c. difficile infection: population problem, …afterward, in a hospital emergency room, doctors...
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C.DIFFICILEINFECTION:POPULATIONPROBLEM,POPULATIONSOLUTION
SUSANM.KELLIE,MD,MPHPROFESSOREMERITA
DIVISIONOFINFECTIOUSDISEASES,UNMSOM
OBJECTIVES
1.Participantswillunderstandtheroleofantimicrobialresistanceinthespreadofnew C.difficile strains.
2.Participantswillbeabletodescribetheevidenceforantimicrobialstewardshipinthecontrolof C.difficile.
3.Participantswillbeabletodesigninterventionsforantimicrobialstewardshiptargetedfor C.difficile reduction.
TALKOUTLINE
• Thepatientexperience
• Backtobasicsinpatientsafety-variationandoverutilization
• InsightsfromtheUKintotheroleofantimicrobialstewardshipinC.difficileprevention
• High-valuetargetsinstewardship
Doctors See Gains Against ‘an Urgent Threat,’ C. DiffPaula SpanTHE NEW OLD AGE NYT FEB. 10, 2017
• Therewasnoproblemwithhisprostate,itturnedout.Butafewdayslater,Mr.Bocci developedseverediarrhea,fever andvomiting.Hegrewdehydrated.Fivedaysafterward,inahospitalemergencyroom,doctorsdiagnosedaClostridiumdifficile infection.
TomBocci’s encounterwithabacteriumhehadneverheardofbeganinApril,whenhisdoctorsuggestedatestforprostatecancer.Becausetheresultsappearedslightlyabnormal,Mr.Bocci underwentabiopsy,takingantibioticsbeforehandasastandardprecautionagainstinfection.
MOREONTHEPATIENTEXPERIENCE
• Antibioticsappearedtosquelchtheinfectionbut,ashappensin20to30percentofcases,thesymptomsreturnedwithavengeanceassoonashefinishedthedrugs.Overseveralmonths,Mr.Bocci sufferedfrommigraines,weakness,anxietyandhypertension.
• Toldtoisolatehimself,hewarnedfamilymembersnottovisithishomeinTroy,Mich.;hiswife,Wendy,movedintoasparebedroom.Helost30pounds.Afterthethirdrecurrence,“IreallythoughtIwasgoingtodie,”Mr.Bocci,now71,said.“AndsometimesIfeltIwantedto.”
THEWORDISOUTAMONGPATIENTS
• AsMr.Bocci learned,C.diffsymptomsaretoordinarydiarrheaasanukeistoahomemadefirecracker.“Peoplewhohaveopen-heartsurgeryandtakeantibiotics—andthengetC.diff— tellmethey’dratherhavethesurgeryagainthanC.diff,”saidDr.DaleGerding,whodirectstheresearchlabattheEdwardHinesJr.VeteransAffairsHospitalinChicago.
EXTENDINGOURCONCEPTSOFQUALITY
• PertheInstituteofMedicine,problemswithqualityincludeunderuse (notdoingenough),misuse (preventablecomplications)andoveruse (doingtoomuch)• Low-valuecareincludesthatforwhichthepotentialbenefitsareoutweighedbythepotentialadverseevents.• 1/3ofcaredeliveredintheUSisconsideredwasteful,healthcarewillconsume20%ofGDPby2020.
WHAT’STOOMUCH?
• Overtreatment-provisionoftreatmentsthataremorelikelytoharmthanbenefitpatients.
• Overtesting-useofteststhataremorelikelytoresultinpatientharmthanpatientbenefit
• Overdiagnosis-diagnosticlabellingofconditionsthatarenotclinicallyrelevant
Zapataetal.Editorial.Isexcessiveresourceutilizationanadverseevent?&Lipitz-SnydermanandKorenstein.Reducingoveruse-ispatientsafetytheanswer?JAMAFebruary28,2017Vol317,No.8
CHALLENGESINIDENTIFYINGANDINTERVENINGINOVERUSE
• Trackingandprioritizing• Needfordevelopedandvalidatedperformancemeasures
• Theproblemisunderappreciatedbecauseharmsaredifficulttorecognizeandmayonlyoccurafteralongcascadeofinterventionsandadverseevents
• Cliniciansmayconflateattemptstocontroloverusewith“rationing”
• Overusemaynothaveanadministrative“home”.• Littlecollectiveinstitutionalenergytoaddresstheseproblems
ANTIBIOTICSTEWARDSHIPISREADYTOGO!
• Clear-cututilizationmetricsandnationalbenchmarkingtoolshavebeendeveloped.
• Theperformancemeasureshavebeendeveloped.• HarmsareevidentandmeasurableinCDI,antibioticresistance,readmissions,andadversedrugevents
• Increasinglyacceptedbycliniciansininpatientsettings.• InstitutionalhomeinPharmacyManagementwithrequirementformultidisciplinarycommittee
• TJCandCMSrequirementscreateinstitutionalincentive,aswellasreimbursementpenaltiesforselectedHAIandreadmissions.
KEEP INTOUCHWITHPATIENTSAFETYTOMAKESURESTEWARDSHIPISAFOCUS
CDI SIR NHSN, 2008-14
SIRof1.0SIRof0.8
NATIONALACTIONPLANTARGETSFOR2020
Measure Datasource
PriorBaselineyears
Baselinedata
2013targetSIR
Progress Proposedtargetfrom2015baseline
CDI NHSN 2010-11
1.0 .70 8%↓by2014
30%↓
CDIhospitalizations
HCUP 2008 11.6per1,000discharges
30%↓ 13.6per1,000dischargesfor2012
30%↓
NEWMEXICOSIRIN2016ANNUALREPORT
Havewenotbeendoingenoughorareweoverlookingsomethingimportant?
EARLYINTUITION• C.difficile-anantimicrobialresistanceproblem
• DaleGerding.Clindamycin,Cephalosporins,Fluoroquinolones,andClostridiumdifficile–AssociatedDiarrhea:ThisIsanAntimicrobialResistanceProblem.ClinInfectDis2004;38:636-7
SUCCESSIVEWAVESOFRESISTANCEINC.DIFFICILE
• Forclindamycin,C.difficile resistanceisvariable,andriskofCDADassociatedwithaclindamycin-resistant organismisincreasedinpatientsreceivingclindamycin.
• Forthethirdgenerationcephalosporins,C.difficile resistanceisuniversal,andpresumablyanytoxigenicC.difficileorganismiscapableofcausingCDADduringcephalosporinadministration.
EFFECTSOFFLUOROQUINOLONERESISTANCEANDRESTRICTION
• HighratesofC.difficileaftergatifloxacin comparedtolevofloxacin,butbothfluoroquinoloneshadhighratesofC.difficile(34%and17%)
• C.difficileresistancetofluoroquinoloneswasdescribed,aswellasclonality
• Gaynes R,Rimland D,Killum E,etal.OutbreakofClostridiumdifficileinfectionsinalong-termnursingfacility:associationwithgatifloxacin use.Clin InfectDis2004;38:640–5.
FLUOROQUINOLONEUSETRENDSINHOSPITALS
OUTPATIENTPRESCRIBING-PERCDC
POPULATIONCONNECTIONSBETWEENFQUSEANDCDIRATES
• GlobaldispersionofthehypervirulentNAP1/Ribotype O27C.difficilestrainrevealedanassociationbetweenfluoroquinoloneresistanceandepidemicspread.
• IntheUK,CDIhasdecreasedover70%sinceitspeakrate
CORRELATIONWITHFQPRESCRIBING
OUTPATIENTPRESCRIBINGINCREASED
TRENDSINSUSCEPTIBILITIESOFC.DIFFICILE
BROAD GUIDELINESACROSSTHEHEALTHCARESYSTEM-BOLSTEREDBYCOMMUNITYDATA
• ThePHEguidancerecommendsthatsimplegenericantibioticsshouldbeusedifpossiblewhenantibioticsarenecessary.Broad-spectrumantibiotics(forexample,co-amoxiclav,quinolonesandcephalosporins)needtobereservedtotreatresistantdisease.
• https://www.nice.org.uk/advice/ktt9/chapter/evidence-context
FEATURESOFTHEUKPROGRAMME
• Guidelinesinplacewithregionalstewardshipgroupssincemid2000s
• Linknowtopayments:inApril2016,NHSEnglandlauncheda nationalprogramme toreduceinappropriateantibioticprescribing.
• DatafromMay2016 showedthetotalnumberofantibioticsprescribedbyGPswasdownby7.3%in1 year(atotalof2,696,143 feweritems)andtheuseofbroad-spectrumantibioticswasreducedby16%(areductionofover600,000 items).
• For2016/17,anew improvementandassessmentframework wasalsolaunched,whichincludesantimicrobialresistanceindicators.
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
2012 2013 2014 2015
RibotypeO27aspercentageofallstrainstestedNewMexico2012-15
https://www.cdc.gov/vitalsigns/antibiotic-prescribing-practices/index.html
MARKETANTIMICROBIALSTEWARDSHIP
• AlignStewardshipwithsubspeciality“ChoosingWisely”campaign
• Lookforwaysto“improveprescribing”
• EngagehospitalistsinPIeffortsforMOCpointsfortheircertification
EXPANDING THECONCEPTOFSTEWARDSHIP
• Thinkaboutimpactofstewardshipinotherareaseg.Protonpumpinhibitoruse,urinecultures
• PPIusedrivesC.diffratesandrecurrences
• Improperuseofculturingandculturetechniquesdrivesantimicrobialusage
PPISANDH2BLOCKERSINCREASERATEOFRECURRENCE• Meta-analysisof16observationalstudiesexaminingtheassociationbetweengastric acidsuppressants,suchasproton-pumpinhibitors(PPIs)orhistamineH2-receptorblockers(H2Bs),andrecurrentCdifficile infection.• Theyobserveda50%increaseinoddsofrecurrentCdifficileinfectionamongpatientsreceivingPPIsorH2Bscomparedwith patientsnottakinggastricacidsuppressants.• Tariqetal.[onlineMarch27,2017].JAMAInternMed.doi:10.1001/jamainternmed.2017.0212
COSTOFRECURRENTCDI:$34KPERPATIENT
Rodriguesetal.AComprehensiveStudyofCostsAssociatedWithRecurrentClostridiumdifficileInfection.ICHEFeb2017
THESTRUCTUREFORSTEWARDSHIP
Leadershipcommitment:Dedicatenecessaryhuman,financial,andITresources.
Accountability:Appointasingleleaderresponsibleforoutcomes.
Drugexpertise:Appointasinglepharmacistleadertosupportimprovedprescribing.
Act:Takeatleastoneprescribingimprovementaction,suchasrequiringreassessmentwithin48hours,tocheckdrugchoice,dose,andduration.
Track:Monitorprescribingandresistancepatterns.
Report:tostaffonprescribingandresistancepatterns,andstepstoimprove.
Educate:aboutresistanceandimprovingprescribing.NowincorporatedintoTJCMedicationManagementStandardsfor2017
http://www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf
AREASWHEREANYHOSPITALCANIMPROVEANTIMICROBIALUSE
• Rethinkthecatheter-associatedUTI
• RethinkHCAP
• Lookcriticallyatskinandsofttissueinfections
• De-escalatepromptlywhendiagnosesaremadeinpatientswithsepsis
RETHINKCAUTI
• DoIneedaurinecultureineveryhospitalizedpatientwithaFoleyandnewfever?
• Doesmyurineculturemeananything?
• DoIknowifmypatienthasaFoleycatheterandforhowlong?
EXAMPLE:TARGETINAPPROPRIATEFLUOROQUINOLONEUSE
• FQusehasbeenassociatedwithincreasedratesofMRSAandincreasedratesofC.difficile-associateddiarrhea.
• Respiratoryfluoroquinolonese.g.moxifloxacinorlevofloxacinhaveanevengreaterriskofC.difficileandareoftenusedwherealess-broadspectrumFQegciprofloxacinwouldbeadequate
• IncreasedexpendituresonFQhavebeenassociatedwithdecreasedsusceptibilityofPseudomonas toFQs.• Bhavnani SMet.al. AmJHealth-SystemPharm 200360:1962-1970.
RESULTS:INPATIENTRETROSPECTIVEREVIEWOFFQUSE
SampleanalysisfromVA2007-EleanaZamora,MD,IDfellow
Estimatedannualcost-savingswithFQappropriateuse:$33k
Interventionperiods:significantdecreasesinnosocomialC.difficile everythreemonthperiodfellowrestrictedFQ
FINDINGTHEUNNECESSARYFQS• Lookforthefollowing:• theduration oftherapywaslongerthanrecommended,
• theFQprovidedredundant antimicrobialcoverageintheabsenceofanindicationforcombinationtherapy,
• theFQprovidedinadequatecoverageofexpectedordocumentedpathogens,
• theFQwascontinueddespitenegativeevaluationforinfectioussyndromes and/oranoninfectiousconditionwasdemonstratedtoberesponsiblefortheclinicalsyndrome.
• Werneretal.Unnecessaryuseoffluoroquinoloneantibioticsinhospitalizedpatients.BMCInfectiousDiseases201111:187DOI: 10.1186/1471-2334-11-187
THEPARADOXESOFANTIMICROBIALSTEWARDSHIP
• Resistanceanywhereisresistanceeverywhere…butallresistanceislocal
• Thepreventionparadoxapplies:theincrementalimprovementinsafetyforeachindividualpatientissmall,butforthepopulation,theeffectofasaferhealthcaresystemwouldbemuchgreater.
MAKEANTIBIOTICSGREATAGAIN!
• ReflectionsfromSarahCosgrove,MD,MS,CurrentPresidentofSHEA
• Stewardshipprogramshavemovedfromjustsavingmoneytooptimizingpatientsafety
• Emergenceofnationalrequirements
BUILDINGTHEANTIMICROBIALSURVEILLANCEANDCONTROLSYSTEMINTHEUS
• CDCAntimicrobialUseModule• TJCandCMSCOPAntimicrobialStewardshipStandard• CMSupdatedregulationsforLong-TermCareFacilitiesrequireaninfectionpreventionandcontrolofficerandanantibioticstewardshipprogramthatincludesantibioticuseprotocolsandasystemtomonitorantibioticuse.
ISSUESWITHTHENEWREQUIREMENTS
• TJCwillbefocusingonareasnotalwayscoveredbystewardshipprograms:• Emergencydepartmentpatientsprescribedantimicrobials• Ambulatoryclinicpatients• Inpatientsdischargedonantimicrobials
• Nursinghomeswillrequirepharmacistreviewofthemedicalrecordduringthemonthlyreview,butfurtheractionandpracticechangesareunclear.
WHAT’SMISSINGINOURAPPROACHTOC.DIFFICILE?
• Integrationofantimicrobialstewadardshipacrossallhealthcaresettingsandintoambulatoryareas• Leveragetoimprovestewardshipinoutpatientsettings• Bettertoolsfordecision-makingatthepointofcarethatdonotundulyburdenproviders.
SCALABLEMODELFORALLHEALTHCARESETTINGS
• Individualorderreview
• Localantimicrobialsusceptibilitiesandinfectioncontroldata
• Clinicalpathwaydevelopment
• Formularyclean-up
RightAbx
available
Directionforspecificclinicalconditions,dosing
protocols
Antimicrobialtime-out,doseadjustment
Informationand
outcomesfortheprogram
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