jason newland 3-4-2018 -...

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Jason G. Newland MD, MEd@JasonGNewland

@sharpsgroup

©The Children's Mercy Hospital, 2015

Antibiotic Stewardship and Its Role in Dialysis

Department of PediatricsDivision of Infectious Diseases

Disclosures• Merck- grant and industry funded clinical trials


OBJECTIVES• Describe the history of antibiotic use.• List the reasons for antibiotic stewardship.• List strategies for antibiotic stewardship in children

requiring dialysis.

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Pre-Antibiotic Era

Soma Weiss J. Mt Sinai Hospital 1941-42

• 1921- 13yo develops choreiform movements• 1931 as a 4th year Harvard Medical student noted

petechiae on his wrist“I shall be dead in 6 months…”

• Blood cultures were positive for S. viridans“I could always find a loophole in the evidence here and there . . ., but now I was confronted with the dictum ultimatum from which there was no escape.”



“The greatest possibility of evil in self-medication is the use of too small doses so that instead of clearing up infection the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out which can be passed to other individuals and from them to others until they reach someone who gets a septicaemia or pneumonia which penicillin cannot save.”

Alexander Fleming, New York Times 1945

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Clatworthy 2007


Carbapenem-Resistant Enterobacteriaceae (CRE)

February 2015


Carbapenem-Resistant Enterobacteraceae in Children

Logan LK, EID 2015; 21:2014

ICU

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PD associated Peritonitis Pathogens

Sethna C, CJASN 2016

391 Peritonitis Episodes


Inadequate Antibiotic Therapy Increases Mortality

0102030405060708090

100

Ibrahim2000

Leibovici1998

Luna 1997 Alvarez-Lerma1996

Rello 1997

Morta

lity (

%)

Adequate therapy Inadequate therapy

Bloodstream Infections Nosocomial Pneumonia/VAP4Alvarez-Lerma et al. Intensive Care Med.1996;22:387–394. 5Rello et al. AJRCCM. 1997;156:196–200.

1Ibrahim et al. Chest. 2000;118:146. 2Leibovici et al. J Intern Med. 1998;244:379. 3Luna et al. Chest. 1997;111:676.


CDC Threat Report• 23,000 Americans die annually from an antibiotic

resistant infection• 2 million Americans are infected annually with an

antibiotic resistant infection• 250,000 Americans suffer from C. difficile

infection • 19,000 die from C. difficile infection

http://www.cdc.gov/drugresistance/threat-report-2013/

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Amr-review.org accessed 7-20-2017

Deaths Attributable to AMR

Based on:MalariaTBHIVS. aureusE. coliK. pneumoniae

$100 Trillion Dollars


Antibiotic-Associated Adverse Events

Clostridium difficile • Increasing in hospitalized children• 10 fold increase in community-onset• Hospital-onset C. difficile infections associated

• Increased risk of mortality OR 6.73 (3.77-12.02)• Increased length of stay - 5.5 days (4.5-6.5 days)• Increased hospital costs - $93K (80-107,200)

Kim J et al. Pediatrics 2008 Sammons J et al Clin Infec Dis 2013


Solutions• New antimicrobial development• Antimicrobial stewardship programs• Better diagnostics• Know best lengths of therapy• Reduction of hospital acquired infections• Vaccines• Decrease antimicrobial use in agriculture

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Antimicrobial Stewardship

�optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection with minimal toxicity to the patient and minimal impact on subsequent resistance�

Gerding DN. Joint Commission J Qual Improv 2001


CDC 7 Core Elements for Antimicrobial Stewardship

• Leadership Commitment• Accountability• Drug Expertise• Actions• Tracking• Reporting• Education


ASP Strategies

• Guideline(s)/Pathways• Consensus Guidelines for the Prevention and Treatment

of Catheter-related Infections and Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis: 2012 Update

• Prospective-audit with feedback• Prior-approval• Communication and Collaboration

http://www.qualityforum.org/Publications/2016/05/National_Quality_Partners_Playbook__Antibiotic_Stewardship_in_Acute_Care.aspx

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Impact of SCOPE Collaborative

Neu A et al. Kidney International 2016


• Empiric Antibiotic Recommendation• Base on antibiogram data• Cefepime• Vancomycin if history of MRSA or high institution

rate of MRSA• Duration of therapy• Gram positive and most Gram negatives- no

recommendations• Pseudomonas- 3 weeks• Culture negative- 2 weeks

Peritoneal Dialysis ConcensusGuideline

Warady B et al. PDI 2012


• Review antimicrobials after prescribed• Dosing, appropriateness and duration

determined• Discuss with teams and physicians about

recommendations of ASP• Daily Rounding- Handshake Stewardship

Prospective-Audit with Feedback

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Prospective Audit with FeedbackASP Implemented

18% Monthly Decline

Newland JG et al. JPIDS 2012


Additional ASP Strategies

• De-escalation based on culture results• Stopping vancomycin for MSSA

• Antibiotic Time-out• Clinicians discuss antibiotics daily

• Intravenous to Oral transition• Quinolones, Linezolid, Clindamycin,

Fluconazole• Stop Antibiotics with negative cultures and

no evidence of infection


Diagnostics

• Rapid identification systems• Molecular based• MALDI-TOF• Phenotypic susceptibility methods

• Next Generation Sequence based assays• Serum

• 16S Ribosomal assays

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Nudge• RCT 5 outpatient adult clinics in LA• Signed commitment letter with photo in exam rooms• One year observation period total, with intervention in 12

weeks at height of cold and influenza season

Meeker, JAMA Int Med 2014Slide from Matt Kronman


Outpatient Stewardship- Behavioral Economics• Cluster randomized approach among 47

adult primary care practices in Boston and

Los Angeles

• Randomized to 0 or 3 of the following:

• Suggest alternatives

• Accountable justification

• Peer comparison

• All received educationMeeker D et al. JAMA 2016


Behavioral Economics• Peer Comparison

Meeker D et al. JAMA 2016

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Date of download: 5/27/2016

Copyright © 2016 American Medical Association. All rights reserved.

From: Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical TrialJAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275

Accountable justification and Peer Comparison had a statistically significant improvement

The Future


Regulations• Joint Commission Standards• Eight elements of practice• Patient/family education no longer required

• Effective January 1, 2017• CMS condition of participation• Long term Care Facilities• Acute Care Facilities on hold

• Missouri State Law• Requiring stewardship in all facilities• Antimicrobial use submitted to the CDC

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Collaboration

Slayton RB et al. MMWR 2015;64..

10% increase of HAIs by 2016


Impact of a National Effort

• Implementation of infection control and antibiotic stewardship will in 5 years:• Reduce MDR HAIs or CDI deaths by 37,000• Reduce MDR HAIs or CDI infections by

619,000• Effective national, state, community wide

collaboration is essential!

Thank You

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SHARPS Collaborative

• SHaring Antimicrobial Reports for Pediatric Stewardship

• Quality improvement collaborative of over 45 children’s hospitals

• Utilizing PHIS/data reports on antibiotic use to help develop best interventions

• Social media presence: @Sharpsgroup and http://sharpsgroup.tumblr.com/





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