THE ANTIBIOTIC STEWARDSHIP CONTINUUM Oklahoma City Area Annual - PDF document

5/21/2019 THE ANTIBIOTIC STEWARDSHIP CONTINUUM Oklahoma City Area Annual Pharmacy Seminar June 30, 2019 Yvette Morrison, Pharm.D., BCPS, FASHP Dwayne David, Pharm.D., MHA, BCPS, NCPS Russell Kern, Pharm.D., BCPS Disclosure Statement Under guidelines established by the Accreditation Council for Pharmacy Education, disclosure must be made regarding financial relationships with commercial interests within the last 12 months. ■ Yvette Morrison I have no relevant financial relationships or affiliations with commercial interests to disclose. ■ Dwayne David I have no relevant financial relationships or affiliations with commercial interests to disclose. ■ Russell Kern I have no relevant financial relationships or affiliations with commercial interests to disclose. 1

5/21/2019 Learning Objectives At the completion of this activity, pharmacists will be able to: ■ Indicate the rationale for implementing an Antibiotic Stewardship Program (ASP) ■ Recognize the Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship in a variety of patient settings ■ Discuss methods of implementing an outpatient ASP in a multi- facility health system ■ Explain possible reasons for differences in stewardship outcomes within the health system ■ Demonstrate the importance of an interdisciplinary ASP team ■ Discuss methods of implementing an inpatient ASP and measuring outcomes Presentation Outline Yvette Dwayne Russell 2

5/21/2019 Approximately what percentage of outpatient antibiotic prescriptions are unnecessary? A. 10% B. 30% C.75% D.90% Approximately how many people in the US develop an antibiotic-resistant infection each year? A. 250,000 B. 500,000 C.1,000,000 D.2,000,000 3

5/21/2019 How many new antibacterial drugs is the Infectious Diseases Society of America calling for by 2020? A. 0 B. 5 C.10 D.20 Definition of Antibiotic Stewardship “Antibiotic stewardship is the systematic effort to improve antibiotic use to improve patient outcomes in order to help patients and combat antibiotic resistance.” CDC. 2017 Antibiotic Use in the United States: Progress and Opportunities 4

5/21/2019 Why? ■ Antibiotic overprescribing ■ Microbial resistance trends ■ Lack of new antibiotics https://www.cdc.gov/antibiotic-use/community/programs-measurement/state-local-activities/outpatient-antibiotic-prescriptions-US-2016.html 5

5/21/2019 Additional US Antibiotic Use Statistics Outpatient setting 2010 - 2011 ■ Majority of use and expenditure – 1 in 3 antibiotic prescriptions are unnecessary ■ Adding inappropriate prescribing  50% Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. JAMA 2016 Further Evidence of Overprescribing Outpatient setting - 2016 ■ ICD-10-CM diagnosis code classification ■ Insurance claims data of privately insured – Children (0-17YO) and adults (18-64YO) Chua KP, Fischer MA, Linder JA. BMJ 2019 6

5/21/2019 Proportion of Antibiotic Fills by Category Categories 40 35… 35 30 28.5 25 23.2 Percentage 20 15 12.8 10 5 0 Appropriate Potentially Appropriate Inappropriate Not coded Categories Microbial Resistance ■ Each year in the U.S., at least 2 million people are infected with antibiotic-resistant bacteria, resulting in at least 23,000 deaths CDC. Antibiotic resistance threats in the Unites States, 2013 7

5/21/2019 Antibiotic Resistance Threats in the US, 2013 CDC. Antibiotic resistance threats in the Unites States, 2013 https:www.cdc.gov/drugresistance 8

5/21/2019 Antibiotic Development IDSA 2010 https:www.centerwatch.com ■ Infectious Diseases Society of America 10 x ‘20 Initiative Approval Year Antibiotic Name Indication 2010 ceftaroline (Teflaro) Bacterial skin infections, bacterial pneumonia 2011 fidaxomicin (Dificid) CDAD 2013 telavancin (Vibativ) HAP and VAP due to S. aureus 2014 dalbavancin (Dalvance) ABSSI tedizolid (Sivextro) ABSSI oritavancin (Orbactiv) ABSSI ceftolozane + tazobactam (Zerbaxa) cIAI, cUTI 2015 ceftazidime + avibactam (Avycaz) cIAI and cUTI isavuconazonium sulfate (Cresemba) Invasive aspergillosis and invasive mucormycosis 2016 Bezlotoxumab (Zinplava) Recurrent CDI in patients receiving antibacterial treatment 2017 delafloxacin (Baxdela) ABSSI meropenem + vaborbactam (Vabomere) cUTI ozenoxacin (Xepi) Impetigo 2018 plazomicin (Zemdri) cUTI eravacycline (Xerava) cIAI omadacycline (Nuzyra) CABP and ABSSI Other Goals for 2020 Healthy People 2020 “CARB” Counting ■ Inappropriate use ■ Treatment courses – 50% in outpatient – Acute otitis media – Common cold – 20% in inpatient National Action Plan for Combating Antibiotic-Resistant Bacteria 2015 https://www.cdc.gov/nchs/healthy_people/hp2020.htm 9

5/21/2019 CDC Core Elements for Antibiotic Stewardship ■ Hospital Antibiotic Stewardship Programs (2014) ■ Antibiotic Stewardship for Nursing Homes (2015) ■ Antibiotic Stewardship in Outpatient Settings (2016) ■ Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals (2017) Core Elements of Outpatient Antibiotic Stewardship ■ Commitment ■ Action for policy and practice ■ Tracking and reporting ■ Education and expertise https://www.cdc.gov/antibiotic-use/community/improving-prescribing/core-elements/core-outpatient-stewardship.html 10

5/21/2019 Core Elements of Hospital Antibiotic Stewardship Programs ■ Leadership commitment ■ Accountability ■ Drug expertise ■ Action ■ Tracking ■ Reporting ■ Education https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html Approximately what percentage of outpatient antibiotic prescriptions are unnecessary? A. 10% B. 30% C.75% D.90% 11

5/21/2019 Approximately what percentage of outpatient antibiotic prescriptions are unnecessary? A. 10% B. 30% C.75% D.90% Approximately how many people in the US develop an antibiotic-resistant infection each year? A. 250,000 B. 500,000 C.1,000,000 D.2,000,000 12

5/21/2019 Approximately how many people in the US develop an antibiotic-resistant infection each year? A. 250,000 B. 500,000 C.1,000,000 D.2,000,000 How many new antibacterial drugs is the Infectious Diseases Society of America calling for by 2020? A. 0 B. 5 C.10 D.20 13

5/21/2019 How many new antibacterial drugs is the Infectious Diseases Society of America calling for by 2020? A. 0 B. 5 C.10 D.20 OUTPATIENT ANTIBIOTIC STEWARDSHIP 14

5/21/2019 Which of the following interventions are least effective? A. Posters in exam rooms with signed commitment statement from provider B. Educate parents on child’s antibiotic use including possible adverse effects C. Educate adults on their antibiotic use including possible adverse effects D. Utilizing interactive case-based education to teach medical staff E. All of the above are effective interventions Which of the following is likely to lead to problems when implementing an ASP? A. Designating a single leader for the ASP B. Training clinicians on how to use a new clinical decision tool C. Selecting more than one high-priority condition to monitor D. Building new clinical decision tool without user input E. All of the above can lead to problems 15

5/21/2019 Clinician Checklist for Core Elements Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12 Commitment 1. Can you demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety related to antibiotics? Write and display public commitments in support of antibiotic stewardship Example: Poster containing a public commitment to use antibiotics appropriately ■ Include clinician picture and signature ■ Display in patient examination rooms Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12 16

5/21/2019 Action 2. Have you implemented at least one practice to improve antibiotic prescribing? Use evidence-based diagnostic criteria and treatment recommendations Use national guidelines (e.g., IDSA) along with local pathogen susceptibilities to guide antibiotic choices Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR- 6):1–12 Action 2. Have you implemented at least one practice to improve antibiotic prescribing? Use delayed prescribing practices or watchful waiting, when appropriate ■ Delayed prescriptions and watchful waiting were both effective at reducing antibiotic prescriptions Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR- 6):1–12 17