Ron E. Polk, Pharm.D., FIDSA, FSHEA

Virginia Commonwealth University

Richmond, Virginia, USA

Background EU-US Summit Declaration from 3 November 2009

called for a “transatlantic taskforce on urgent antimicrobial resistance issues…”

TATFAR report from 22 September 2012 included 17 recommendations in 3 key areas.

Recommendation # 2: Convene a joint US/EU working group to propose standards for measuring antimicrobial use in hospital settings.

TATFAR WG: Participants & PresentationsECDC, 18/19 June, 2013

Surveillance of US hospital antimicrobial consumption CDC’s NHSN: Scott Fridkin Risk adjustment strategies: Ron Polk Pediatric considerations: Jason Newland, Kevin Garey

Surveillance of EU hospital antimicrobial consumption ESAC project: Hermann Goossens ECDC surveillance: Klaus Weist, Arno Muller Review of DDDs: Hege Salvesen Blix Pediatric measurements by DDD: Mike Sharland German stewardship module: Katja de With The French Stewardship Experience: Catherine

Dumartin,

Methods for Collection of Antimicrobial Consumption Data Klaus Weist, Arno Muller (contractor to ECDC). Surveillance Section, Surveillance and Response Support Unit, Antimicrobial Resistance & Healthcare-Associated Infections (ARHAI) Programme, ECDC

“Invited experts will convene with acknowledged expertise in data collection of antimicrobial consumption in hospitals, expertise in corresponding methods and risk adjustment, and hospital stewardship, respectively.

“They should identify the steps needed to synchronisemethodology or produce comparable data and propose standards for measuring antimicrobial use in hospital settings”.

The Goals and ChallengesHow to compare EU/U.S. antimicrobial

consumption data in hospitals?

Methodologies for collection of antimicrobial consumption data

Units of measurement for antimicrobial consumption

Denominators applied for the hospital sector

Implementation of indicators for antimicrobial consumption

Klaus Weist, MD

Why Measure Hospital Antimicrobial Use?

National Healthcare Safety Network (S. Fridkin)

Which antimicrobials are being used

How much are being used

What is variability in among hospitals [Causes of Variability (eg, case mix, “inappropriate use”, etc)]

[Can “benchmarking” improve use]

What are the trends in usage over time

How does U.S. compare to other countries [Is there an common and valid metric?]

NHSN Antimicrobial Use Option Objective: Measure antimicrobial usage to provide

risk-adjusted inter- and intra-facility comparisons

Antimicrobial Metric: Antimicrobial days (DOT)/ Days present by month, patient care location.

Locations: Facility-wide npatient patient care locations & emergency department

Data Source: eMAR / BCMA

Implementation: Partner with vendors to electronically capture numerator and denominator for importation into NHSN

Fridkin S, Srinivasan A. Clinical Infectious Diseases 2014;58(3):401–6

NHSN/AU Update(Scott Fridkin, 7 Feb 2015)

Launched January 2014

Currently about 60 hospitals are reporting required data

Risk adjustment remains challenging Likely adjusted by patient location

Likely Standardized utilization ratio (observed : expected)

CDC is working with partners to identify reasonable performance measures Goal is for some federal required reporting by 2018

Metrics may be mutually exclusive groups (draft) Broad spectrum anti-gram negative

Commonly used agents for surgical prophylaxis

Anti-MRSA agents

Adult Antibacterial and Antifungal Use (2013) in US Academic Medical Center Hospitals (UHC)

Ibrahim & Polk. Infect Dis Clin N America 28 (2014) 195-214

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amphotericin b (fungizone) amphotericin b lipid complex (abelcet) amphotericin b liposome (ambisome)

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Risk Adjustment (by Indirect Standardization) of Adult Antibacterial Drug Use using MS DRG

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Ibrahim O, Polk RE. Expert Review of Anti-Infective Therapy. 2012; 10: 445-457

Summary of US Surveillance Measuring hospital antimicrobial consumption is

becoming possible in many/most US hospitals. Purchase data is least reliable Billing data (what the patient is charged for) Dispensing data is better yet; validation needed Administration data (e.g., BCMA, eMAR) is best, but not yet

well adapted to routine surveillance NHSN is linking proprietary pharmacy information systems

(eg, Theradoc™, Epic™) to resistance, but obstacles remain. DOT/1000PDs is current standard for US consumption, but

additional measures need evaluation (e.g., LOT ) Intensity of stewardship activities related to consumption*

* Pakyz et al. JAC, 21 Jan, 2015, Advance Access

EU Surveillance: H Goossens ESAC: European Surveillance of Antimicrobial

Consumption; Transferred to ECDC in 2011 (ESAC-Net). ESAC Longitudinal Survey (ESAC-LS):

Collect standardised pharmacy data , one hospital /country (N=18 hospitals). Apply a practical surveillance method:

To other hospitals in each country; to other countries Trends within hospitals, comparison between hospitals or

countries by appropriate stats analysis (i.e., TSA) Adjustment for clinical activity Assess metrics (DDD/occupied bed days vs. admissions)

ESAC Point Prevalence Surveys (ESAC-PPS) ARPEC: Antibiotic Resistance and Prescribing in

European Children

ESAC-Point Prevalence Survey Results

German training module to implement ABS (Katja de With, MD) DART (2008-13) included special training on hospital

ABS & infection control.

Clinical pharmacology, microbiology & infectious diseases, reading clinical trials, case study, therapy, pharmacoeconomics, epidemiology, AMS strategies, surveillance

Goal: produce ~350 experts by 2013

(and intensify ID physician training. )

Hospital Antimicrobial Consumption: French experience with

ATB-RAISIN (Catherine Dumartin)

Objectives

Describe France antibiotic consumption/trends

To provide a tool for benchmarking

To identify areas for improvement

Pharmacy dispensing to inpatients; DDD/PDs

1262 hospitals in 2011 (60% of all PDs in France)

ABT-Raisin: Results

The Goals and Challenges (K. Weist)Comparison of EU/U.S. Antimicrobial Use? Methodologies for collection

Purchase, dispensing, billing, eMAR, BCAD, other?

Units of measurement DDD vs. DOT vs LOT & others yet to be identified

Denominators applied for the hospital sector Patient (bed) days vs. admissions/discharges vs ?

Implementation of indicators for antimicrobial consumption How to control for between-hospital differences ?]

[ASP activities and desired outcomes?] [How can ASPs best use these data? Most effective interventions ?

Role of technology in guiding therapy? ] [Outcomes: Cost savings, fewer adverse effects, lower rates of

resistance and CDI, improved clinical response, reduced LOS and readmissions]

[What is the role of benchmarking? Best methods to risk-adjust?] [How to develop multicenter investigations and comparable data?]

So where are we?? Is it possible to “harmonize” hospital

measurement of antibiotic consumption between EU and US?

What exactly is the goal of doing so?

How important is it to link hospital antibacterial drug use with outpatient use and non-human use? Are their common and meaningful measures?

Many possible outcomes of AS interventions. Which ones are feasible and most important?

“Don’t let the perfect be the enemy of the good.”?

19

#1) Do Less; Get More

• Measuring, severity-adjusting, and reporting institutional antibiotic use

• Reward lower institutional users with a financial bonus

• Penalize higher institutional users with a financial penalty