can de-escalation be measured without chart ......infectious syndrome (based on icd-10 diagnosis for...
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dicon.medicine.duke.edudason.medicine.duke.edu
CAN DE-ESCALATION BE MEASURED WITHOUT CHART REVIEW? A PROPOSED ELECTRONIC DEFINITIONR E B E K AH W. M O E H R I N G , M D , M P H 1 ; X I N R U R E N , P H D 2; D E V E R I C K J . A N D E R S O N , M D , M P H 1; A N G E L I N A D AV I S , P H A R M D 1; A P R I L D Y E R , P H A R M D 1; Y U L I YA L O K H N Y G I N A , P H D 2; L A U R I A . H I C K S , D O 3; A R J U N S R I N I VA S A N , M D 3; E L I Z A B E T H D O D D S A S H L E Y, P H A R M D , M H S 1
1D U K E C E N T E R F O R A N T I M I C R O B I A L S T E W A R D S H I P A N D I N F E C T I O N P R E V E N T I O N , D U R H A M , N C , U S A
2D U K E B I O S TAT I S T I C S C O R E , D U R H A M , N C , U S A
3C E N T E R S F O R D I S E A S E C O N T R O L A N D P R E V E N T I O N , AT L A N TA , G A , U S A
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Disclosures Funding: Centers for Disease Control and Prevention FoundationThe source of this information is the Patient Tools for Antibiotic Stewardship Programs, a joint project made possible by a partnership between the CDC Foundation and Merck & Co., Inc.
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Rationale: De-escalation EventsDe-escalation is a core principle of Antimicrobial Stewardship.Target/narrow antibiotic therapies after more data returnsStop therapy when infection has been ruled outTracking de-escalations may:Demonstrate impact of AS activities Identify where AS interventions are needed
EmpiricBroad-spectrum
TargetedNarrow-spectrum
Tim
e
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Aim: Create an objective definition for de-escalation based on electronic dataDe-escalation should be considered for any infection treated empirically More broad than pneumonia and ICU1,3,4
De-escalation occurs after a few days of empiric therapy Subset to a hospital population that is eligible2
Instead of only “spectrum,”1 we will also consider “protected” agents Agents we have interest in conserving from AS perspective (e.g. risk of toxicity, safety,
development of resistance, cost)
1. Madaras Kelly ICHE 2014 2. Braykov/Morgan Lancet ID 20143. Yamana JHI 20164. Tabah CID 2015
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MethodsSetting: 5 Pilot Hospitals from Duke Health System and the Duke Antimicrobial Stewardship Outreach Network (DASON)Data: electronic medication administration records (eMAR) and demographic dataRetrospective, descriptive, among:HospitalsUnits Infectious syndrome (based on ICD-10 diagnosis for admission)
Calendar year 2016
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Inclusion/Exclusion CriteriaInpatient units, excluding behavioral health and procedural unitsAge>=18Anti-bacterial only, excluded inhaled/topical antifungal, antiviral agentsLength of stay 3 days or greater since first calendar day of antibiotic exposure on an inpatient unit (Day 1)Did not die prior to Day 5Minimum time on antibiotics 2 or more days
No:Pediatrics
OutpatientsShort stays
Dead people1x doses
Inhaled agents
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Antibiotic RankNarrow spectrum Broad spectrum Extended spectrum,
including MDRO and Pseudomonas
Restricted
1 2 3 41st- and 2nd-generation cephalosporinsAmoxicillin TMP/SMX Nafcillin, OxacillinMetronidazoleDoxycyclineNitrofurantoinPenicillin
CeftriaxoneAzithromycinClarithromycinAmoxicillin/clavulanateAmpicillin/sulbactamClindamycin
Antipseudomonal penicillinsFluoroquinolonesAminoglycosidesVancomycinCefepime, CeftazidimeErtapenemAztreonam
Antipseudomonal carbapenemColistinTigecyclineLinezolid, TedizolidDaptomycinCeftarolineCeftazidime/avibactamCeftolozane/tazobactam
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Calculate both N Antibiotics and Rank Term DefinitionAntibiotic Rank
Highest individual agent rank for all agents given on the same calendar day.
N antibiotics
Number of different antibiotic agents administered in a calendar day.
Calendar Day
Agent 1 VancoAgent 2 Pip/TazoAgent 3 AzithroRank 3N Antibiotics 3
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Define 2 time pointsTerm DefinitionDay 1 First day of antibiotic exposure on an inpatient unit during hospitalization,
using a calendar day definition (12am to 1159pm)
Day D Day of discharge or day 5 of antibiotic exposure, whichever comes first.
8/24 8/25 8/26 8/27 8/28 8/29 8/30Abx started in MICU
Transfer to Gen Med
Discharged
Day 1 Day 5
Day D is 3, 4, or 5
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Direction of Change: Day 1 vs. Day D
N AntibioticsLower Same Higher
Rank
Lower De-esc De-esc Unchanged
Same De-esc Unchanged EscHigher Unchanged Esc Esc
9 combos, 3 outcomes
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Results39,226 admissions among 5 hospitals
De-escalation: 36%Escalation: 13%Unchanged: 51%
N AntibioticsLower Same Higher
Rank
Lower 10551 (27) 1269 (3) 146 (<1)
Same 2318 (6) 19703 (50) 3048 (8)Higher 110 (<1) 732 (2) 1349 (3)
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De-escalation varied among Hospitals
De-escalation:Median 37%, range 31-39%, p<0.001
39% 38% 37% 33% 31%
51% 49% 52% 52% 53%
11% 13% 11% 15% 16%
0%
20%
40%
60%
80%
100%
Hospital
De-escalation Unchanged Escalation
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ICU vs. non-ICUICUs had both higher escalation and de-escalation when compared to non-ICU wards, p<0.001
0%
5%
10%
15%
20%
25%
0% 20% 40% 60% 80%
Esc
alat
ion
%
De-escalation %
De-escalation % and Escalation % among Units
Non-ICU ICU
N De-escalation Escalation
ICU 5319 2264 (43%) 831 (16%)
Non-ICU 33907 11874 (35%) 4298 (13%)
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Syndromes (ICD-10)N (%) De-escalation Escalation
>1 Infection Diagnosis Code 16874 (43%) 35% 17%
No Infection Diagnosis Code 7476 (19%) 40% 7%
GI Tract 19%Intra-abdominal 23%
ENT/URI 28%SSTI 28%
UTI 43%Pneumonia 44%
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LimitationsPilot study sample of 5 hospitals in Southeastern United StatesDid not measure appropriateness or eligibility for de-escalation Prophylaxis MDRO infection
Rankings may not align with an individual ASP practice (e.g. restricted agents)Only evaluated first antibiotic course per admissionICD-10 codes for infection diagnosis?
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ConclusionsWe developed an objective definition for de-escalation based on electronic data.De-escalation occurred in ~1 in 3 admissions; similar to other estimates in the literature.2,5
Variability among hospitals, units, and syndromes.De-escalation could be used as a process metric to demonstrate ASP impact on antibiotic decisions.De-escalation may help identify areas for intervention if paired with benchmarking and risk-adjustment methods.
EmpiricBroad-spectrum
TargetedNarrow-spectrum
Tim
e
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AcknowledgementsCo-authorsCDC FoundationASP staff at Study Sites: Duke University Hospital (Dev Anderson, Christina Sarubbi, Rebekah Wrenn, Jason Jackson) Duke Regional Hospital (John Boreyko, Ted Hendershot) Piedmont Fayette Hospital (Janice Davis, Angela Swayne) Piedmont Newnan Hospital (David Copeland, John Marsalis) Southeastern Regional Medical Center (April Dyer, Eric Locklear)
DASON Clinical and Data Teams
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References1. Madaras-Kelly et al. Infect Control Hosp Epid. 2014 September; 35(9): 1103–1113.2. Braykov and Morgan et al. Lancet Infect Dis 2014; 14: 1220–27.
3. Yamana et al. Journal of Infection (2016) 73, 314e325.
4. Tahbah et al. Clin Infect Disease 2016;62(8):1009–17.5. Madaras-Kelly et al. J Antimicrob Chemother 2016; 71: 539–546.
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Extra Slides
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Example: De-escalation
8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo
Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir
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Example: De-escalation
8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo
Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir
3 3 2 2 2 2 22 2 1 2 2 2 2
RankN Abx
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Example: De-escalation
8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo
Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir
3 3 2 2 2 2 22 2 1 2 2 2 2
RankN Abx
Day 1 Day 5
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8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo
Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir
3 3 2 2 2 2 22 2 1 2 2 2 2
RankN Abx
Day 1 Day 5
N Antibiotics
Lower Same Higher
Rank
Lower De-esc De-esc Unchanged
Same De-esc Unchanged Esc
Higher Unchanged Esc Esc
Rank: LowerN Abx: Same
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Other Unit type estimatesN units De-escalation Escalation Unchanged
Med/Surg Wards 7 35% 13% 52%
Surgical Wards 7 33% 12% 55%
Medical Wards 16 35% 13% 52%
Hem/Onc Wards 3 33% 13% 54%