Antimicrobial Stewardship/Statewide Antibiogram · CDC Outpatient Antibiotic Stewardship Action for policy and practice • Implement at least one policy or practice to improve antibiotic

Antimicrobial Stewardship/Statewide Antibiogram

Felicia Matthews

Senior Consultant, Pharmacy Specialty

BD MedMined Services

Disclosures

• Employee of BD Corporation

– MedMined™ Services

© 2017 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company.

Agenda

• CMS and JCAHO

• CDC Outpatient AMS

• Antibiogram

• Antibiotics


JCAHO and CMS

Regulatory

JCAHO MMS 09.01.01

• Effective January 1, 2017

CMS Antimicrobial Stewardship requirement

• October 4, 2016 CMS published the final rule adding AMS to the 1986 infection control condition of participation (CoP)

• Hospitals must met CoP to receive payments

Regulatory

CMS-3295-P

• Updates have been delayed because new administration has taken office

• 3/13 Seema Verma, MPH, confirmed as Medicare and Medicaid Administrator

• 3/24 House Republicans removed bill to repeal and replace the ACA from House floor vote

• Although it’s not a controversial rule, it will be reviewed because it will cost money – up to $1 billion

• Final ruling will be November 10th

Regulatory

CMS-3295-P Infection Prevention

• Focus on prevention

• Ensuring the Infection Preventionist is actually trained in Infection Prevention

• Focus on transmission across the care continuum including patients, hospital personnel, visitors, environment and other outpatient facilities

Regulatory

CMS-3295-P Antimicrobial Stewardship

• Require hospitals to have policies and procedures for, and to demonstrate evidence of, an active and hospital-wide antibiotic stewardship program.

• Hospitals would be required to improve their internal coordination among all components responsible for antibiotic use

CDC Outpatient Antimicrobial Stewardship

RegulatoryCDC Outpatient Antibiotic Stewardship

11/20163/2014 9/2015


2009 $10.7 Billion Spent on Antibiotics in US

• 61.5% outpatient

• 33.6% inpatient

• 4.9% long-term care settings

Suda KJ, A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. JAC. 2013;68:715–8.


Intended Audiences

• Health care systems

• Urgent care clinics and clinicians

• Retail health clinics and clinicians

• Outpatient specialty and subspecialty clinics

• Primary care clinics

• Emergency departments (EDs)

• Dental clinics and dentists

• Nurse practitioners and physician assistants


Core elements

• Commitment

• Action for policy and practice

• Tracking and reporting

• Education and expertise


Commitment

• Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety by all healthcare team members


Action for policy and practice

• Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.

• Diagnosis guidelines

• Prescribing guidelines

• Written justification in chart


Tracking and reporting

• Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves.

• Chart review

• Follow-up on initiatives


Education and expertise

• Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing

• Communication strategies

• Patient education

AHQI Antibiogram


What is included?

Duplicate isolates removed

Significantly different susceptibility results are considered unique or non-duplicate

Includes data from 1/2016 to 12/2016

One isolate per organism per 365 day period

Isolates from 56 hospitals in Alabama


Community versus Hospital

• That which is collected from an outpatient or an inpatient within the first 3 days of an admission who has had no admissions within the past 14 days

Community isolate

•That which is collected from a inpatient on or after day 3 of an admission or within 14 days of discharge

Hospital isolate


0

200

400

600

800

1000

1200

1400

1600

1800

2000

2010 2011 2012 2013 2014 2015 2016

E Faecium

E Faecalis

19001767 1799

1535

1500

1327

1149

Hospital Enterococcus Isolates (Non-Urine)

31% (29%) of Enterococcus isolates are the more resistant faecium strain


E. faecium resistant to vancomycin down slightly from last year 80% (81%)

E. faecium resistance to linezolid increased to 6% (4%). Still below 2007 levels

* 95% of E. faecalisremain susceptible to vancomycin

Vancomycin Resistant E Faecium(Hospital Non-Urine)

80%

6%

0

10

20

30

40

50

60

70

80

90

Vancomycin

Linezolid


MRSA has returned to it’s lowest point in in 2013 at 57%.

The percent still remains high relative to other regions in the US

Hospital MRSA (Non-Urine)

57%

40

45

50

55

60

65

70

75

80


MRSA All HAIs | 2011-2014

http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html


MRSA Hospital versus Community (Non-Urine)

Hospital and Community saw declines in 2016. Community will include patients from nursing homes and long-term care hospitals and may not reflect “Community” in the traditional sense.

57%

53%

40

45

50

55

60

65

70

Hospital

Community


Klebsiella pneumonia Isolates Resistant to Meropenem (KPC)

Previous presentations have reported K. pneumonia strains tested against imipenem. A greater number of hospitals have been testing meropeneminstead of imipenem. We will report meropenemmoving forward.

2015 testing against imipenem showed 5549 isolates tested with 206 being resistant.

75

44

97

62

2015 (N=6267) 2016 (N=6310)

Comm Hosp

172 total

106 total


Hospital Non-Urine A. baumannii Isolates Susceptible to Meropenem

Carbapenem tested was changed to meropenemreflecting most health systems.

Multi-drug Resistant A. baumannii is associated with high mortality and is difficult to treat.

Combination therapy of carbapenem with ampicillin/sulbactam, colistinor tigecycline still may be necessary


78

92

64%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015 2016

0

10

20

30

40

50

60

70

80

90

100

Total Isolates % Susceptible

Carbapenms R or I Acinetobacter NATIONAL HAIs | 2011-2014

http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html


MDR Acinetobacter IsolateAlabama Hospitals


Hospital P. aeruginosaNon-Urine

B-Lactams

Pipercillin/Tazobactam and Cefepime are stable

Aztreonam has continued to steadily improve over the last 5 years


83%

66%

85%

50

60

70

80

90

100

Cefepime

Aztreonam

Pip/Tazo


AminoglycosidesAmikacin and Tobramycin steady at over 90%

Gentamicin continues to improve over the last 4 years


91%

91%

81%

50

55

60

65

70

75

80

85

90

95

100

Amikacin

Tobramycin

Gentamicin


Carbapenems

P. aeruginosa susceptibility to imipenem at it lowest since data collection started, 68%

Meropenem declining since 2011

Concern here as this one of our last lines of defense against resistant gram negative bacteria.


68%

73%

50

60

70

80

90

100

Imipenem

Meropenem


Quinolones

Poor activity against Pseudomonas

There is a trend towards improvement over the past 3 years and since 2006


66%

50

60

70

80

90

100

Levofloxacin

Antibiogram Summary

• Enterococcus faecium resistant to vancomycin or linezolid, hospital non-urine, remains stable (80%, 6%)

• MRSA, hospital non-urine, trend continues to decline. Geographically, still high.

• CRKP, hospital and community, declined in 2016. Monitor closely.

• A. baumannii , hospital non-urine,susceptibility improved (70% vs 64%). Still a dangerous pathogen.

• P. aeruginosa, hospital non-urine, resistance to carbapenems a concern with overall trend declining


AHQI Antibiotic Utilization


Antibiotic National Comparison

Antibiotics



Carbapenems



Piperacillin / Tazobactam



Vancomycin, Linezolid, Daptomycin, Tigecycline



Quinolones



3rd/4th Generation Cephalosporins



Proton Pump Inhibitors


Thank you!

Antimicrobial Stewardship/Statewide Antibiogram · CDC Outpatient Antibiotic Stewardship Action for policy and practice • Implement at least one policy or practice to improve antibiotic

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