Antibiotic Stewardship in Acute Care:

Blurred Boundaries Ripe for Engagement

Scott K. Fridkin, MD

Professor of Medicine

Department of Medicine, Division of Infectious Diseases, Department of Epidemiology, Rollins School of Public Health

Emory University

Context and Objectives

• Infectious Disease Epidemiologist, focused on surveillance and policy at federal level

• Thrust into a Hospital System

• Observe tension between limited resources to improve care and payment incentives to improve required metrics

• Describe the context of antibiotic stewardship program acceleration in general, and where it intersects acute care quality concerns

Case – Mrs. J• 85 yo female with moderate dementia and arthritis admitted after

ground level fall at home

• Baseline function: Supervision with ADLs, Dependent with IADLs, Ambulates with a walker

• She was diagnosed with pelvic fracture, Orthopedics consulted and recommended conservative management.

• At time of discharge, she is deconditioned and unable to do her basic ADLS or ambulate

Case Continued - Day 10• Daughter concerned about foul smelling and dark urine

• Vitals normal, no catheter, no change in condition except patient is slightly more confused

• Daughter requested for U/A and now staff is requesting

• On call MD orders UA and culture; no antibiotic started

• After two days, provider notes positive urine culture >100,000 CFU and U/A positive for nitrites, no blood

• Patient stable with no fever or urinary symptoms and mental status improved with hydration

Antibiotics Started8-10 fold increase risk for C. difficile4-8 fold increase risk for antibiotic resistance in GI tract

A lot of Guidance Now - CDC has Advanced the Architecture of Stewardship Across All Healthcare Settings

https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html;

https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

https://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.html

https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.html

Antibiotic Stewardship Programs in Hospitals:Using CDC’s Core Elements

▪ In 2014, CDC called on all hospitals to implement an antibiotic stewardship program (Vital Signs).

▪ Created the “Core Elements” to outline structures and functions associated with effective programs.

▪ Implementation guidance/assistance:– CMS-funded Hospital Improvement Innovation Networks (HIINs) – AHRQ Comprehensive Unit-based Safety Program (CUSP)

▪ Adopted by several initiatives as a requirement:– The Joint Commission for their antibiotic stewardship standard– DNV for their antibiotic stewardship standard– Medicare Beneficiary Quality Improvement Project (MBQIP) (QI for

Critical Access) four years (2022) to have a program

The Joint Commission: antibiotic stewardship standard - effective January 2017

▪ Variability in best documentation of compliance

▪ Requirement for family education removed

▪ Some “action” lost in translation around “antibiotic time out”

▪ Still in learning period about what is minimum and outstanding

44.6%

19.6%

53.1%

26.3%

69.5%

43.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General acute care hospitals Critical access hospitals

Percentage of U.S. acute care hospitals reporting uptake of all 7 Core Elements, by facility type, 2014 - 2016

2014 2015 2016

Increase in Implementation of Stewardship Programs Across All Types of Acute-Care Facilities

Overall=64%

43.0%

58.1%

69.5%73.9%

46.0%

69.0%

81.5%

58.5%

76.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Critical accesshospital

Surgical hospital General acutecare hospital

Children'shospital

≤50 beds 51 - 200 beds >200 beds Non-teaching Major teaching

Facility Type Bed Size Teaching Status

Percentage of U.S. acute care hospitals reporting uptake of all 7 CDC Core Elements, by facility demographic,

National Healthcare Safety Network, 2016 (N=4,781)

https://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html

Emory Healthcare JC visit

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√ √ √

√√

▪ Standards 1-7: mostly documentation of commitment, FTE investment, outline of educational sessions, program and committee composition, protocols and order sets in place

▪ Standard 8: Action and Improvement Opportunities

– “Re-active”” vs. “Pro-active” Pharmacist Time

+++++++++++++++

What is relative amount of spent on reactive stewardship?

▪ Examples from the audience Reactive

– Pro-Active

Pro-active Stewardship Requires Robust Data Infrastructure to Target and Prioritize: Hospital Antibiotic Use Data – what metrics

▪ For internal or historical tracking – metric most widely used”

– Days of Therapy (DOT) per 1000 patient days

– Various grouping of antibiotics

▪ DOT/1000 PD or Days Present

– NHSN - 600 hospitals have now reported (some) data on antibiotic use to CDC – requires approved vendor

▪ For external comparison/benchmarking

– CDC risk adjusted benchmark measure of hospital antibiotic use for targeting stewardship programs

• Limited experience with the Standardized Antimicrobial Administration Ratio (SAAR); but endorsed by The National Quality Forum in 2016

• Adjusting for only location type (ICU, surgical; ward medical)

Pros and Cons of AU metrics

▪ ProsElectronically derived a must

Reproducible

Clinically meaningful

Reactive to stewardship and best prescribing

Credible (risk adjusted if possible)

▪ Cons

Manual

Corrective or interpretation needed

Useful only for internal purpose

Poor risk adjustment

Not responsive to stewardship or best practice

Using NHSN Antibiotic Use Data to Focus Stewardship Efforts

Courtesy of Eddie Stenehjem

Pilot Evaluation of Metrics▪ 5 facilities participated in feasibility assessment

https://dason.medicine.duke.edu/developing-stewardship-measures

Figure 2. Variation in electronic versus manual extraction of excessive antibiotic duration (2b). Model-based distributions across facilities were plotted for the proportions of hospitalizations with excessive antibotics (b). Distributions obtained from electroinc MUE (dashed lines) are more concentrated, implying less variation, than the corresponding distributions obtained from manual MUE(solid lines).

2b. Excessive antibiotic use.

Barbara E Jones, MD MS. Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS 2.0) Center of Innovation, VA SLC Health System; and Division of Pulmonary & Critical Care Medicine, University of Utah. (Draft)

Duration of use has potential for electronic capture, inpatient and discharge: benefit of electronic capture demonstrated at 30 VAMC

De-escalation: Potential for Electronic Determination

• One Day 4, 5, 6, etc of hospital day assess if de-escalation occurred by combination of

– Change in no. of agents

– Change in “rank” of the agent

Change in no. of ABX

Fewer Same More

Change in ABXRank

Lower De-escalate No change

Same De-escalate No Change Escalate

Higher No Change Escalate

https://dason.medicine.duke.edu/developing-stewardship-measures

https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html

Outpatient Prescribing Practices Vary Greatly Across States and Regions

▪ There is a lot of unnecessary use, especially for respiratory conditions.

– 30% of outpatient antibiotic prescriptions are unnecessary.

▪ There is often a mismatch between the recommended antibiotic and the one prescribed.

– Nearly half of patients do not receive first-line antibiotic therapy.

▪ Antibiotics: most common cause of drug-related emergency department visits in children.

– Nearly half of visits for medication-related adverse events were due to antibiotics.

Antibiotic Stewardship Programs in Outpatient SettingNeed for targeted interventions

▪ Outpatient prescribing practices vary greatly across provider-type and professional setting– Among visits for antibiotic-inappropriate respiratory diagnoses, 46% received an antibiotic in

urgent care, versus 25% in emergency departments, 17% in offices and 14% in retail clinics2

▪ Drivers of Better Practice– The Joint Commission—developing new accreditation standard requiring outpatient

stewardship programs

– Private payers

• Aetna audit and feedback intervention

• Anthem providing incentives to providers to implement antibiotic stewardship

▪ Acute Care can have influence over affiliated Clinics: Emory Healthcare exploration of variability in primary care successful 1CDC IQVIA data

2CDC 2014 Marketscan data

Stewardship at The Emory Clinic: Clinic- and Provider-Specific Prescribing Data (Prelim)

Figure courtesy of Sophia Jung

Figure courtesy of Sophia Jung

Behavioral “Nudge” Works: Public Commitment Posters

▪ Simple intervention: poster-placed in exam rooms with clinician picture and commitment to use antibiotics appropriately

▪ Randomized-controlled trial

▪ Principle of behavioral science: desire to be consistent with previous commitments

▪ “Behavioral nudge” to make the right choice

“As your doctors, we promise to treat your illness in the best way possible. We are also dedicated to avoid prescribing antibiotics when they are likely do to more harm than good.”

▪ Adjusted absolute reduction in inappropriate antibiotic prescribing: -20%

Meeker et al. JAMA Intern Med. 2014;174(3):425-31.

Commitment Posters in Illinois, Texas and New York

http://blogs.cdc.gov/safehealthcare/?p=5900

Put a Commitment Poster in Your Clinic!

▪ CDC created a poster template for download

▪ Also available in Spanish

▪ Add your picture and signature

▪ Place in your examination rooms

▪ Available at: https://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/index.html

Add your picture and signature here

Meeker et al. JAMA Intern Med. 2014;174(3):425-31.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing

Meeker, Linder, et al. JAMA 2016;315(6): 562-570.

▪ Cluster randomized trial—47 primary care practices (248 clinicians)

▪ Three specific interventions via Electronic Health Record (0,1,2,3)

– Suggested alternatives

– Accountable Justification

– Peer Comparison

▪ Prescribing rates for visits with inappropriate antibiotics for acute respiratory infections

– Accountable Justification and Peer Comparison resulted in statistically significant decreases

▪ Idea: Clinicians want to preserve their reputation

Peer Comparison

“You are a Top Performer”You are in the top 10% of clinicians. You wrote 0 prescriptions out of 21 acute respiratory infection cases that did not warrant antibiotics.

“You are not a Top Performer”Your inappropriate antibiotic prescribing rate is 15%. Top performers' rate is 0%. You wrote 3 prescriptions out of 20 acute respiratory infection cases that did not warrant antibiotics.

Meeker, Linder, et al. JAMA 2016;315(6): 562-570.

Levers to Improve Nursing Home Antibiotic Use

▪ CDC released Core Elements for Nursing Homes in 2015

▪ CMS finalized long term care requirements of participation in October 2016 requiring antibiotic stewardship to become part of infection prevention and control programs and pharmacy services for 2018.

▪ CMS Quality Innovation Network and Quality Improvement Organizations (QIN-QIOs) recruiting nursing homes to implement CDC’s Core Elements– CDC supporting implementation through expert input and tools

▪ What is the role of Acute Care??

Figure from CDC Vitals Signs: http://www.cdc.gov/vitalsigns/stop-spread/index.html

The Acute Care Hospitals Benefit by Collaboration between Acute Care and Nursing Homes

Emergence & Rapid Regional Spread of K. pneumoniae Carbapenemase-Producing Enterobacteriaceae, Chicago

Won et al, Clin Infect Dis 2011; 53(6):532-40

✓Although an LTAC was the epicenter

✓30% cases linked to 3 LTC

✓Only 10% acquired in acute care

Counter-clockwise move to less connected

EUH

ESJH

EJCH

EUMH

Ego-Network for Health District 3; EUH is most connected in Atlanta Metropolitan Area

Most Connected Facilities

5-6% of all EUH discharges (5,000 per year) are discharged to SNF

Budd T

Antibiotic Stewardship Implementation Can Improve Antibiotic Prescribing in Nursing Homes.

▪ A systemic review of 14 studies assessing antibiotic stewardship programs in NHs revealed the following:1

– 8 studies showed a decrease in overall or indication-specific antibiotic prescribing;

– 10 studies reported improved “guideline adherence” as an outcome; and

– None reported a significant change in mortality or hospitalization.

▪ However, studies are needed evaluate outcomes

– Antibiotic resistance

– C. difficile infection2

1. Feldstein et al, J Am Med Dir Assoc. 2017 Aug 7.

2. McElligott et al, Infect Dis Clin North Am. 2017 Dec;31(4):619-638.

Action at Budd Terrace: Improve Antibiotic use for Urinary Tract Infections

Modified CDC assessment of appropriateness of antibiotics for UTI form: http://www.cdc.gov/getsmart/healthcare/implementation.html

Education and Action

Resources for Stewardship in LTC

▪ http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/

▪ https://asap.nebraskamed.com/about/

▪ http://www.rochesterpatientsafety.com/index.cfm?Page=For%20Nursing%20Homes

▪ MN

▪ NE

▪ Rochester, NY

Antibiotic Stewardship in Acute Care Facilities:Challenges to Implementation both inside and outside

the Facility

▪ Slave to Information Technology

▪ Complex implementation

– How to leveraging influence by Quality Office with great experience in rapid response and multidisciplinary teams

▪ Investment in pro-active actions, what is needed to justify investment

▪ Can business outreach to primary care and nursing homes be used to share experience (incentivize) to improve stewardship in LTC and Primary Care

Intervention Persistence

Pre-intervention

Intervention Post-

intervention

% antibiotic prescribing

Suggested alternatives

22 6 9

Accountable justifications

23 5 8

Peer comparison

20 4 5

Slide content courtesy of Dr. Jeff Linder, presented at IDWeek 2016