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  • Successes, Challenges, and Directions Forward for

    New Hampshire Stewardship

    Michael S. Calderwood, MD, MPH

    Regional Hospital Epidemiologist, Dartmouth-Hitchcock Medical Center

    Assistant Professor of Medicine, Geisel School of Medicine at Dartmouth

    May 23, 2018

  • Outline

    • Overview of Inpatient/Outpatient Antibiotic Use

    • Discussion of Core Element Performance Data

    • Outpatient Stewardship…A New Frontier

  • • In the inpatient setting…

    • 55-64% of adult patients in U.S. hospitals receive at least one antibiotic drug while hospitalized1,2,3

    • With the use of extended-spectrum antibiotics on the rise, including later generation cephalosporins, beta-lactam/beta- lactamase inhibitor combinations, carbapenems, and glycopeptides3,4

    Setting the Stage

    1. Clin Infect Dis 2011;53:1100-10 3. JAMA Intern Med 2016;176:1639-48 2. MMWR Morb Mortality Wkly Rep 2014;63:194-200 4. J Antimicrob Chemother 2013;68:2393-9

  • Where Do We Stand in New England?

    JAMA Intern Med 2016;176:1639-48

    Mean Days of Therapy per 1,000 Patients Days (2006-2012) Top Performing Census Divisions: - New England - Mid Atlantic - Pacific

  • JAMA Intern Med 2016;176:1639-48

    BUT…

    There was a 10% increase in inpatient DOT/1,000 patient days across New England from 2006 to 2012

    Where Do We Stand in New England?

  • JAMA Intern Med 2016;176:1639-48

    AND…

    There are limited publicly available data on inpatient antibiotic use since 2012

    Where Do We Stand in New England?

  • • In the outpatient setting…

    • 423-553 antibiotic prescriptions written for every 1,000 people in the U.S.1

    • More than one antibiotic per child per year under the age of 2

    • 13% of outpatient office visits in the U.S. results in an antibiotic prescription2

    • 154 million office visits per year

    • 30% are unnecessary3

    • 44% for acute respiratory conditions, many of which are viral

    Thinking Beyond Inpatient Stewardship

    1. http://www.pewtrusts.org/~/media/assets/2016/05/antibioticuseinoutpatientsettings.pdf 2. J Antimicrob Chemother 2013;68:715-8. 3. JAMA 2016;315:1864-73.

  • How is New Hampshire Doing?

    10th best state in the U.S. 2nd best state in New England

    https://gis.cdc.gov/grasp/PSA/AUMapView.html

  • How is New Hampshire Doing?

    https://resistancemap.cddep.org

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    1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

    Outpatient antibiotic prescriptions declined in NH by 2.1% per year from 1999 through 2010 Reduced by ~200 prescriptions per 1,000 persons Over 243,000 presumably unnecessary outpatient prescriptions avoided in 2010

  • How is New Hampshire Doing?

    https://resistancemap.cddep.org https://gis.cdc.gov/grasp/PSA/AUMapView.html

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    1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20102010 2011 2012

    Unfortunately, there was then a significant increase through 2012

  • How is New Hampshire Doing?

    0

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    1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20102010 2011 20122012 2013 2014

    With improvements seen in 2013 and 2014…but not back to low seen in 2010

    https://gis.cdc.gov/grasp/PSA/AUMapView.html

  • What is Being Prescribed?

    https://resistancemap.cddep.org

  • What is Being Prescribed?

    https://resistancemap.cddep.org

    #1 Outpatient Prescribed Antibiotic = Azithromycin (Clin Infect Dis 2015;60:1308-16)

  • What is Being Prescribed?

    https://resistancemap.cddep.org

    Quinolones most common in older adults [Medicare] (BMC Infect Dis 2016;16:744)

  • Hospital Stewardship Programs

    The local performance is even more impressive when you realize that only 27% of NH hospitals in 2015 had a stewardship program that followed all 7 of the CDC’s Core Elements

  • Hospital Stewardship Programs

    However, this 27% hides the fact that all but one NH hospital had at least one element of stewardship in place by 2015… Compared with 81% nationally in 2015 [According to a survey by The Advisory Board Company, 11/2015]

  • Hospital Stewardship Programs

    By 2016, 38% of NH hospitals had a stewardship program that followed all 7 of the CDC’s Core Elements • 50% of acute care

    hospitals with ≥200 beds • 71% of acute care

    hospitals with

  • http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

    Core Elements of Hospital Antibiotic Stewardship Programs

  • N = 25 NH Hospitals (3,041 beds)

    All Responding Hospitals - 2015

    All Responding Hospitals - 2016

    Leadership Commitment 52% 72% Accountability 72% 88% Drug Expertise 88% 92% Action 88% 92% Tracking 48% 60% Reporting 84% 76% Education 64% 64% All 7 Core Elements 28% 40%

    Things are Improving Overall

  • N = 25 NH Hospitals (3,041 beds)

    All Responding Hospitals - 2015

    All Responding Hospitals - 2016

    Leadership Commitment 52% 72% Accountability 72% 88% Drug Expertise 88% 92% Action 88% 92% Tracking 48% 60% Reporting 84% 76% Education 64% 64% All 7 Core Elements 28% 40%

    Things are Improving Overall

    But, the following continue to be areas for improvement 1. Leadership commitment in critical access hospitals (50% in 2016) 2. Tracking (and reporting) of use metrics 3. EDUCATION

  • Leadership Commitment

    • In making a case for your ASP, it is important to engage both the C-Suite and Quality Leadership

    – Outline your Mission Statement

    – Focus on Patient Safety

    – Develop a Business Case

  • “[Optimize] antimicrobial selection, dosing, route, and duration of therapy to maximize clinical cure or

    prevention of infection while limiting the unintended consequences, such as the emergence of resistance,

    adverse drug events, and cost. The ultimate goal of antimicrobial stewardship is to

    improve patient care and health care outcomes.”

    Clin Infec Dis 2007;44:159-77

  • ASPs associated with:

    1. 20-35% in antimicrobial use

    2. 40% in appropriate recommendation

    3. 20% in clinical cure rate

    4. 10-15% in treatment failure

    5. Fewer reported adverse drug events

    Link to Patient Safety/Quality

    Clin Infect Dis 2001;33:289-95 Clin Infect Dis 2007;44:159-77 PLoS One 2016;11:e0150795

  • ASPs associated with:

    1. Reductions in Clostridium difficile infections

    2. Reductions in colonization or infection with:

    • Fluoroquinolone, cephalosporin, and aminoglycoside- resistant gram (-) bacteria

    • Methicillin-resistant Staphylococcus aureus

    • Vancomycin-resistant Enterococcus

    Link to Patient Safety/Quality

    Infect Control Hosp Epidemiol 2006;27:155-69 Clin Infect Dis 2007;45S:S112-21 J Antimicrob Chemother 2012;67:2988-96 Int J Antimicrob Agents 2013;41:137-42 Cochrane Database of Syst Rev 2013;4:CD003543

    J Antimicrob Chemother 2014;69:1748-54 J Clin Microbiol 2016;54:2343-7 Infect Control Hosp Epidemiol 2017;38:461-8

  • Barriers to Implementation of ASP

    Infect Control Hosp Epidemiol 2009;30:1211-7

  • Cost Savings from ASP

    ASP started in 2001 46% in antimicrobial costs (FY01-FY08)

    Infect Control Hosp Epidemiol 2012;33:338-345

  • Cost Savings from ASP

    Hospital cut funding for ASP in 2008 32% in antimicrobial costs (FY09-FY10)

    Infect Control Hosp Epidemiol 2012;33:338-345

  • Leadership Commitment in New Hampshire

    • 12 out of 19 surveyed hospitals have a formal letter of support for their stewardship program from senior leadership

    • But…only 5 out of 19 surveyed hospitals have financial support from the hospital to support stewardship activities

    2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

  • Accountability

    • It is important to identify a leader or co-leads who will take ownership of the hospital stewardship program and outcomes

    Survey by The Advisory Board Company, published 11/2015

  • Accountability in New Hampshire

    Physician 16%

    Pharmacist 31%

    Co-Led by Physician

    and Pharmacist

    53%

    NH STEWARDSHIP LEADERSHIP

    2018 NH Antimicrobial Stewardship Qualitative Survey (results courtesy of NH HAI AR Program)

  • Infrastructure

    Infection Control and Prevention

    Clinical Microbiology

    Informa

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