a fantastic point of view: sharing new ams possibilities

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A Fantastic Point of View:Sharing New AMS Possibilities

Marsha Crader, PharmD, FASHP

Katherine Lusardi, PharmD, BCPS‐AQ ID, BCIDP

James “Buddy” Newton, MD, FACP, FIDSA

UAMS Disclosure Policy

It is the policy of the University of Arkansas for Medical Sciences (UAMS) to ensure balance, independence, objectivity, and scientific rigor in all directly or jointly provided educational activities.

All individuals who are in a position to control the content of the educational activity (course/activity directors, planning committee members, staff, teachers, or authors of CE) must disclose all relevant financial relationships they have with any ineligible companies as well as the nature of the relationship. The ACCME and ACPE describe relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CE activity.

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Disclosure

The following planner/speaker of this CE activity has financial relationships with commercial interests to disclose:

Marsha Crader, PharmD, FASHP

• Edwards Lifesciences – Ownership

All relevant financial relationships have been mitigated.

Learning Objectives

1) Summarize the core elements of an outpatient antimicrobial stewardship (AMS) program

2) Describe outpatient and inpatient AMS quality improvement initiatives from Arkansas hospitals

3) Identify successes and obstacles to implementing AMS quality improvement strategies

4) Explain how to obtain and implement rapid diagnostics in the institutional setting

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Outpatient AMS

Dark =Highest rate

Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions –

United Sates, 2019.https://www.cdc.gov/antibiotic‐use/pdfs/Annual‐Report‐

2019‐H.pdf

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CDC Core Elements of Outpatient AMS

Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12. DOI: http://dx.doi.org/10.15585/mmwr.rr6506a1

•Commitment

•Action for policy and practice• Tracking and reporting• Education and expertise

Joint Commission OutpatientAntibiotic Stewardship Requirements

Standard MM.09.01.03

5 new elements of performance (EPs) effective 1/1/2020

R3 Report Issue 23: Antimicrobial Stewardship in Ambulatory Health Care. The Joint Commission Issue 23, June 20, 2019.https://www.jointcommission.org/standards/r3‐report/r3‐report‐issue‐23‐antimicrobial‐stewardship‐in‐ambulatory‐health‐care/

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Insurance Metrics for Outpatient AMS

• Arkansas Medicaid Patient‐Centered Medical Home (PCMH)• Reduce percent of pediatric patients who receive prescriptions for oseltamivir and respiratory antibiotics on the same day

• Reduce percentage of patients with diagnosis of non‐specified upper respiratory tract infection (URI) who receive an antibiotic

• Reduce oral antibiotic use to ≤ 1,164 prescriptions per 1000 beneficiaries in 2021

• Arkansas BlueCross BlueShield (BCBS)• Increase percentage of pediatric patients who receive appropriate treatment for URIs

• Reduce percent of adult patients with a diagnosis of acute bronchitis who receive prescription for respiratory antibiotic on or 3 days after initial visit

Crader M and Liddell K. Expansion of Antimicrobial Stewardship in the Outpatient Setting. The Arkansas Family Physician. 2021;24(4): 18-19. https://www.arkansasafp.org/wp-content/uploads/arafp-journal__issue-95__spring-2021.pdf

Arkansas Medicaid, Arkansas Department of Human Services Division of Medical Services. PCMH Program Policy Addendum, 2021. https://humanservices.arkansas.gov/wp-content/uploads/2021-PCMH-Program-Policy-Addendum_11.03.20_FINAL.pdf

St. Bernards Healthcare and St. Bernards Medical Center (SBMC)• Location: Northeast Arkansas with referral service for 23 counties including southeast Missouri

• ED: 38 beds• Clinics under Joint Commission which prescribe antibiotics: 16

• ED/Clinic EMR: varies; transitioning to Meditech Expanse

• ID physician: 1 FTE• Antimicrobial Stewardship: 0.5 pharmacist FTE with lead physician support funded through the Clinical Efficiency Program (CEP)

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Commitment and Identification of Leader(s)• Background

• Clinical Efficiency Program (CEP)• Overarching hospital committee with quality improvement goals

• AMS is one of the CEP sub‐committees

• Creation• Inpatient AMS success• Outpatient AMS need

• Membership• Interdisciplinary team with representation from the hospital ER, hospital employee health clinic, and most affiliated clinics

Action for Policy and Practice:Establishment of Annual Goal• Goal Development

• “Easily” obtainable tracking data• Applicable to majority of clinics• Based on diagnosis OR irrespective of diagnosis• Based on national goals and/or local resistance data

• Goal Optimization• Should focus be narrowed further to one clinic or provider to obtain an early success?

• Determination that clinic management must be more involved in the process to encourage providers to meet goals

• 2020 and 2021 Goals• Reduce fluoroquinolone and clindamycin usage

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Actions for Policy and Practice:Evidence‐Practice Guidelines Related to Goal

Urinary tract infection – Uncomplicated Cystitis Reminder #1: Most patients should not have a urinary specimen collected if patient is asymptomatic and does not voice signs/symptoms of UTI. Only patients with asymptomatic bacteriuria that are considered high risk should be treated, which includes patients undergoing genitourinary surgery or who are pregnant.Reminder #2: If history of ESBL(+), Pseudomonas, or Enterococcus as a UTI pathogen, see previous microbiology susceptibilities for most appropriate empiric therapy.Reminder #3: If concerned patient has complicated cystitis, including patients with a urinary catheter, please refer to the “ASP – Urinary Tract Infection Adult Order Set”Typical organisms: Gram (‐) organisms such as E.coli, Klebsiella, and Proteus

Best option Cephalexin 500 mg PO bid x 3‐7 days

Nitrofurantoin 100mg PO bid x 5 days

*Nitrofurantoin is not recommended for

CrCl </= 30 mL/min

*Nitrofurantoin is not a viable option for Proteus

species, and some Klebsiella species have

significant resistance on local antibiogram.

Antibiotic “Cheat Sheet”

Example

Education and Expertise:Educational Resources Related to Goal

• Lead AMS pharmacist leads ongoing education efforts• Education must include “when,” “why,” and “how” to improve prescribing

• Initial Joint Commission Education Kick‐off• Individual/group provider education and inpatient/outpatient AMS CME

• Annual Education• CEP annual provider update, Joint Commission annual staff education, physician newsletters, medical resident education, etc.

• PRN Education• Local nurse practitioner education; targeted education based on infection, antibiotic, or provider

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• Urinary tract infections (UTIs)

• Community acquired pneumonia (CAP)

• DiverticulitisWhen

• Local susceptibilities for E. coli and Pseudomonas

• FDA MedWatch Warnings1

• Possibly reduce C. difficile occurrenceWhy

• Provided treatment alternatives that incorporated guidelines and local outpatient‐specific antibiogram

• Provided penicillin allergy educationHow

Avoid Fluoroquinolones

1FDA MedWatch alerts. Fluoroquinolone Antimicrobial Drugs Information.https://www.fda.gov/drugs/information‐drug‐class/fluoroquinolone‐antimicrobial‐drugs‐information


• Skin/soft tissue infections (SSTIs)

• Anaerobic infectionsWhen

• Local susceptibilities for methicillin resistant Staph aureus (MRSA) and anaerobic organisms

• Possibly reduce C. difficile occurrenceWhy

• Provided treatment alternatives that incorporate guidelines and local outpatient‐specific antibiogram

• Provided penicillin allergy educationHow

Avoid Clindamycin

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Tracking and Reporting

• Tracking• Obtaining Data

• Lead AMS pharmacist obtained antibiotic usage data in Excel format from outpatient IT personnel who created SQL reports

• Tracking Antibiotic Usage• Listed by clinic and provider• Monthly usage data standardized by number of clinic visits

• Identifying Other Valuable Information• Example: Targeted antibiotic usage with documented penicillin allergies

• Reporting• Clinical Efficiency Program Committee Structure• Medical Staff Meetings and Other Education Outlets

Education and Expertise:Patient and Public EducationU.S. Antibiotics Awareness Week• Posters• Radio/TV spots• Social media• Blog• Newsletter for hospital staff

• Flyers in hospital cafeteria

• Expert panel discussion

https://www.cdc.gov/antibiotic‐use/week/toolkit.html

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Outpatient AMS Intervention Recap

• Successes• Provider and public engagement• Providers utilize antibiotic “cheat sheets”

•Obstacles• COVID‐19 pandemic• Multiple EMRs and obtaining all clinic data for tracking

• Lessons Learned• Increased participation of providers/staff within individual clinics is needed

• Change takes time• Perseverance and repetition of key information is key

Available as Document for Clinic Use

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CDC OutpatientAntibiotic Stewardship Resources


https://www.cdc.gov/antibiotic‐use/community/pdfs/16_268900‐A_CoreElementsOutpatient_appendix_508.pdf

Dalbavancin for Uncomplicated SSSTI

Buddy Newton, MD FIDSA FACPDirector of Antimicrobial StewardshipWashington RegionalFayetteville, AR [email protected] or (479) 463‐6135

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Disclosure

The following speaker of this CE activity has no relevant financial relationships with ineligible companies to disclose:

• James “Buddy” Newton, FIDSA, FACP

Washington Regional Medical Center

Location: Fayetteville, AR (Go Hogs!)Referral base: Tertiary center for NWA, NE OK, SW MOBed Size: 425EMR: CernerCSDS: Sentri7Physician Model: hospitalists/intensivists and private practicePharmacists: About 20 FTE PharmacistsID: 4 (3 private practice, 1 hospital-employed)ASP: 1.0 FTE ID MD; 0.5 FTE 3 ASP-trained pharmacists

rotating through for a total of 20h weekly

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Uncomplicated SSSTI

• IDSA PG’s recommend a 5‐day course of cefazolin, ceftriaxone, penicillin, or clindamycin for moderate nonpurulent infections and 5 days of vancomycin or daptomycin or linezolid or doxycycline or TMP/AMX (after I&D) for moderate to severe purulent infections

• DRG reimbursement is based on a 3.8 day LOS

• WRMC average LOS=5.2 days• ~120 annual admissions• Estimated annual loss‐ $400K

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Recuperating Losses

1. Reduce LOS• Difficult to do with MD’s ingrained thoughts for treatment • IDSA PG’s recommend 5‐day treatment leading to

inherently longer LOS

2. Admission Avoidance• Outpatient treatment with an effective regimen via

infusion center or ED

3. Hybrid treatment• Inpatient treatment for 1‐2 days followed by an effective

long‐term Rx to complete course

WRMC Model

• 120 admissions annually• Goal is 80% hospital avoidance (about 100 patients)• Conservative cost savings of $340K (excluding revenue generation)

• Dalbavancin reimbursement• Inpatient

• Included in DRG payment (net loss)• Outpatient (revenue generation)

• Insurance payment for drug (about 80% reimbursement by insurers)• Patient savings card thru company (up to $600)• Billing code- J0875

• Chair time• Vial replacement of uninsured (both inpatient & outpatient)

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WRMC Experience

• ED (90%) or Infusion Clinic (10%) administration of dalbavancin (admission avoidance)

• 8/19 thru mid 3/20• 20 patients treated with 15% failure (admitted with same Dx)

• COVID (everything came to a standstill)

• 10/20 thru 7/21• 18 patients treated with 5% failure rate (admitted with same Dx)

• COVID (delta variant)- (everything came to a standstill again)

Conclusions

• Current inpatient reimbursement system is a revenue drain unless LOS can be significantly reduced

• Outpatient dalbavancin can plug the revenue drain AND result in a positive revenue stream

• Biggest stumbling block is education and awareness for outpatient dalbavancin use

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Questions?

DATE

Penicillin Allergies and Pre-op Antibiotics


Clinical Pharmacy Specialist

Antimicrobial Stewardship & Infectious Diseases

UAMS Medical Center

Little Rock, AR

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DATEDisclosure

• Speaking and consulting for Accelerate Diagnostics, Inc.

DATEUAMS Medical Center

• Location: Little Rock, AR

• Bed Size: 535 beds

• EMR: Epic

• Clinical decisions support: Epic ‘bugzy’

• Physician model: all UAMS physicians, and training programs

• Pharmacists: ‐‐ FTE

• ID Group: 8 ID physicians, 4 fellows, 1 APRN for 4 services

• Antimicrobial Stewardship: 1.0 FTE Pharmacist with 0.5 FTE ID Physician

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DATEPenicillin Allergy

• Approximately 10% of all U.S. patients report having an allergic reaction to a penicillin class antibiotic in their past.

• However, many patients who report penicillin allergies do not have true IgE‐mediated reactions. When evaluated, fewer than 1% of the population are truly allergic to penicillins.

• Approximately 80% of patients with IgE‐mediated penicillin allergy lose their sensitivity after 10 years.

• Broad‐spectrum antibiotics are often used as an alternative to penicillins. The use of broad‐spectrum antibiotics in patients labeled “penicillin‐allergic” is associated with higher healthcare costs, increased risk for antibiotic resistance, and suboptimal antibiotic therapy.

• Correctly identifying those who are not truly penicillin‐allergic can decrease unnecessary use of broad‐spectrum antibiotics.

Joint Task Force on Practice Parameters representing the American Academy of Allergy, Asthma and Immunology; American College ofAllergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010 Oct;105(4):259‐273.

DATE

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DATE

• Retrospective cohort study 2010‐2014 at MGH

• Compared surgical site infection rates and perioperative antibiotic use in patients with and without reported penicillin allergy

• 9,004 procedures (hip/knee, CABG, HYS, CRS)

• 920 (11%) reported PCN allergy• Only 5 (0.5%) reactions were true contraindications

• Patients had a 50% increased risk of surgical site infection if reported PCN allergy

• Total Cohort: 4% vs 3% (CI 1.02‐2.22)

• Colon Surgery: 14% vs 10%

OR 2.1

DATEHistory: just ask a few questions

• What medication were you taking when reaction occurred?

• What kind of reaction occurred?

• How long ago did the reaction occur?

• How was the reaction managed?

• Have you ever tolerated:• Amoxicillin –

• Augmentin (amoxicillin/clav)‐

• Keflex (cephalexin; PO version of cefazolin)‐

• Ceftriaxone ‐

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DATEHistory: just ask a few questions

• What medication were you taking when reaction occurred?• Don’t remember

• What kind of reaction occurred?• Nausea

• How long ago did the reaction occur? • When I was 6 (>10 years ago)

• How was the reaction managed?• Didn’t seek care

• Have you ever tolerated:• Amoxicillin –Not sure• Augmentin (amoxicillin/clav)‐ yes• Keflex (cephalexin; PO version of cefazolin)‐ not sure• Ceftriaxone ‐yes

DATEAntibiotic Challenge

Macy et al. J Allergy and Clin Imm; 5(3): 2017

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DATE

Areas for Improvement

DATE

UAMS Surgery 2018-201916,376 Procedures

24%

17%

10%9%

7%

7%

6%

5%UROLOGY

NSGY ENT

GENERAL

OB

GENERAL ORTHO

GYN

ORTHO JOINT

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DATEUAMS Surgery 2018-2019

16,376 ProceduresPre‐Op Antibiotic N=16,376 (%)

Cefazolin 12,756 (77.9%)

Clindamycin 1,396 (8.5%)

Vancomycin 735 (4.5%)

Piperacillin/tazobactam 443 (2.7%)

Ertapenem 412 (2.5%)

Cefuroxime 299 (1.8%)

Azithromycin 273 (1.7%)

Ampicillin/Sulbactam 216 (1.3%)

DATEUAMS Surgery 2018-2019 Pre-op Antibiotic per ServiceCT CV ENT GI GEN GYN HAND NSGY OB

#1 Cefuroxime(65%)

Cefuroxime(65%)

Cefazolin(75%)

Cefazolin(86%)

Cefazolin(65%)

Cefazolin(89%)

Cefazolin(80%)

Cefazolin(85%)

Cefazolin(93%)

#2 Cefazolin(23%)

Vanc(25%)

Clinda(13%)

Levaquin(9%)

Erta(15%)

Clinda(8%)

Clinda(14%)

Vanc(9%)

Azithro(20%)

#3 Zosyn(6%)

Cefazolin(15%)

Unasyn(11%)

Zosyn(2%)

Clinda(7%)

Azithro(6%)

Zosyn(4%)

Nafcillin(4%)

Clinda(5%)

PLASTIC OPHTO ORTHO ORTHO‐J ORTHO‐T TX URO VASC

#1 Cefazolin(75%)

Cefazolin(76%)

Cefazolin(85%)

Cefazolin(82%)

Cefazolin(75%)

Cefazolin(78%)

Cefazolin(74%)

Cefazolin(86%)

#2 Clinda(11%)

Clinda(19%)

Clinda(11%)

Clinda(10%)

Clinda(11%)

Vanc(17%)

Gent(7%)

Zosyn(8%)

#3 Vanc(9%)

Levaquin(4%)

Vanc(6%)

Vanc(9%)

Vanc(9%)

Erta(11%)

Clinda(6%)

Vanc(7%)

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Reported PCN Allergy


Post Surgical Clostridioides difficile Infection (CDI)

• 114 Cases of CDI 90 days post op• Cefazolin 0.5%

• Alternative Antibiotic 1.1%

• Odds Ratio 2.1; (95% CI 1.5‐2.9; p<0.0001)

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Case-Control Risk factor analysis for Cdiff 90d post-op

• Multivariate Analysis: Controlling for antibiotic exposure, surgical procedure, age, weight, renal function

No CDI within 90dN=16,262

CDI within 90d N=114

Odds Ratio

95% CI P value

Non‐Cefazolin Abx 3,839 (23.6) 44 (38.6) 1.6 1.1‐2.4 0.015

General Surgery 2,632 (16.2) 40 (35.1) 4.2 2.6‐6.7 <0.001

Urology 805 (5.0) 12 (10.5) 4.3 2.2‐8.5 <0.001

CTS 284 (1.8) 6 (5.3) 5.2 2.1‐12.8 <0.001

Vascular 401 (2.5) 6 (5.3) 4.0 1.7‐9.9 <0.001

NSGY 1,385 (8.5) 17 (14.9) 4.0 2.2‐7.2 <0.001

Age >65 4,386 (27.0) 35 (30.7) 1.0 0.7‐1.5 0.950

Obesity 8,457 (52.0) 38 (33.0) 0.5 0.4‐0.8 0.002

CKD 1,626 (10.0) 25 (21.9) 1.6 1.0‐2.6 0.042

DATEUAMS Surgery 2018-2019 Surgical Site Infections

• Only collected data for THAs and TKAs

• 18 Surgical Site Infections reported to CDC• 6 (33%) reported PCN allergy

• 13% of surgical cohort reported PCN allergy (p=0.008)

Received Guideline Recommended ppx

Reported serious type I PCN reactions

Previously received cephalosporin

Infection not covered by administered ppx

0/6 (0%) 0/6 (0%) 4/6 (67%) 3/6 (50%)

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DATE

Intervention

DATEEducation

• Anesthesiology Rounds July 2019• Antibiotic selection based on surgery

• Review of penicillin allergy data

• Impact of non‐cefazolin antibiotics

• Ongoing education for new incoming anesthesiology practitioners

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DATEAntibiotic Handbook

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DATE

DATEChanges in Antimicrobial Use

Peri‐operative Antibiotic Use (DOT/1000 PD)

FY2019 FY2020 % ChangeFY19‐>FY20

Cefazolin 511.39 534.9 +4.6%Vancomycin 73.7 61.4 ‐16.7%Clindamycin 49.4 31.0 ‐37.2%

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DATELessons Learned

• Address the right target: who is actually giving the pre‐op antibiotics

• Capture activities within already existing work flows

DATEThank you!

• Many thanks and credit to Dr Ryan Dare for this initiative and data

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Inpatient AMS

Potential Joint Commission Updates

Examples of Proposed Changes • Implement evidence‐based guidelines that address the following:

• Diagnosis AND treatment of CAP, UTI, SSTI, and inappropriate use of urine testing for patients without symptoms of UTI

• Document evidence‐based use of antibiotics in all departments and services of the hospital

• Evaluate adherence (antibiotic selection and duration) to at least one of the following evidence‐based guidelines

• Diagnosis AND treatment of CAP, UTI, SSTI, and inappropriate use of urine testing for patient without symptoms of urinary tract infections

The Joint Commission. Proposed New Requirements at MM.09.01.01 Antibiotic Stewardship Field Review – HAP and CAH. https://www.jointcommission.org/standards/standards‐field‐reviews/proposed‐new‐requirements‐at‐mm090101‐antibiotic‐stewardship‐hap‐

and‐cah‐field‐review/

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St. Bernards Medical Center (SBMC)

• Location: Jonesboro, AR with referral service for 23 counties including southeast Missouri

• Bed size: 440• EMR: Meditech 6.08; Meditech Expanse 1/2022• Clinical Decision Support: VigiLanz• Physician Model: hospitalists/intensivists and private physicians• Pharmacists: 38.7 FTEs• ID Physician: 1 FTE• Antimicrobial Stewardship: 0.5 pharmacist FTE with lead physician support funded through the Clinical Efficiency Program

2020‐21 Inpatient AMS Goal:Decrease Carbapenem Usage

• Avoid carbapenems unless needed based on previous/current multi‐drug resistant (MDR) organisms, true penicillin allergies, etc.When

• CDC urgent threat: goal is to reduce carbapenem‐resistant Enterobacteriaceae (CRE)1

• Reduce CRE development and keep carbapenems viable for MDR gram‐negative infections

Why

• Ongoing education to providers and pharmacists

• Maximization of EMR and clinical surveillance software

• Microbiology updatesHow

1Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019. DOI: http://dx.doi.org/10.15620/cdc:82532

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Education Initiatives

Empiric Therapy

• Antibiogram susceptibilities

• Penicillin allergies

Definitive Therapy

• De‐escalation opportunities

• Length of therapy

Both Types of Therapy

•Microbiology updates and recommendations

Penicillin Allergy Education Points

• 10% of patients in the U.S. report an allergy to a penicillin (PCN) class antibiotic

• Of that, less than 1% have a true (IgE‐mediated, type 1 reaction) allergy

• ~80% of patients with a true allergy will lose their sensitivity to PCN after 10 years

• Many cephalosporins, especially in the later generations, can be safely tolerated despite a penicillin allergy. Patients with anaphylaxis or other severe reactions may require further evaluation prior to the use of cephalosporins.

https://www.cdc.gov/antibiotic‐use/community/pdfs/penicillin‐factsheet.pdf

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Penicillin Allergy Education Points

Blumenthal KG, et al.. Antibiotic Allergy. Lancet. 2019 Jan

12;393(10167):183‐198. DOI:http://dx.doi.org/10.1016/S0140‐

6736(18)32218‐9

De‐escalation Education Points

• If a non‐septic patient only needs antibiotics for an ESBL+ UTI, find an alternative antibiotic based on susceptibilities and patient specific factors

• Examples: Nitrofurantoin, Fosfomycin, TMP/SMX• Fosfomycin Testing

• Fosfomycin antibiotic disc utilized once cultures demonstrate ESBL+ E. coli

• Fosfomycin Treatment• Limit fosfomycin usage to only ESBL+ E. coli cystitis to keep antibiotic viable for this organism

• Fosfomycin 3 grams PO every 72 hours x 3 dosesBabiker A , et al. Fosfomycin for treatment of multidrug‐resistant pathogens causing urinary tract infection: A real‐world perspective and review of the literature. Diagn Microbiol Infect Dis. 2019; 95(3): 114856. DOI: http://www.doi.org/10.1016/j.diagmicrobio.2019.06.008

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Length of Therapy Education Points

Wald‐Dickler N and Spellber B. Short‐course Antibiotic Therapy – Replacing Constantine Units with “Shorter is Better.” Clin Infect Dis. 2019; 69(9): 1476‐1479. DOI: http://www.doi.org/10.1093/cid/ciy1134

EMR and Clinical Surveillance Initiatives

• Pharmacy technician allergy assessment

• Meropenem indications with guidance when other antibiotic options are appropriate

• Provider EMR time‐outs 48 hours after initiation of antibiotic

• Pharmacist clinical surveillance alerts at the initial meropenem order and again at 72 hours

• Pharmacist clinical surveillance alerts to improve allergy documentation

Electronic Medical Record (EMR) Clinical Surveillance Software

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Allergy Assessment byMedication Reconciliation Technicians

Additional Allergy Comments by Pharmacists

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Meropenem Indication Requirement

Meropenem Indication Requirement: Antibiotic Guidance Pop‐ups

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Meropenem Indication Requirement: Antibiotic Guidance Pop‐ups

Microbiology Initiaves

• Fosfomycin antibiotic disk tested on all inpatient and outpatient ESBL(+) E. coli urine specimens

• Addition of MALDI‐TOF instrument

• Quicker organism identification

• Fluoroquinolone breakpoints updated to correctly reflect CLSI “S,” “I,” and “R,” so providers can feel confident in susceptibility results

• Urine culture indication required in 2022 to avoid unnecessary treatment of asymptomatic bacteriuria

Microbiology Updates Diagnostic Stewardship

Nicolle LE, et.al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the IDSA. Clin Infect Dis. 2019; 68(10): e83‐75. DOI: http://www.doi.org/10.1093/cid/ciy1121

ESBL = extended‐spectrum beta‐lactamaseCLSI = Clinical Laboratory Standards Institute

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Upcoming Microbiology Initiatives:CAUTI HiRO PackageUrine Specimen Bundle“Unjustified ordering or improper collection of urine for analysis or culture from non‐catheterized patients, or misinterpretation of positive results, often leads to adverse health events, increased financial burden, over‐reporting of mandated CAUTIs, overtreatment of patients with antimicrobial agents, and selection of MDRs”

• Mayo Clinic • “modify clinician ordering practices of UA and urine for culture to limit

overuse and better control medical and clinical microbiology laboratory resources”

• ABIM Foundation Choosing Wisely Campaign• “Don’t perform UA, urine CX, Blood CX, or C. diff testing unless patients have

specific s/s of infection. Falsely positive tests lead to over diagnosis and overtreatment”

• Veteran Affairs• JAMA Internal Medicine, An Implementation Guide to Reducing Overtreatment

of ASB (2018)• IDSA Clinical Practice Guideline for the Management of ASB (2019)

Infection Prevention Role Out: 2022

ALL RECOMMEND….• Require indication when

ordering UA or culture• Appearance and smell of

urine should not trigger a urine culture

• If chronic Foley, change out prior to culture

• Utilize UA reflex to culture with UTI‐specific criteria

Thanks to SBMC Infection Prevention for This Slide

Inpatient AMS Intervention Recap

• Successes• General surgery education to reduce pre‐op ertapenem• Therapy guidance based on meropenem indication

•Obstacles• COVID‐19 pandemic• Some providers unwilling to de‐escalate from meropenem to another option in ESBL(+) cystitis

• Lessons Learned• Change takes time

• Perseverance and repetition of key information is key• Thinking outside the box may be needed

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National Penicillin Allergy Day:September 28, 2021• Penicillin allergy label may impact medical costs

• Antibiotic costs are up to 63% higher than for those who do not report being penicillin‐allergic1

• Penicillin allergy label may increase adverse events (ADEs)• Up to threefold increased risk of ADE2

• In the hospital setting• 10% more hospital days1

• 30% higher incidence of VRE infections3

• 23% higher incidence of C. difficile infections3

• 14% higher incidence of MRSA infections3

1. Macy E and Contreras R. Healthcare Use and Serious Infection Prevalence Associated with Penicillin “Allergy” in Hospitalized Patients: A Cohort Study. Journal of Allergy and Clinical Immunology, 2014;133(3), 790-796. DOI: http://www.doi.org/10.1016/j.jaci.2013.09.021

2. Owens, RC and Fraser GL.. Antimicrobial Stewardship Programs as a Means to Optimize Antimicrobial Use. Pharmacotherapy, 2004;24(7), 896-908. DOI: http://www.doi.org/10.1592/phco.24.9.896.36101

3. Blumenthal KG., et al. Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation. The Journal of Allergy and Clinical Immunology: In Practice 5.3 2017;: 616-625. DOI: http://www.doi.org/10.1016/j.jaip.2017.02.019

U.S. Antibiotics Awareness Week:November 18‐24, 2021


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Vancomycin Reduction

Buddy Newton, MD FACP FIDSADirector of Antimicrobial StewardshipWashington RegionalFayetteville, AR [email protected] or (479) 463‐6135


Location: Fayetteville, AR (Go Hogs!)Referral base: Tertiary center for NWA, NE OK, SW MOBed Size: 425EMR: CernerCSDS: Sentri7Physician Model: hospitalists/intensivists and private practicePharmacists: About 20 FTE PharmacistsID: 4 (3 private practice, 1 hospital-employed)ASP: 1.0 FTE ID MD; 0.5 FTE 3 ASP-trained pharmacists

rotating through for a total of 20h weekly

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Why Vancomycin?

Methods for Vancomycin Reduction

• Restricted formulary (nonstarter at WRMC)• Daily ASP review (labor‐intensive) • Disease‐specific pathways via EMR

• gently guides ABX use where you want it to go• SSSTI, PNA, CDI guidelines

• “Nudges” placed in prescribing pathway• Staph nasal screen when vanco used for PNA Rx • EMR display of CDC guidelines at order entry

• Dosing manipulation• AUIC dosing (typically requires specialized software such as

DoseMeRx)• Trough‐based pharmacokinetic dosing

WRMC techniques

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• Dosing manipulation• AUIC dosing (typically requires specialized software such as

DoseMeRx)• Trough‐based pharmacokinetic dosing

WRMC techniques

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• Dosing manipulation• AUIC dosing (typically requires specialized software such

as DoseMeRx)• Trough‐based pharmacokinetic dosing

WRMC techniques

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WRMC Vancomycin DOT over the years

Conclusions

• Multiple methods for reducing vancomycin use (some sneaky and some are not)

• Pick one or more and try to insert this method into your ASP. With patience you will eventually see improvement (it took us 1.5 years!)

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Questions?

DATE

Rapid Diagnostics And Stewardship


Clinical Pharmacy Specialist

Antimicrobial Stewardship & Infectious Diseases

UAMS Medical Center

Little Rock, AR

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DATEObjectives

• Explain how to obtain and implement rapid diagnostics in the institutional setting

DATEUAMS Medical Center

• Location: Little Rock, AR

• Bed Size: 535 beds

• EMR: Epic

• Clinical decisions support: Epic ‘bugzy’

• Physician model: all UAMS physicians, and training programs

• Pharmacists: ‐‐ FTE

• ID Group: 8 ID physicians, 4 fellows, 1 APRN for 4 services

• Antimicrobial Stewardship: 1.0 FTE Pharmacist with 0.5 FTE ID Physician

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DATEMy Personal Experience

• AMS Program for 10 years

• RDT Landscape:• bioMerieux MALDI‐TOF

• Cepheid GeneXpert

• BioFire FilmArray

• Accelerate Pheno System

DATE

Assessing the Landscape

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DATERDT Landscape

• New vs Existing Platforms

• Needs of groups

• Volume to support

• Space (and personnel)

• Reagent rentals vs Cost per reportable vs outright purchasing

Morency‐Potvin P, et al. Clin Microbiol Rev. 2017; 30: 381‐407.Hernandez M, et al. Becker’s Hospital Review. https://www.beckershospitalreview.com/supply‐chain/to‐buy‐or‐not‐to‐buy‐purchasing‐decisions‐in‐the‐clinical‐lab.html

DATERDT Landscape

New Platform

• New technology benefit

• Expand for future tests

• High up front costs for budget

Existing Platform

• Upfront capital expense paid

• Validation of additional test

• Familiar work flow/space

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DATEBloodBLOOD Platforms Results Source Time Technology Literature Comment

MALDI‐TOF(Bruker, bioMerieux)

IDPlate growth

20 mins Mass spectrometry24/7 ASP notification‐ Reduce hospital costs1,2

‐ Reduce LOS2

Accelerate Pheno™ System

IDSusc.

+ Bld Cxbottle

7 hours ID ‐ Fluorescent in situ Hybridization AST ‐Bacterial growth Imaging

8‐hr ASP notification‐ Reduce hospital LOS‐ Reduce DOT3

Verigene® (Luminex)IDResistance Genes

2 hours Nucleic Acid Extraction & PCR Amplification

12‐hr ASP notification ‐ Reduce TTOT, LOS, abx for contam.4

PNA FISH® (OpGen) ID 2 hoursPeptide Nucleic Acid (PNA) Fluorescent in situ Hybridization

14‐hr ASP notification‐ Reduce TTOT, hosp. cost5

BioFire® (bioMérieux)IDResistance Genes

1 hour Multiplex PCR24/7 ASP notification‐ Reduce ICU LOS, abx for contam,

TTOT6,7

GeneXpert® (Cepheid)

ID < 1 hour PCR9‐hr ASP notification‐ Faster ID consult, lower hosp. costs8

T2Direct Diagnostics™(T2 Biosystems)

IDWholeblood

3‐5 hoursNuclear magnetic resonance and PCR

13‐ hour shorter time to effective AF therapy9

Less AF exposure10

ePlex BCID GNB, GP, Fungal (GenMark)

IDResistance Genes

+ Bld Cxbottle

1.5 hours Multiplex PCRFairly new to market, no AMS intervention data available

1. Patel TS et al. J Clin Micro. 2016; 55:60‐67.; 2. Perez KK, et al. Arch Pathol Lab Med. 2013; 137: 1247‐1254.; 3. Dare RK, et al. Clin Infect Dis. 2020, doi:10.1093/cid/ciaa649; 4. Box MJ, et al. Pharmacotherapy. 2015; 35: 269‐276. 5. Heil EL, et al. AJHP. 2012; 69: 1910‐1914.; 6. Banerjee R, et al. Clin Infect Dis. 2015; 61: 1071‐1080.; 7. MacVane SH, et al. J Clin Micro. 2016; 54: 2455‐2463.; 8. Bauer KA, et al. Clin Infect Dis. 2010; 51: 1074‐1080.; 9. Zacharioudakis IM, et al. J. Fungi. 2018; 4: 45; Jariwala R, et al. IDWeek 2019 Poster #270.

DATERespiratory

Technology Target/Results Source Time Technology Literature Comment

Unyvero (Curetis)29 (19 bacterial ID, 10 resistance genes)

<5 h Multiplex PCRFairly new to market, no AMS intervention data available

BioFire® FilmArrayRP 1&2 (bioMérieux)

21‐22 (17 viral ID, 4 bacterial ID) RP2 has additional Bordatellaresults

NP Swab 45 m‐ 1 h Multiplex PCRStewardship initiatives centered on RVP/RPP have not shown benefit1

BioFire® Pneumonia Panel (bioMérieux)

33 (18 bacteria ID, 8 viral ID, 6 resistance genes)

Sputum, BAL, Mini‐BAL

1 h Multiplex PCRFairly new to market, no AMS intervention data available

NxTag (Luminex) 20 (18 viral, 2 bacteria) 5 h Multiplex PCR

Stewardship initiatives centered on RVP/RPP have not shown benefit1

Verigene Flex Test (Luminex)

16 (14 virus, 3 bacteria)2 h Multiplex PCR

ePlex RP (GenMark) 17 (15 viral, 2 bacterial) 2 h Multiplex PCR

Nasal MRSA PCR (Various)

S. sureus ID, resistance (MecA)

NP Swab <1 h PCRDecreased vancomycin consumption2

1. Vos LM, et al. CID 2019; 69(7): 1243‐1253; 2. Metlay JP, et al. Am J Respi Crit Care. 2019; 200 (7): e45‐e67. Manufacturer Websites.

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DATERDT Landscape

• New vs Existing Platforms

• Needs of groups

• Volume to support

• Space (and personnel)

• Reagent rentals vs Cost per reportable vs outright purchasing

Morency‐Potvin P, et al. Clin Microbiol Rev. 2017; 30: 381‐407.Hernandez M, et al. Becker’s Hospital Review. https://www.beckershospitalreview.com/supply‐chain/to‐buy‐or‐not‐to‐buy‐purchasing‐decisions‐in‐the‐clinical‐lab.html

DATE

Making the Business Case

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DATEStart the Sell

• Know your audience• What outcomes are of interest?

• Does it fit the mission of your facility?

• Support for initiative• National organizations

• Regulatory bodies

• ROI support/Business plan

Buckel WR, et al. Infect Dis Clin N Am. 2020; 34: 1‐15.

DATEKnow the Audience

Hospital Administrator

• Antimicrobial cost – 41.5%

• Appropriateness of abx use –4.9%

• Infection/abx associated LOS –4.9%

ID Physician

• Infection related mortality – 37%

• Appropriateness of abx use –27%

• Infection/abx associated LOS –7%

Bumpass et al. Clin Infect Dis. 2014; 59 (s3): s108‐s111.

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DATECDC Core Elements

• Leadership Support• Financial commitment to RDT

• Accountability• Implementation and outcomes• Use of RDT in AMS activities

• Drug Expertise• Streamline delivery of optimal antibiotic therapy

• Actions• Prospective audit and feedback• Measurable outcomes

• Tracking/Monitoring• Tangible clinical outcomes to monitor• Monitor compliance with ASP recommendations

• Reporting• Share outcomes with key stakeholders

• Demonstrate pharmacy activities and impact

• Education• Increase confidence in ASP recommendations regarding RDT

Wenzler E, et al. AJHP, 2018; 75: 1191‐1202.Buckel WR, et al. Infect Dis Clin N Am. 2020; 34: 1‐15.

DATEFacility Impact: Cost Efficacy

• Cost efficacy analysis of mRDT and AMS

• mRDT = PCR, MALDI‐TOF, PNA FISH, micro array

• Interventions:• mRDT with or without AMS

• mRDT with AMS

• mRDT without AMS

• Conventional microbiology with AMS

• Conventional microbiology without AMS (baseline)

Pliakos EE, et al. Clin Microbiol Rev. 2018; 31: e00095‐17.

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Cost Probability of Survival

QALYValue

$/QALYGained

mRDT with or without AMS $36,301.50 0.89 11.99 ‐36,434

mRDT with AMS $31,274.24 0.89 11.91 ‐45,764

mRDT without AMS $57,220.14 0.90 12.12 1,913

Conventional microbiology w/ AMS $41,723.98 0.84 11.31

Conventional microbiology without AMS (baseline)

$55,932.02 0.85 11.45 Baseline



• mRDT with AMS – strongest cost effectiveness in the model


Cost Prob of Survival

QALY Value $/QALYgained

PCR $47,917 0.88 11.85 ‐19,833

MALDI‐TOF $28,394 0.92 12.39 ‐29,205

PNA FISH $53,226 0.85 11.45 0

BC‐GP $24,904 0.84 11.31

BC‐GN $33,691 0.92 12.39 ‐23,587

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DATEFacility Impact: Patient Outcomes

• 64.5% (20/31) of studies with mRDT + AMS

Outcome of Interest Result

Mortality with RDT OR 0.66; 95% CI, 0.54– 0.80

Gram‐negative bloodstream infection OR 0.51; 95% CI, 0.33 – 0.78

Gram‐positive bloodstream infection OR 0.73; 95% CI, 0.55 – 0.97

Time to effective therapy, hours ‐5.03; 95% CI, ‐8.46 to ‐1.45

Hospital length of stay, days ‐2.48; 95% CI, ‐3.90 to ‐1.06

Timbrook TT, et al. Clin Infect Dis. 2017;64:15‐23.

DATE

Using RDT Resources Wisely

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DATEImprove Stewardship of RDT

• Ordering• 2020 Survey on RVP testing sent to SHEA Research network

• 60% had guidance on ordering published

• 54% had restrictions to limit inappropriate ordering

• Interpretation

Claeys KC et al. ICHE. 2020; doi: 10.1017/ice.2020.1328Kuper KM, et al. ICHE. 2019; 40:501‐511

DATETest Stewardship: C difficile

• Single center retrospective review of C difficile PCR testing

• Intervention: Education via memos, grand rounds, screen savers• Allow LIS cancellation of orders if sample not received in 24 hours

• Implemented lab “stick test”

• Pre‐intervention: May – December 2016

• Post‐intervention: January – December 2017

• Outcomes: changes in SIR

Yen C, et al. ICHE. 2018; 39: 734‐736.

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DATETest Stewardship: C difficile

• $2017.80/month reduction in lab costs

• ~$5000/month reduction in drug costs

Yen C, et al. ICHE. 2018; 39: 734‐736.

# Cdifftests/month

True +/month SIR

Pre‐intervention

148 11 1‐1.2

Post‐intervention

85 1 0.2‐0.6

DATEUAMS Examples

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DATE

Put RDT into Action

DATEEMR Integration of RDT

• 67% of the US EHR Market is comprised of 3 EHR:• Epic

• Cerner

• Meditech

• Built in AMS Modules have varying capabilities

• External CDS increase your options

Kuper KM, et al. ICHE. 2019; 40:501‐511Nasef R. Int J of Infect Dis. 2020; 20:124‐128

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DATEIntegrated InterpretationBanerjee R, et al. Clin Infect Dis. 2015; 61: 1071‐1080

RDT Platform FilmArray BCID

ASP Study Intervention Templated comments and comments with 24/7 paging to AMS team Recommended changes to primary team

Comparison(n= 617)

Control(n= 207)

BCID + template comments(n= 198)

BCID + AMS(n= 212)

Primary Outcome Duration of abx therapy

Outcomes (h (IQR))1. Vanc in organisms not requiring Vanc2. Cefepime3. Pip/tazo4. Time to first de‐esc

1. 8.2 (0‐26)2. 55 (28‐96)3. 56 (39‐82)4. 34 (21‐55)

1. 0 (0‐16)2. 71 (43‐96)3. 44 (27‐74)4. 38 (22‐66)

1. 0 (0‐3)2. 58 (32‐96)3. 45 (19‐78)4. 21 (7‐37)

Main Takeaway Intervention acceptance rate was 78% in first 24 hours. De‐escalation accounted for 58% of recommendations, and escalation for 18% of recommendations. Templated comments did not make as much impact as PAF.

DATECerner

• ASP Pharmacist alerts/Real time notifications can populate a work queue

• Mpages (Millenium Pages) provide a one line snapshot of patient information, and can be customized

• IT resource intense to build out

Katzman M, et al. Open Forum Infect Dis. 2019; doi: 10.1093/ofid/ofz352Pogue JM, et al. Clin Infect Dis. 2014; 59:416‐424.

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DATEEpic

• “BPA” Best Practice Advisory• Pop up triggered at different points of chart access

• Can be user “type” targeted

• “In‐basket” messages • Can be triggered by results

• Patient lists• Can be populated by results

• Can be populated by medication, length of medications

Moradi T, et al. Clin Infect Dis. 2019; doi: 10.1093/cid/ciz1042Pettit NN, et al. Open Forum Infect Dis. 2019; doi: 10.1093/ofid/ofz412Lloyd EC, et al. JPIDS. 2020; DOI: 10.1093/jpids/piaa058

DATEEpic: BPA

• Quasi‐experimental study in 99 SAB episodes in pediatric patients

• Intervention: implementation of a BPA for SAB, recommending ID consult (provides ordering link) and optimal therapy

• Optimal therapy delineated on mecA

• Outcomes• Primary: receipt of ID consult

• Secondary: optimal therapy, time to ID consult

Lloyd EC, et al. JPIDS. 2020; DOI: 10.1093/jpids/piaa058

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DATEEpic: BPA Results

• 151 SAB cases in 137 unique patients• 52 excluded due to ID consult being placed prior to culture positivity

• 99 cases included: 70 (70.7%) pre‐intervention & 29 (29.3%) post‐intervention

• Results:

Lloyd EC, et al. JPIDS. 2020; DOI: 10.1093/jpids/piaa058

Pre‐Intervention Post‐Intervention P‐value

ID Consult 68.6% 93.1% 0.01

Time to ID Consult 19.8 hours 2.7 hours <0.01

Optimal Therapy 88.6% 96.6% 0.28

Time to Optimal Therapy 26.1 hours 5.5 hours 0.04

DATEUAMS Epic BPA

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DATESummary

• Decide what RDT will make meaningful impact at your institution, and be able to compromise to the best test to fit the most needs

• Keep communication open between ASP and Microbiology lab

• Use your key stake holders to champion your RDT business case• Support the case with guideline support and regulatory requirements

• Look at your abilities to limit testing to appropriate patient populations, and empower the microbiology lab to cancel inappropriate tests

• Make the computers work for you and take advantage of EHR functionality to streamline intervention workflow

a fantastic point of view: sharing new ams possibilities

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