

7

Infection Rates Pre- and Post-Implementation of an ASP

C. DIFFICILE RESISTANT ENTEROBACTERIACEAE

Carling P et al. Infect Control Hosp Epidemiol. 2003;24(9):699-706.

Expanding ASPs Beyond the Inpatient SettingTo date, ASPs have primarily targeted the inpatient acute care setting~136 million ED visits occur annually in the U.S. ~16.2 million visits result in hospital admission An interface between the inpatient and community settings

The ED represents a critical setting for initiating interventions that can reduce inappropriate antibiotic prescribing

www.cdc.gov/nchs/fastats/emergency-department.htmMay L, et al. Annals of Emergency Medicine 2013; 62 (1): 69 - 77

The ED as a Target for ASPsED practitioners are optimally positioned to determine appropriate empiric antimicrobial therapyInitial prescribing in the ED has the ability to impact the care continuum (i.e. admission, observation, discharge)Antimicrobial overprescribing in the ED can cause collateral damage downstream Adverse drug events (ADEs) Hypersensitivity/allergy Side effects Clostridium difficile infection Antimicrobial resistance Increased health-care costs

Antimicrobial Prescribing in the EDLeading infection related primary diagnosis groups: Acute upper respiratory infections (URIs), excluding pharyngitis Cellulitis and abscess Urinary tract infection (UTI), site not specified Otitis media and eustachian tube disorders

ED trends in antibiotic overprescribing ~48% of patients with antibiotic inappropriate URI received antibiotics >40% of visits for UTI included broad-spectrum fluoroquinolones Unnecessary use of antibiotics with broad gram-negative and/or

anaerobic coverage frequency observed for cellulitis or abscess2011 National Hospital Ambulatory Medical Care Survey (NHAMCS), https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdfDonnelly JP, et al. Antimicrob Agents Chemther. 2014; 58 (3): 1451 – 1457May L, et al. Acad Emerg Med. 2014; 21 (1): 17 – 24Jenkins TC, et al. Clin Infect Dis. 2010; 51 (8): 895 - 903

Antimicrobial Prescribing in the ED

ED Visits for Antibiotic ADEsOver 142,000 visits annually in the US for antibiotic-related ADEs Antibiotics implicated in 19% of all ED visits for drug-related ADEs Allergic reaction was the most common antibiotic-related ADE (79%)

Shehab N, et al. CID 2008; 47: 735 - 743

Challenges to AS in the EDHigh patient turnoverHigh physician turnoverDiagnostic uncertainty Rapid decision-makingAutomated dispensingNational health care quality benchmarks (i.e. CMS Core Measures)Lack of patient follow up

ASP Implementation in the EDSuccessful implementation highly dependent on involvement of ED and administrative leadershipRequires a collective and multi-disciplinary effort AS Physician Champion AS Pharmacy Champion and/or ED Pharmacist (EPh) ED Antibiotic Stewardship Champion Microbiology Information Technology

Antimicrobial stewardship interventions must be applied to commonly encountered ED scenarios

AS Interventions in the EDEducationPost-prescription reviewStreamlining/De-escalationDose optimizationShortening duration of therapyED antibiogram developmentGuidelines and clinical pathwaysFocused order setsClinical decision supportRapid diagnostic testing

Pharmacist-Managed ASP for Patients Discharged from the EDStudy Design: A retrospective case-control study of 212 patients >18 years old who were

discharged from the ED with subsequent positive cultures Pre-implementation (November 2007 - January 2008) vs. post-implementation of

an EPh-managed program (November 2008 - January 2009) Conducted at a university teaching hospital with over 97,000 ED visits per year

Intervention: EPh involvement included education regarding appropriate empiric antibiotic

selection and assistance with follow up Education involved didactic lectures and preparation of clinical resources for use

when EPh unavailable

Outcomes: Primary: time to positive culture review and time to patient or PCP notification Secondary: appropriateness of antimicrobial therapy

Baker SN, et al. Journal of Pharmacy Practice; 25: 190 - 194

Post-Implementation Culture and Susceptibility Follow Up Process

Step #1: Night-shift MLP separates positive

and negative culture results

Step #2: Night-shift MLP obtains patient charts for those with

positive culture results

Step #3: Positive culture results and

charts assessed by the EPh between 1100 and

1500

Step #4:Antimicorbial changes based on EPh

assessment are relayed to patient, PCP, or patient’s

pharmacy (issues are discussed with the day-shift MLP as needed)

Baker SN, et al. Journal of Pharmacy Practice; 25: 190 - 194

Weekend culture review was performed by the mid-level provider (MLP) as the EPh does not provide clinical services during this time.

Results

Note: Discontinuation of unnecessary antimicrobials or optimization of therapy when broad-spectrum agents were not necessary was not addressed

The Impact of AS Intervention on UTI Treatment in the EDStudy Design: A quasi-experimental study comparing two separate periods before and after

intervention 439-bed tertiary-care teaching center with > 57,000 ED visits annually Patients aged 12 to 70 years old, discharged home from the ED with an uncomplicated

UTI, and received an antibiotic prescription

Interventions: ED-specific antibiogram Institution-specific recommendations for empiric treatment of uncomplicated UTIs Education of resident physicians and ED providers

Outcomes: Primary: Adherence to recommendations for the treatment of uncomplicated UTIs based on local

resistance rates Secondary: Agreement between empiric antibiotics prescribed and isolated pathogen susceptibilities Reevaluation in the ED or hospital admission for a UTI within 30 days

Percival KM, et al. American Journal of Emergency Medicine. 2015; 33: 1129 - 1133

Empiric Treatment for UTI


Results of Adherence Recommendations


Secondary Outcomes and Antibiotics Prescribed at DischargeSecondary Outcomes: Prescribed antibiotic was susceptible to the isolated pathogen more

often in cystitis after education (74% vs 89%, P = 0.05) but not in pyelonephritis patients (90% vs 76%, P = 0.23) Rate of patients seeking follow-up care for a UTI at the institution

within 30 days was unchanged at 4.6% compared with 7.4% (P = 0.27)


Effect of an Electronic Order Set on Guideline Adherence in UTIStudy Design: Before and after study at an academic urban level 1 trauma center with >90,000 visits annually Women age 18 – 65 with UTI and no structural or functional abnormalities of the urinary system

seen in the ED during twelve specified months over a 3 year time period (2010 – 2012)

Interventions: Electronic order set (period 1) Audit and feedback (period 2) Additional interventions: Educational lecture and pre-existing policy providing small financial incentive

based on compliance with quality indicators

Outcomes: Primary Overall adherence to guidelines (medication choice and duration of therapy)

Secondary Total and unnecessary days of antibiotic therapy for UTI Use of fluoroquinolones for uncomplicated cystitis Treatment failure Adverse events Diagnostic accuracy

http://dx.doi.org/10.1371/journal.pone.0087899

Electronic UTI Order Set


Audit and FeedbackPharmacist reviewed cases daily and discussed them with an ID physician ~1.5 – 3 hours of pharmacist time ~30 minutes of ID physician time

Feedback given to providers via staff messages in the EMR within 5 – 7 days of the ED visit for the following: Recommended UTI medication choice or duration of therapy not used Urine cultures not sent in cases of suspected pyelonephritis UTI diagnosis determined unlikely or rejected

Results – Overall Adherence


Results – Secondary Outcomes


Percentage of Cases Deemed Unlikely or Rejected


Clinical Decision Support in the EDUse of health information technology to deliver information to the clinician at the point of careEffective in reducing antibiotic use in other clinical settings (i.e. ICU, outpatient)Limitations: Lack of information technology infrastructure Need for streamlined clinical decision support Cost

The Role of Rapid DiagnosticsStandard techniques for identification of organisms are based on phenotypic methods (48 – 72 hrs)Rapid diagnostics are considered “game changers” Provide organism identification within hours of growth Speed up the diagnostic process Guide antimicrobial selection and treatment duration

Rapid molecular methods commercially available Polymerase chain reaction (PCR) Multiplex PCR Nanoparticle probe technology (Nucleic acid extraction and PCR amplification) Peptide nucleic acid fluorescent in situ hybridization (PNA FISH) Matrix-assisted laser desorption/ionization time-of-flight mass spectometry

(MALDI-TOF MS)

Bauer KA, et al. CID 2014; 59 (S3): S134 – S145

Rapid Molecular Testing for S. aureus vs. Standard of Care for Patients with Cutaneous Abscesses in the EDStudy Design: Prospective, randomized controlled trial comparing multiplex PCR

with standard of care culture-based testing Patients ≥18 years years old presenting with a chief complaint of

abscess, cellulitis, or insect bite and receiving incision and drainage Enrolled 252 patients presenting to two urban, academic EDs from

April 1, 2011 through April 30, 2014

Outcomes: Primary: Antibiotic selection (anti-MRSA, beta-lactam, or no antibiotic

therapy) stratified by detection of MRSA or MSSA Secondary: Clinical outcomes (1 week, 1 month and 3 months)


Clinical Actions Based on Rapid Test Results


ResultsNo decrease in overall antibiotic use observedNo significant differences found in 1-week or 3-month outcomesMean turnaround time for molecular testing was 82 minutesAvailability of rapid molecular test results was associated with more-targeted antibiotic selection


SummaryExpansion of AS efforts to the ED has the ability to impact the care continuum Although potential barriers to implementation exist, successful implementation can be achieved with multi-disciplinary involvement including ED and administrative leadershipSeveral general AS strategies can be effectively applied to the ED setting to improve antimicrobial useRapid diagnostics offer timely identification which can further optimize antimicrobial prescribing

Questions?

Email: [email protected]

Question 1

39

The emergency department (ED) presents an opportunity for creative antimicrobial stewardship interventions to affect change across the care continuum.

a) Trueb) False

Question #2

40

Rapid diagnostics that can be utilized to guide antimicrobial prescribing in the ED include which of the following?a) BioFire FilmArray b) BD Phoenixc) Cepheid Xpertd) a and be) a and cf) all of the above

Question #3

41

Potential barriers for successful implementation of antimicrobial stewardship in the ED include which of the following?a) High patient turnoverb) High physician turnoverc) Rapid decision makingd) a and be) a and cf) all of the above

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