neuhauser ss64 handout - ferris state university · •led to decreased inappropriate antibiotic...
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NationalCenterforEmergingandZoonoticInfectiousDiseases
CoreElementsofOutpatientAntibioticStewardship:
ImplementingAntibioticStewardshipIntoYourOutpatientPractice
MelindaNeuhauser,PharmD,MPH
OfficeofAntibioticStewardshipDivisionofHealthcareQualityPromotionNationalCenterforEmergingandZoonoticInfectiousDiseasesCentersforDiseaseControlandPrevention
May16,2016
Objectives
§ Defineantibioticstewardship.
§ Describeoutpatientantibioticuse.
§ Discussopportunitiesforpharmaciststoplayaroleinimprovingantibioticuseintheoutpatientsetting.
Life-SavingBenefitsofAntibiotics§ Oncedeadlyinfectiousbacterialdiseasesaretreatable,
substantiallyreducingdeathscomparedtopre-antibioticera
§ Importantadjuncttomodernmedicaladvances– Surgeries– Transplants– Cancertherapies
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AntibioticResistance
CDC.AntibioticresistancethreatsintheUnitedStates,2013.www.cdc.gov/drugresistance/threat-report-2013/
$20billioninexcessdirecthealthcarecostsannually
AntibioticUseDrivesResistance
http://www.cdc.gov/drugresistance/about.html
Dateofantibioticintroduction
Penicillin1943
Methicillin1960
Vancomycin1972
Levofloxacin1996
Ceftaroline2010
Dateofresistanceidentified
1940Penicillin-R
Staphylococcus
1962Methicillin-R
Staphylococcus
1988Vancomycin-REnterococcus
1996Levofloxacin-RStreptococcus
2011Ceftaroline-RStaphylococcus
It’saMatterofPatientSafety
§ Adverseeventsfromantibioticsrangefromminortosevere
– Sideeffectslikerashorantibiotic-associateddiarrhea
– Allergicreactions,includinganaphylaxis(life-threatening)
§ 1in1000antibioticprescriptionsleadstoanemergencydepartment(ER)visitforanadverseevent
– 142,000ERvisitsperyearforantibiotic-associatedadverseevents
– Antibioticsaremostcommoncauseofdrug-relatedemergencydepartmentvisitsforchildren
§ Long-termconsequences:growingevidencethatantibioticsassociatedwithchronicdiseasethroughdisruptionofthemicrobiotaandmicrobiome
Shehab,etal.ClinInfectDis.2008Sep15;47(6):735-43.Bourgeois,etal.Pediatrics. 2009;124(4):e744-50.Linder.ClinInfectDis.2008Sep15;47(6):744-6.Vangay,etal.Cellhostµbe2015;17(5):553-564.
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It’saMatterofPatientSafety:Clostridiumdifficile
Morerecentestimate:453,000infectionsandcaused15,000deathsintheUSannually
CDC.AntibioticresistancethreatsintheUnitedStates,2013.www.cdc.gov/drugresistance/threat-report-2013/LessaNEJM2015;372(9):825-34
AntibioticExpendituresinUnitedStatesbyTreatmentSetting
Sudaetal.JAntimicrobChemother2013;68:715–718https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_Report_2014__3_.pdf.https://www.folkhalsomyndigheten.se/pagefiles/20281/Swedres-Svarm-2014-14027.pdf.
Estimate80-90%ofantibioticuseoccurringinoutpatientsetting
Fleming-Dutraetal.JAMA2016;315(17):1864-1873.http://www.pewtrusts.org/~/media/assets/2016/05/antibioticuseinoutpatientsettings.pdf;
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WhatisAntibioticStewardship?§ Antibioticstewardshipistheeffortto:
– Measureantibioticprescribing– Improveantibioticprescribingsothatantibioticsare
onlyprescribedandusedwhenneeded– Minimizemisdiagnosesordelayeddiagnosesleading
tounderuseofantibiotics– Ensurethattherightdrug,dose,anddurationare
selectedwhenanantibioticisneeded
It’saboutpatientsafetyanddeliveringhigh-qualityhealthcare.
CDC’sCoreElementsofAntibioticStewardshipforHospitalsandNursingHomes
SanchezGV,Fleming-DutraKE,RobertsRM,HicksLA.CoreElementsofOutpatientAntibioticStewardship.MMWRRecommRep2016;65(No.RR-6):1-12.https://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e
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Who are the Core Elements of Outpatient Antibiotic Stewardship intended for?
InitialStepsforOutpatientAntibioticStewardship
– Conditionsforwhichantibioticsareoverprescribed– Conditionswhichareoverdiagnosed– Conditionsforwhichthewrongdose,durationoragentoftenis
selected– Conditionsforwhichwatchfulwaitingordelayedprescribingis
underused– Conditionsforwhichantibioticsareunderusedortheneedfor
timelyantibioticsisn’trecognized
InitialStepsforOutpatientAntibioticStewardship
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InitialStepsforOutpatientAntibioticStewardship
TheCoreElementsofOutpatientAntibioticStewardship§ Commitment:demonstratededicationtoand
accountabilityforoptimizingantibioticprescribingandpatientsafety
§ Actionforpolicyandpractice:implementatleastonepolicyorpracticetoimproveantibioticprescribing,assesswhetheritisworking,andmodifyasneeded
§ TrackingandReporting:monitorantibioticprescribingpracticesandofferregularfeedbacktocliniciansorhavecliniciansassesstheirownantibioticuse
§ EducationandExpertise: Provideeducationalresourcestocliniciansandpatientsonantibioticprescribingandensureaccesstoneededexpertiseonantibioticprescribing
https://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.html
Commitment§ Demonstratededicationtoandaccountabilityforoptimizingantibioticprescribing
andpatientsafetybydoingoneofthefollowing:
Clinicians Organizational Leadership
• Write and display public commitments in support of antibiotic stewardship
• Identify a single leader to direct antibiotic stewardship activities within a facility
• Include stewardship-related duties in position descriptions or job evaluation criteria
• Communicate with all clinic staff to set patient expectations
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PublicCommitmentPosters§ Simpleintervention:poster-placedinexamroomswithclinicianpictureandcommitmenttouse
antibioticsappropriately§ Randomized-controlledtrial§ Principleofbehavioralscience:desiretobeconsistentwithpreviouscommitments§ “Behavioralnudge”tomaketherightchoice
“Asyourdoctors,wepromisetotreatyourillnessinthebestwaypossible.Wearealsodedicatedtoavoidprescribingantibioticswhentheyarelikelydotomoreharmthangood.”
§ Adjustedabsolutereductionininappropriateantibioticprescribing:-20%comparedtocontrols,p=0.02
Meekeretal.JAMAInternMed.2014;174(3):425-31.
CommitmentPostersinIllinois,TexasandNewYork
http://blogs.cdc.gov/safehealthcare/?p=5900
PutaCommitmentPosterinYourClinic!§ CDCworkedwiththeauthorsofthestudytocreatea
postertemplatefordownload§ WillbecominginSpanish§ Addyourpictureandsignature§ Placeinyourexaminationrooms
§ Availableat:https://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/index.html
Addyourpictureandsignaturehere
Meekeretal.JAMAInternMed.2014;174(3):425-31.
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Commitment§ Demonstratededicationtoandaccountabilityforoptimizingantibioticprescribing
andpatientsafetybydoingoneofthefollowing:
Clinicians Organizational Leadership
• Write and display public commitments in support of antibiotic stewardship
• Identify a single leader to direct antibiotic stewardship activities within a facility
• Include stewardship-related duties in position descriptions or job evaluation criteria
• Communicate with all clinic staff to set patient expectations
Action§ Implementatleastonepolicyorpracticetoimproveantibioticprescribing,assess
whetheritisworking,andmodifyasneeded
Clinicians Organizational Leadership
• Use evidence-based diagnostic criteria and treatment recommendations
• Use delayed prescribing practices or watchful waiting, when appropriate
• Provide communications skills training for clinicians
• Require explicit written justification in the medical record for nonrecommended antibiotic prescribing
• Provide support for clinical decisions
• Use call centers, nurse hotlines, or pharmacist consultations as triage systems to prevent unnecessary visits
http://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/index.html
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Action§ Implementatleastonepolicyorpracticetoimproveantibioticprescribing,assess
whetheritisworking,andmodifyasneeded
Clinicians Organizational Leadership
• Use evidence-based diagnostic criteria and treatment recommendations
• Use delayed prescribing practices or watchful waiting, when appropriate
• Provide communications skills training for clinicians
• Require explicit written justification in the medical record for nonrecommended antibiotic prescribing
• Provide support for clinical decisions
• Use call centers, nurse hotlines, or pharmacist consultations as triage systems to prevent unnecessary visits
CommunicationTrainingasanAntibioticStewardshipIntervention§ Enhancedcommunicationtrainingreducesantibioticprescribingforrespiratoryinfectionsinallages
whilemaintainingpatientsatisfaction
§ Communicationgoals– Understandingthepatient’sexpectations– Explainingwhyantibioticswill/willnothelp– Providingsymptomaticrecommendations– Discussingwhentoreturnifthepatientisnotbetter
§ Effectappearstobesustainableovertime
Calsetal.AnnFamilyMed2013;11(2)157-64.Littleetal.Lancet 2013:382(9899)1175-82.
TrackingandReporting§ Monitorantibioticprescribingpracticesandofferregularfeedbacktocliniciansor
havecliniciansassesstheirownantibioticprescribingpracticesthemselves
Clinicians Organizational Leadership
• Self-evaluate antibiotic prescribing practices
• Participate in continuing medical education and quality improvement activities to track and improve antibiotic prescribing
• Implement at least one antibiotic prescribing tracking and reporting system
• Assess and share performance on quality measures and established reduction goals addressing appropriate antibiotic prescribing from health care plans and payers
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TrackingandReporting§ Monitorantibioticprescribingpracticesandofferregularfeedbacktocliniciansor
havecliniciansassesstheirownantibioticprescribingpracticesthemselves
Clinicians Organizational Leadership
• Self-evaluate antibiotic prescribing practices
• Participate in continuing medical education and quality improvement activities to track and improve antibiotic prescribing
• Implement at least one antibiotic prescribing tracking and reporting system
• Assess and share performance on quality measures and established reduction goals addressing appropriate antibiotic prescribing
WhatShouldYouTrackandReportinYourOutpatientFacility?§ Decisionsshouldbemadeineachpracticeorfacilitybasedonyouropportunitiesforimprovement§ Options:
– Antibioticprescribingforoneormorehigh-priorityconditions(e.g.acutebronchitis)– Percentageofallvisitsleadingtoantibioticprescriptions– Atthelevelofahealthcaresystem
• Complicationsofantibioticuse(e.g.adversedrugevents,C.difficile infections)• Antibioticresistancetrendsamongcommonoutpatientbacterialpathogens
TrackingandReportingwithPeerComparisons§ Effectivefeedbackinterventionsoftenincludepeerperformancecomparisons
– Comparingclinician’santibioticselectionpatternsforrespiratoryconditionstocolleagues’performance1
• Ledtoincreaseduseofguidelinerecommendedagents
– Comparingclinician’spercentageofinappropriateantibioticprescribingforacuterespiratoryconditionsto“top-performers”intheirpractice 2
• Ledtodecreasedinappropriateantibioticprescribingforacuterespiratoryinfectionsthatshouldnotbetreatedwithantibiotics(e.g.coldsandacutebronchitis)
– Notifyingcliniciansthattheyprescribemoreantibioticsthan80%oftheirpeers,basedonthepercentageallvisitsleadingtoantibioticprescriptions3
• Ledtodecreasedoverallantibioticprescribingandcost-savings
1.Gerber.JAMA 2013;309(22):2345-2352.2.Meekeretal.JAMA 2016;315(6): 562-570.3.Hallsworthetal.Lancet 2016;387(10029):1743-1752.
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EducationandExpertise§ Provideeducationalresourcestocliniciansandpatientsonantibioticprescribing
andensureaccesstoneededexpertiseonoptimizingantibioticprescribing.
Clinicians Organizational Leadership
• Use effective communications strategies to educate patients about when antibiotics are and are not needed
• Educate about the potential harms of antibiotic treatment
• Provide patient education materials
• Provide face-to-face educational training (academic detailing)
• Provide continuing education activities for clinicians
• Ensure timely access to persons with expertise
EducatingPatientsThroughEffectiveCommunication§ Clinicianscitepatientdemandforantibioticsasareasontheyprescribeinappropriately1
– Cliniciansarenotverygoodatcorrectlydeterminingwhichpatientswantantibiotics2
– Cliniciansaremorelikelytoprescribeantibioticswhentheythinkthatthepatientwantsthem2
§ Patientscanbesatisfiedwithoutantibiotics,eveniftheyexpectthem,witheffectivecommunication– Combiningexplanationsofwhyantibioticsarenotneededwithrecommendationsformanaging
symptomshavebeenassociatedwithincreasedvisitsatisfaction3
– Providingrecommendationsofwhentoseekmedicalcareifthepatientworsensordoesn’timprove(i.e.acontingencyplan)hasbeenassociatedwithincreasedsatisfactionforpatientswhoexpectedantibioticsbutdidnotreceivethem4
1.Sanchez,EID;2014;20(12);2041-7.2.Mangione-SmithPediatrics 1999;103(4):711-8.3.Mangione-SmithAnnFamilyMed2015;13(3)221-7.4.Mangione-SmithArchPediatrAdolescMed2001;155:800-6.
EducationandExpertise§ Provideeducationalresourcestocliniciansandpatientsonantibioticprescribing
andensureaccesstoneededexpertiseonoptimizingantibioticprescribing§ Inappropriateantibioticprescribingisrarelyduetoclinicalknowledgegapsalone
Clinicians Organizational Leadership
• Use effective communications strategies to educate patients about when antibiotics are and are not needed
• Educate about the potential harms of antibiotic treatment
• Provide patient education materials
• Provide face-to-face educational training (academic detailing)
• Provide continuing education activities for clinicians
• Ensure timely access to persons with expertise
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www.cdc.gov/getsmart
http://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.htmlMedscapevideo:http://www.medscape.com/viewarticle/871205?src=par_cdc_stm_mscpedt&faf=1
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https://www.whitehouse.gov/the-press-office/2016/11/10/presidential-proclamation-get-smart-about-antibiotics-week-2016
Summary§ Antibioticstewardshipisoneofthemostimportantstrategiestocombatantibioticresistanceand
keepourpatientssafe
§ TheCoreElementsofOutpatientStewardshipprovidesaframeworkforimprovingoutpatientantibioticprescribing
§ TheCoreElementsofOutpatientStewardshipincludethefollowing:– Commitment– ActionforPolicyandPractice– TrackingandReporting– EducationandExpertise
§ Wecanallbeantibioticstewards— pleaseimplementtheCoreElementsinyourpractice!
Formoreinformation,contactCDC1-800-CDC-INFO(232-4636)TTY:1-888-232-6348www.cdc.gov
ThefindingsandconclusionsinthisreportarethoseoftheauthorsanddonotnecessarilyrepresenttheofficialpositionoftheCentersforDiseaseControlandPrevention.
www.cdc.gov/[email protected]
Acknowledgements:MemoSanchez,RebeccaRoberts,LauriHicks
JonathanA.Finkelstein,JeffreyS.Gerber,AdamL.Hersh,DavidY.Hyun,JeffreyA.Linder,LarissaS.May,DanielMerenstein,KatieJ.Suda,RachelZetts,KellyO’Neill,AustynDukes,RachelRobb,MeredithReagan