Assessing Department-specific Antibiotic Susceptibility to Guide Selection and Improve Outcomes

Live Symposium Outcomes ReportMerck & Company Grant ID: ANN-19-3148

Activity Description: This live dinner symposium at ASM 2019 featured three faculty members who engaged the audience in interactive discussion around patient video cases on the assessment and treatment of serious infections. Expert faculty reviewed Gram-negative infections, diagnostic approaches, molecular epidemiology of antibiotic resistance and new and emerging approaches to Gram-negative organisms.

Symposium Date: June 20, 2019Location: Marriott Marquis, San Francisco, CA

Credit: 1.50 AMA PRA Category 1 Credits™ & 0.2 IACET CEUs

Sponsored by: The Academy for Continued Healthcare Learning (ACHL)Supported by: An educational grant from Merck & Company

Intended Audience: ID specialists, researchers, clinical microbiologists, hospitalists, internists, pharmacists, pulmonologists and other healthcare professionals who care for patients at risk of serious infection.

Outcomes Methodology: Activity-related changes in knowledge, competence and performance were evaluated by using a pretest, posttest, evaluation and a 30-day post-conference follow-up survey.

Overview

Faculty

Patricia (Trish) Simner, PhD, D (ABMM)Director of Medical Bacteriology and Parasitology LaboratoriesAssociate Professor of PathologyJohns Hopkins School of MedicineBaltimore, MD

Jason M. Pogue, PharmD, BCPS, BCIDPClinical Assistant Professor of MedicineWayne State University School of MedicineDetroit, MI

Pranita D. Tamma, MD, MHSDirector, Pediatric Antimicrobial Stewardship ProgramAssociate Professor of PediatricsJohns Hopkins University School of MedicineBaltimore, MD

Featuring video commentary from:James Lewis, II, PharmD, FIDSAInfectious Disease Clinical Pharmacy SupervisorCo-Director of Antibiotic StewardshipDepartment of PharmacyOregon Health & Science UniversityPortland, OR

Activity Marketing

Participation123 Clinical Learners; 70 Certificates Issued

Practicing Type66% Microbiologists, 17% Physicians, 11% Pharmacists, 4% RNs/PAs, 2% Industry

Objectivity & BalanceObjectivity and balance rated as good/excellent by 95% of learners

Learning Objectives

86% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.42/4.0

Faculty

Drs. Pogue, Simner and Tamma were highly rated 3.79/4.0

Executive Summary

Executive Summary64% of learners intend to change their practice. Among other changes, 54% plan to seek new AST methods for their institution.

This activity was highly effective, with 73% of attendees indicating participation in this activity will improve their patients’ outcomes.

There was a 283% increase in learners who identified as being “very confident” selecting and/or advising on therapy for patients with serious Gram-negative infections post-activity.

Learners demonstrated increased awareness of ceftolozane-tazobactam’s higher inhibitory activity against P. aeruginosa; yet, additional education on dosing is necessary.

Participants indicated lack of administrative support as most common barrier to implementing changes in their practice, followed by lack of experience with challenging infections and cost.

75% of learners plan to always consult their institutions local antibiograms when selecting and/or advising on empiric therapy for patients with serious infections following participation in the symposium.

Participation

66%

11%

17%

2%2%2%

Participation by Clinician Type

Microbiologist

Pharmacist

Physician

Physician Assistant

Nurse

Industry

Participants Certificates 123 70

Susceptibility Testing Access

46%46% of learners have access to susceptibility testing for

newer agents such as ceftazidime-avibactam and ceftolozane-tazobactam at their institution.

56%35%

4%2%2%1%

Participation by Specialty

Infectious Disease

Microbiology

Pathology

Pharmacy

Allergy/Immunology

Other

Learning Objectives

97% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.42.

Please rate the following objectives to indicate if you are better able to: Analysis of RespondentsRating scale:

4=Strongly Agree; 1=Strongly Disagree

Discuss the molecular epidemiology of antibiotic resistance in bacterial pathogens 3.43

Compare and contrast antibiotics currently in development for use against Gram-negative pathogens 3.38

Describe strategies to optimize antimicrobial therapy to ensure effectiveness of antibiotics and reduce resistance 3.45

N=59

Satisfaction

All aspects of the activity were highly rated at 3.52 or higher.

Overall Evaluation Analysis of Respondents

Rating scale: 4=Excellent; 1=Poor

Quality of educational content 3.65Usefulness of course handouts/educational material 3.53Time allotted for presentation of information 3.52Time allotted for question-and-answer session 3.58Facilities, technical arrangements, efficiently supported this activity 3.65

N=65

99% of learners would recommend this activity to a colleague.

Faculty Evaluation

The faculty were rated good or excellent across all areas by 97% of learners, with an average rating of 3.79.

Please rate the faculty on the criteria listed

Rating scale: 4=Excellent; 1=Poor

Ability to effectively convey the

subject matter

Ability to deliver an

objective and balanced

presentation

Ability to present

scientifically rigorous

information

Ability to adjust to the

knowledge and experience level of the audience

Jason Pogue, PharmD 3.82 3.82 3.77 3.73

Patricia Simner, MSc, PhD 3.83 3.83 3.77 3.72

Pranita Tamma, MD, MHS 3.81 3.84 3.78 3.77

N=64

Objectivity & Balance

Activity was perceived as objective, balanced and non-biased.

78%

18%

3% 1%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Excellent Good Fair Poor

Objectivity & Balance

N=64

1%

99%

Did you perceive any bias or commercialism towards any product or

drug in this activity?

Yes No

12%

49%39%

46%51%

3%

89%

11%

Very confident Somewhat confident Not at all confident0%

20%

40%

60%

80%

100%

Pre (n=67) Post (n=58) Follow-up (n=9)

Confidence Assessment

There was a 283% increase in learners who self-identified as “very confident” selecting and/or advising on therapy for patients with serious Gram-negative infections post-activity. This dramatic increase in confidence increased by

642% in the 30-day follow-up survey.

How confident are you [now] in selecting and/or advising on therapy for patients with serious Gram-negative infections?

28%

43%

29%

75%

22%

4%

67%

33%

Always Sometimes Never0%

20%

40%

60%

80%

100%

Pre (n=67) Post (n=51) Follow-up (n=9)

Clinical Assessment

75% of learners plan to always consult their institutions’ local antibiograms when selecting and/or advising on empiric therapy for patients with serious infections, which is a 48% increase from pre-activity frequency.

How often do you consult [plan to consult] your institution’s local antibiogram when selecting and/or advising on empiric therapy for patients with serious infections?

Pretest vs. Posttest Summary

Participants demonstrated improved knowledge and competence on four of four pre/posttest questions.

31%

45%

29% 29%

74% 78%

47%

82%

0%

20%

40%

60%

80%

100%

ResistanceMechanisms

TherapySelection

Dosing EmergingTherapies

Pre Post

Topic % Change*

Resistance Mechanisms 139%

Therapy Selection for P. aeruginosa 73%

Ceftolozane-Tazobactam Dosing 62%

Emerging Therapies 183%

Overview of Correct Responses

*Relative percent change between pre-assessment score and post-assessment score.

23% 25%31%

10% 11%7% 7%

74%

7% 5%

A B C D E0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=67) Post (n=57)

Knowledge Acquisition: Resistance Mechanisms

The percentage of learners correctly identifying the primary mechanism of carbapenem resistance in P. aeruginosa increased 139% after engaging in the live symposium. This increased appreciation of

resistance mechanisms may translate into improved understanding of epidemiology and its application to selection of therapy.

1. What is the primary mechanism of carbapenem resistance among Pseudomonas aeruginosa?

Resistance Mechanisms

A. Upregulation of efflux pumps

B. Carbapenemase production

C. Loss of OprD porin expression

D. AmpC ß-lactamase production

E. Extended-spectrum ß-lactamase production

16%

45%

33%

6%3%

78%

19%

56%

33%

11%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=64) Post (n=58) Follow-up (n=9)

Clinical Competency: Therapy Selection

Immediately post-activity 73% more attendees selected ceftolozane-tazobactam for this patient case compared to the pre-survey, suggesting an increased awareness of

ceftolozane-tazobactam’s higher inhibitory activity against P. aeruginosa than ceftazidime-avibactam. Slightly less follow-up survey respondents selected

ceftolozane-tazobactam, which could be attributed to their institutions’ antibiogram.

2. A 67-year-old woman, returned from Mexico where she was hospitalized for a COPD exacerbation, diagnosed with ventilator-associated pneumonia, and received 14 days of meropenem and ciprofloxacin. After returning home, hospitalized again due to worsening difficulty breathing with fever. After diagnosis of pneumonia, started on cefepime and azithromycin. Sputum cultures reveal numerous Gram-negative rods, subsequently identified as P. aeruginosa. She is not improving clinically, is intubated, and moved to ICU. Susceptibilities return for P. aeruginosa as R to cefepime, ceftazidime, piperacillin-tazobactam, meropenem, and ciprofloxacin. Unfortunately, newer agents are not routinely tested in your lab. What would you recommend for this patient?

A. Continue current therapy until additional susceptibility results are available

B. Switch to ceftolozane-tazobactam

C. Switch to ceftazidime-avibactam

D. Switch to eravacycline monotherapy

Therapy Selection for P. aeruginosa

21%

46%

29%

4%8%

37%

47%

8%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=63) Post (n=51)

Clinical Competency: Dosing

Although there was an 62% increase in learners' knowledge of ceftolozane-tazobactam dosing in HAP/VAP following the symposium,

competence with dose selection remained low, with learners continuing to select the approved dose for complicated urinary tract

infections versus HAP/VAP. This confusion between dosage warrants continued educational reinforcement and delineation between these

infection types.

3. Additional susceptibilities return for this 67-year old woman with VAP, P. aeruginosa is susceptible to ceftolozane-tazobactam and ceftazidime-avibactam. After consultation, it is determined that ceftolozane-tazobactam will be initiated. At what dose would you use?

Ceftolozane-Tazobactam Dosing

A. 750 mg every 8 hours infused over 1 hour

B. 1.5 g every 8 hours infused over 1 hour

C. 3 g every 8 hours infused over 1 hour

D. 4 g every 8 hours infused over 1 hour

38%

9%

29%24%

12%

3%

82%

3%

A B C D0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre (n=63) Post (n=59)

Knowledge Acquisition: Emerging Therapies

82% of learners' post-activity identified relebactam as the non-β-lactam, bicyclic diazabicyclooctane β-lactamase under investigation in combination with imipenem. Given the recent approval of this agent, education on its use across diverse patient populations is warranted.

4. A combination of imipenem and which of the following agents is under investigation as an approach to imipenem-resistant P. aeruginosa?*

Emerging Therapies

A. Tazobactam

B. Cefiderocol

C. Relebactam

D. Vaborbactam

*Relebactam in combination with imipenem/cilastatin was not approved at the time of the symposium.

Activity Impact

This activity was highly effective, with 73% of attendees indicating participation in this activity will improve their patients’ outcomes.

Self-reported activity impact Yes No No change

Increase competence 83% 4% 13%

Improve performance 81% 5% 14%

Improve patient outcomes 73% 10% 17%

N=57

Practice Change

64% of learners intend to change their practice. Among other changes, 54% plan to seek new AST methods for their institution. 30 days post-participation, 33% of follow-up respondents indicated they already either fully or

partially implemented these changes.

67%

22%

22%

11%

22%

36%

8%

26%

31%

18%

13%

54%

0% 10% 20% 30% 40% 50% 60% 70% 80%

This activity validated my current practice; no changes will be made

Other changes

Increase use/application of antibiograms at my local institution/clinical unit

Update clinical antimicrobial stewardship protocols, policies, and/orprocedures

Select a different therapy for patients with identified P. aeruginosa

Change the management and/or treatment of my patients with Gram-negative VAP/HAP. Please specify

Seek new AST methods for my institution

Post (n=39)

Follow-up (n=9)

Multiple responses allowed

Practice ChangesOpen-ended participant responses to changes in practice: • Review modular mechanisms involved• Optimized therapy• Will verify our practices• Update site specific reports• Use more frequently• Discuss the next step• Look at upcoming molecular• Looking at accelerate• Molecular rapid methods for AST• Rapid AST availability will improve patient outcomes

• Deescalate sooner• Emphasize de-escalation when possible• May provide urine antibiogram as well as a regular

antibiogram• Interaction among related professionals• Reflex testing• Use information to provide updated information and

knowledge to other learners• Seek panels with new drugs• Themotybic system• Use of rapid IN and ASI

Barriers to Planned Change

17%

11%

6%

8%

8%

8%

8%

14%

17%

19%

39%

0% 10% 20% 30% 40% 50% 60%

No barriers

Other

Patient compliance issues

Reimbursement/insurance issues

Lack of time to assess/counsel patients

Lack of opportunity (eg patients w/ these infections)

Lack of susceptibility testing resources

Cost of novel therapies

Lack of resources/equiptment

Lack of experience with challenging infections

Lack of administrative support

Post (n=36)

Participants indicated lack of administrative support (39%) as the most common barrier to implementing changes in their practice, followed by lack of experience with challenging infections (19%) and cost (14%). Of those who

identified barriers, 68% will attempt to address the perceived barrier(s) in order to affect change.

Multiple responses allowed

Barriers to Planned Change

13%

25%

25%

25%

50%

0% 10% 20% 30% 40% 50% 60%

None

Appointment of leadership for antimicrobial stewardship

IT infrastructure

Access to new antimicrobials

Time allotted for antimicrobial stewardship

Financial resources

Follow-up (n=8)

N=9; multiple responses allowed

In the 30-day follow-up survey, respondents were asked to define lack of administrative support in their clinical setting:

Financial resources was rated as the most common administrative support barrier to implementing changes in practice, followed by time allotted for antimicrobial stewardship, access to new antimicrobials and IT infrastructure.

Topics of Interest

11%

39%

52%

48%

37%

0% 20% 40% 60%

Other

How to implement broad-based antimicrobial-stewardship programs inhospitals/communities

Novel AST methods

Identifying local antibiogram/clinical breakpoints in multi-drug-resistantorganisms

Selecting targeted therapy for resistant Gram-negative infections

Novel AST methods and identifying local antibiogram/clinical breakpoints in multi-drug resistant organisms were rated with highest interest for future education.

N=46; multiple responses allowed

Anticipated Practice ChangesPlease list up to 2 things you will do differently as a result of participating in this activity:• As a nurse I will do more to prevent infections in the first

place, early ambulation, good oral care• Communication with other related professionals and

encourage staff attendance and training• Consider more to represent molecular mechanism of

existence• Consider resistance mechanism while antibiotic in resistant

cases• Consider the audience, more focus on control not only in

therapy• Department specific antibiogram, data for combination

therapy• Develop ED antibiogram and teach ED provider to use it• Discuss options for testing resistant mechanisms with my

staff. Discuss antibiotic stewardship plans with new break points

• Educate my colleagues on new AST methods

• Emphasis on rapid diagnosis , refer to real time data of AMR at institute

• Further consider mechanisms of resistance• I was more focused on GRAM (+) and I will try to increase

my knowledge on GRAM (-)• I'll bring this up to my Directors• Look at alternative Susc panels to automate Avycaz and

Zerbaxa, discuss ESBL confirmation driving more carbapenum use with our ID Pharm- Do we need to bring it back?

• Prioritize development of site/ location and culture- specific antibiograms

• Recommend de-escalation when possible recommend cultures

• Test isolates against newer drugs for emerging resistance More careful scrutiny of AST antibiograms

• To include the knowledge in my lectures• Update my course given to residents, examine rapid

phenotype AST in critical cultures such as blood/SBF cultures

Contact InformationRichard KeenanVP, Education DevelopmentAcademy for Continued Healthcare Learning (ACHL)

E: rkeenan@achlcme.orgP: 773-714-0705 ext. 215C: 610-742-0749