The Path of Least Resistance: A Primer on Outpatient

The Path of Least Resistance:

A Primer on Outpatient

Antimicrobial StewardshipJason Alegro, Pharm.D., BCPS, Infectious Diseases Clinical Specialist, Mount Sinai Hospital

Tanya Abi-Mansour, Pharm.D., Infectious Diseases/Stewardship Clinical Specialist, IU Health

▶Dr. Alegro and Dr. Abi-Mansour declare no conflicts of

interest, real or apparent, and no financial interests in

any company, product, or service mentioned in this

program, including grants, employment, gifts, stock

holdings and honoraria.

Disclosures and Conflict of Interest

At the conclusion of the program, the pharmacists will be

able to:

1. Describe current issues in antibiotic resistance and the

consequences of inappropriate outpatient antibiotic

prescribing.

2. Discuss the 2017 Joint Commission Standard of Antibiotic

Stewardship as well as the Centers for Disease Control

(CDC) Core Elements of Outpatient Antibiotic

Stewardship.

3. Identify evidence-based interventions that can be

implemented in the outpatient setting in order to promote

appropriate antibiotic prescribing.

Pharmacist Objectives

At the conclusion of this program, the pharmacy technicians

will be able to:

1. Define outpatient antibiotic stewardship.

2. List consequences of inappropriate antibiotic prescribing.

3. Describe the role of the pharmacist in antibiotic

stewardship.

Technician Objectives

1. Which of the following best describes antimicrobial

stewardship?

a. Choosing the least expensive antibiotic for a patient

b. Choosing the most appropriate antibiotic for a patient

c. Choosing the most broad-spectrum antibiotic for a patient

d. Choosing the antibiotic which a patient most prefers

Pre-Test Questions

2. Which of the following is a benefit of antimicrobial

stewardship?

a. Decrease in superinfections due to Clostridium difficile

b. Development of antimicrobial resistance

c. Increased antimicrobial costs

d. Increased use of intravenous antibiotics

Pre-Test Questions

3. Which of the following is NOT a CDC core element of

antibiotic stewardship?

a. Action for policy and practice

b. Tracking and reporting

c. Education and expertise

d. Prescriber disciplinary action

Pre-Test Questions

4. Which of the following is an intervention that can improve

utilization of antibiotics in the outpatient setting?

a. Utilize watch and wait practices when appropriate

b. Reprimand patients when they ask for antibiotics

c. Always advocate for empiric antibiotic use

d. Provide education to prescribers only, not patients

Pre-Test Questions

A Day in the Life of an Antibiotic

Steward

A few questions for you!

https://i.ytimg.com/vi/-XLPptxdlic/maxresdefault.jpg

Antimicrobial Resistance:

What’s the Big Deal?

Antibiotics: A Patient Safety Issue

▶ More than 2,000,000 Americans develop infection resistant to one or

more antibiotics

▶ At least 23,000 people die each year as a direct result

▶ Clostridium difficile has become the most common cause of health

care-associated infection

▶ Causes 500,000 infections annually

▶ Excess health care costs ~$4.8 billion for acute care facilities alone

Antibiotic Resistance Threats in the United States, 2013. CDC. Published online September 16, 2013.

13

How well do we use antibiotics?

Of the estimated 154 million outpatient

prescriptions for antibiotics, 30% are unnecessary

Antibiotic Use in the United States, 2017: Progress and Opportunities, 2017. CDC

14

Development of Resistance

Antibiotic IntroducedResistance

IdentifiedOrganism

Penicillin 1943 1940 Staphylococcus

Tetracycline 1950 1959 Shigella

Methicillin 1960 1962 Staphylococcus

Gentamicin 1967 1979 Enterococcus

Vancomycin 1972 1988 Enterococcus

Levofloxacin 1996 1996 Pneumococcus

Linezolid 2000 2001 Staphylococcus

Ceftaroline 2010 2011 Staphylococcus

About antimicrobial resistance, 2018. CDC. 15

National Resistance ThreatsUrgent Threats

• Clostridium difficile • Carbapenem-resistant Enterobacteriaceae (CRE) • Drug-resistant N. gonorrhoeae

Serious Threats • MDR Acinetobacter • MDR Pseudomonas aeruginosa • Extended-spectrum β-lactamases in

Enterobacteriaceae (ESBLs) • Vancomycin-resistant Enterococcus (VRE) • Methicillin-resistant S. aureus (MRSA)

Concerning Threats • Vancomycin-resistant S. aureus (VRSA)

Antibiotic Resistance Threats in the United States, 2013. CDC. Published online September 16, 2013.

16

Oneill, J. Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. Review on Antimicrobial Resistance. 2014.

Oneill, J. Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. Review on Antimicrobial Resistance. 2014.

What is Antibiotic Stewardship?

http://2.bp.blogspot.com/-skCPGjig6Nw/UrRT5z4B8mI/AAAAAAAAApk/zHuX1yMUiGM/s1600/education--Quotes-Albert-Einstein.jpg

What is Antimicrobial Stewardship?

Antimicrobial Stewardship

Right Diagnosis

Right Drug

Right Dose

Right Duration

De-esclation

Clin Infect Dis. 2016 May 15; 62(10) e51-77.

The selection of the optimal antimicrobial drug regimen, including dose, route,

and duration of therapy

20

The Right Diagnosis

Does this patient have bacterial pneumonia, the flu, or an acute viral illness?

Does the patient meet the appropriate criteria for antibiotic treatment for a COPD exacerbation?

Does the child meet appropriate criteria for receiving antibiotics for acute otitis media?


The Right Drug

Is a fluoroquinolone appropriate for a patient based on their indication?

Does the patient require coverage for drug-resistant organisms (i.e. Methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa

Does the patient have a true penicillin allergy where a beta-lactam would be inappropriate?


The Right Dose

Is the antibiotic dose appropriate for the patient’s renal function?

Is the dose appropriate for the patient’s weight?

Is the antibiotic dose appropriate if the patient is on interacting medications?


▶Guideline-recommended duration of therapies for

commonly treated outpatient infections▶ Community-acquired pneumonia: 5 days

▶ Skin and soft tissue Infections: 5-7 days

▶ Urinary Tract Infections:▶ Uncomplicated Cystitis: 1-7 days

▶ Pyelonephritis: 7-14 days

▶ Acute Otitis Media: 10 days

▶ Sinusitis: 5-7 days

The Right Duration


Clin Infect Dis. 2007; 44: S27-72.

Clin Infect Dis. 2014; 59(2):e10-52.

Clin Infect Dis. 2011; 52(5):e103–e120

Clin Infect Dis. 2012; 54(8):e72–112

Pediatrics. 2013; 131(3): e964-999.

Clin Infect Dis. 2012; 55(10):e86–102

▶ De-escalation is the process of simplifying an antibiotic regimen to

ensure the spectrum activity only covers for organisms infecting the

patient, with minimal additional coverage

▶ This intervention can be comfortably performed when more data of

the patient’s infectious process is revealed (i.e organism

identification, organism susceptibility, symptomatic improvement,

etc)

The Right De-escalation


▶ In 2015, 269.4 million antibiotics were prescribed in the U.S.

▶ Per 1,000 people▶ 838 prescriptions

▶ Women > men

▶ Above 20 years old > below 20 years old

▶ Most antibiotics per provider▶ Mid-level providers

▶ Dermatologists

▶ Primary care physicians

▶ Emergency medicine physicians

Why is Outpatient Antibiotic

Stewardship So Important?

Clin Infect Dis, 2015. 60(9): p.1308-16.

Why is Outpatient Antibiotic

Stewardship So Important?

Outpatient Antibiotic Prescriptions – United States, 2015. Atlanta (GA). Centers for Disease Control and Prevention; 2015. https://www.cdc.gov/antibiotic-

use/community/programs-measurement/state-local-activities/outpatient-antibiotic-prescriptions-US-2015.html. Accessed April 14, 2018.

Outpatient antibiotics prescribed based on drug class

Outpatient Antibiotic Prescriptions – United States, 2015. Atlanta (GA). Centers for Disease Control and Prevention; 2015. https://www.cdc.gov/antibiotic-

use/community/programs-measurement/state-local-activities/outpatient-antibiotic-prescriptions-US-2015.html. Accessed April 14, 2018.

Interactive Antibiotic Prescriptions

Dispensed Map in the United States

Antibiotic Prescriptions Dispensed in U.S. Community Pharmacies Per 1000 Population. Atlanta (GA). Centers for Disease Control and Prevention; 2015.

https://gis.cdc.gov/grasp/PSA/AUMapView.html

▶ A 2016 JAMA study sampled 184,032 U.S. ambulatory clinic visits in

2010-2011 to describe inappropriate outpatient antibiotic prescribing

▶ 12.6% were associated with antibiotic prescriptions

▶ Children 0-2 years old demonstrated highest prescription rates at

1,287 per 1,000 children

▶ Top 3 diagnoses included sinusitis, suppurative otitis media, and

pharyngitis

▶ Authors adjudicated appropriateness of antibiotic prescribing based

on national guidelines

Why is Outpatient Antibiotic Stewardship

So Important?

JAMA. 2016;315(17):1864-1873.

Why is Outpatient Antibiotic Stewardship

So Important?

JAMA. 2016;315(17):1864-1873.

Diagnosis/Group Weighted Mean

Annual of Antibiotic

Rx (95% CI)

Estimated Appropriate

Annual Rate of Abx Rx

Potential Reduction in

Annual Abx Rx Rates,

%

Pharyngitis (0-19 y) 91 (76, 105) 60 -34

Sinusitis (20-64 y) 55 (45, 64) 27 -51

All acute respiratory

conditions (all ages)

211 (198, 245) 111 -50

All conditions/age

groups

506 (458, 554) 353 -30

National Initiatives:

The Joint Commission Stewardship Standard &

The CDC Core Elements of Outpatient Antibiotic

Stewardship

The Joint Commission Standard on

Antimicrobial Stewardship (2017)

▶ Mandated in 2017 for all hospitals, critical access hospitals, and nursing care centers

▶ Requires all institutions to establish an antimicrobial stewardship program with the

following elements of performance in order to comply with accreditation standards:

1. Leaders establish antimicrobial stewardship as an organizational priority

2. Educate staff and practitioners involved in antimicrobial ordering, dispensing,

administration, monitoring

3. Educate patients and their families regarding the appropriate use of

antimicrobial medications

4. Team members consist of ID physician, infection preventionists,

pharmacist(s), other practitioners

5. The program includes CDC Core elements of hospital antibiotic stewardship

programs

6. The program uses organization-approved multidisciplinary protocols in order

to improve antibiotic prescribing and use

a. Ex: formulary restriction, system-wide empiric guidelines, parenteral

to oral antibiotic conversion, etc.

The Joint Commission. New Antimicrobial Stewardship Standard. Oakbrook, IL. Joint Commission Perspectives, 2016.

The CDC Core Elements of Outpatient

Antibiotic Stewardship

▶ Published in 2016 by the Centers for Disease Control and Prevention (CDC)

▶ Outlines the appropriate audiences for outpatient stewardship, initial

steps for implementation of stewardship activities, and potential

collaborative opportunities when starting an outpatient stewardship

program

▶ Defines the four core elements to ensure a successful outpatient

stewardship program: ▶ Commitment

▶ Action for Policy and Practice

▶ Tracking and Reporting

▶ Education and Expertise

MMWR Recomm Rep 2016;65(No. RR-6):1–12.

From Policies to Pragmatism:

Implementation Strategies for

Outpatient Stewardship

Is Outpatient Stewardship Right for My

Institution?

▶ The following groups are identified by the CDC as the

intended audience for Outpatient Stewardship ▶ Primary care clinics and clinicians

▶ Emergency departments and emergency medicine clinicians

▶ Dental clinics and dentists

▶ Retail health clinics and clinicians

▶ Outpatient specialty and subspecialty clinics and clinicians

▶ Urgent care clinics and clinicians

▶ Nurse practitioners and physician assistants

▶ Health care systems


How to start the process of antimicrobial

stewardship at my area of practice


1

2

3

The CDC Core Elements of

Outpatient Antibiotic

Stewardship

MMWR Recomm Rep. 2016;65(No. RR-6):1–12.

▶ Write and display public commitments in support of antibiotic

stewardship

▶ Identify a single leader to direct antibiotic stewardship activities

within a facility

▶ Include antibiotic stewardship-related duties in position descriptions

or job evaluation criteria

▶ Communicate with all clinic staff members to set patient

expectations

Commitment


“Demonstrate dedication to and accountability for optimizing

antibiotic prescribing and patient safety.”

▶ Implement at least one policy or practice to improve antibiotic

prescribing, assess whether it is working, and modify as needed

▶ Use delayed prescribing practices or watchful waiting, when

appropriate

▶ Require explicit written justification in the medical record for non-

recommended antibiotic prescribing

▶ Provide support for clinical decisions

▶ Use call centers, nurse hotlines, or pharmacist consultations as triage

systems to prevent unnecessary visits

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.

▶ Self-evaluate antibiotic prescribing practice

▶ Participate in continuing medical education and quality improvement

activities to track and improve antibiotic prescribing

▶ Implement at least one antibiotic prescribing tracking and reporting

system

▶ Assess and share performance on quality measures and established

reduction goals addressing appropriate antibiotic prescribing from

health care plans and payers

Tracking and Reporting


Monitor antibiotic prescribing practices and offer regular feedback to

clinicians, or have clinicians assess their own antibiotic prescribing

practices themselves

▶ Use effective communications strategies to educate patients about

when antibiotics are and are not needed

▶ Educate patients about the potential harms of antibiotic treatment

▶ Provide patient education materials

▶ Provide continuing education activities for clinicians

▶ Ensure timely access to persons with expertise

Education and Expertise


Provide educational resources to clinicians and patients on antibiotic

prescribing, and ensure access to needed expertise on optimizing

antibiotic prescribing

Illinois Department of Public Health:

Precious Drugs and Scary Bugs Campaign

Precious Drugs & Scary Bugs. Illinois Department of Public Health. <http://www.dph.illinois.gov/topics-services/prevention-wellness/patient-safety-quality/precious-drugs-scary-bugs>

▶ Targets healthcare providers in outpatient settings to promote appropriate

use of antibiotics, increase healthcare provider and patient knowledge

regarding appropriate antibiotic use, and provide resources to support

clinicians in improving antibiotic prescribing

▶ Focus on acute respiratory infections

▶ Current participating providers (as of 2015) include:▶ A to Z Pediatrics

▶ Amita Health Medical Group

▶ Community Health Improvement Center

▶ Heartland Health Outreach

▶ OSF Medical Group

▶ Southern Illinois University School of Medicine

▶ Can get involved by completing a Facility Interest Form and a Provider

Commitment Form

Illinois Department of Public Health:

Precious Drugs and Scary Bugs Campaign

Precious Drugs & Scary Bugs. Illinois Department of Public Health. <http://www.dph.illinois.gov/topics-services/prevention-wellness/patient-safety-quality/precious-drugs-scary-bugs>\

▶ Targets healthcare providers in outpatient settings to promote

appropriate use of antibiotics

▶ Increase healthcare provider and patient knowledge regarding

appropriate antibiotic use

▶ Provide resources to support clinicians in improving antibiotic

prescribing

▶ Focus on acute respiratory infections

IDPH Precious Drugs and Scary Bugs

Campaign Initiatives


▶ Current participating providers (as of 2015) include:▶ A to Z Pediatrics

▶ Amita Health Medical Group

▶ Community Health Improvement Center

▶ Heartland Health Outreach

▶ OSF Medical Group

▶ Southern Illinois University School of Medicine

▶ Can get involved by completing a Facility Interest Form and a

Provider Commitment Form

IDPH Precious Drugs and Scary Bugs

Campaign Participants


Vaccine

Percent of children aged

19-35 months receiving

vaccinations in 2016

Diphtheria, Tetanus, Pertussis 84.6%

Polio 93.7%

Measles, Mumps, Rubella (MMR) 91.9%

Haemophilus influenzae tybe b 82.7%

Chickenpox (Varicella) 91.8%

Pneumococcal conjugate vaccine (PCV) 84.1%

Combined 7-vaccine series 72.2%

Improving Immunization Rates

Immunizations. CDC. Retrieved from: https://www.cdc.gov/nchs/fastats/immunize.htm

Apply your knowledge!


stewardship?





Post-Test Questions


stewardship?





Think as simple as possible, but not simpler! Must take into

account efficacy, safety, costs, and the most narrow agent

that will get the job done.

Post-Test Questions


stewardship?





Post-Test Questions


stewardship?





The primary risk factor for Clostridium difficile infection is

antibiotic use. If unnecessary antibiotic use is minimized,

normal GI flora will not be disturbed and allow the

C. difficile organism to overgrow in the intestines and

cause infection.

Post-Test Questions







Post-Test Questions







Antimicrobial stewardship is team effort and you want to

work with your interdisciplinary team, not against them!

The CDC core elements are advocated by the Joint

Commission and provide guidance for institutions to

implement successful stewardship programs.

Post-Test Questions








Post-Test Questions







Watchful waiting and delayed prescribing are important

techniques for certain infections that are self-limiting where

viral causes are highly implicated, such as acute otitis media

and acute uncomplicated sinusitis.

Post-Test Questions

▶Select a disease state

▶ Example: urinary tract infections

▶ Identify barriers

▶ Example: physicians like to prescribe fluoroquinolones due to

comfortability and familiarity

▶Educate and establish standard

▶ FDA warning on prescribing/adverse drug effects

▶ C. difficile superinfection

▶ Resistance

Application

U.S. Food and Drug Administration. 26 July 2016. Retrieved from https://www.fda.gov/Drugs/DrugSafety/ucm500143.htm

▶ Side effects: tendon, joint and muscle pain, a “pins and needles” tingling or

pricking sensation, confusion, and hallucinations

▶ “Collateral damage”

Application

FDA Warning: “We have determined that fluoroquinolones should

be reserved for use in patients who have no other treatment

options for acute bacterial sinusitis (ABS), acute bacterial

exacerbation of chronic bronchitis (ABECB), and uncomplicated

urinary tract infections (UTI) because the risk of these serious side

effects generally outweighs the benefits in these patients. For

some serious bacterial infections the benefits of fluoroquinolones

outweigh the risks, and it is appropriate for them to remain

available as a therapeutic option.”

U.S. Food and Drug Administration. 26 July 2016. Retrieved from https://www.fda.gov/Drugs/DrugSafety/ucm500143.htm

C.difficile Superinfection

Antibiotic CDI Adjusted Hazard Ratio

(95% CI)

Fluoroquinolones 4.0 (2.7, 5.9)

Aminoglycosides 0.9 (0.3, 3.0)

Clindamycin 1.9 (0.8, 4.4)

3rd/4th Generation Cephalosporins 3.1 (1.9, 5.2)

Fluoroquinolones

Stevens V et al. Clin Infect Dis. 2011;53(1):42-48.

59

Collateral Damage: Resistance

0

0.5

1

1.5

2

2.5

3

0 4 8 12 14

Co

ncen

trati

on

(µ

/mL

)

Hours

Ciprofloxacin 750mg PO MIC Breakpoint

“The Sanford Guide to Antimicrobial Therapy.” 2018: p 95. Print.

Peak: 3.6 µ/mL

PB: 20-40%

T ½: 4 h

David HW, et al. Journal of Antimicrobial Chemotherapy. 2000 (46) (5): 669-683

1. Antimicrobial stewardship is EVERYONE’s responsibility, not just

those with special training, knowledge, or job titles focused on

infectious disease

2. The 5 D’s of antimicrobial stewardship include making the right

diagnosis, choosing the right drug initially at the right dose, for the

right duration, and performing appropriate de-escalation once you

have additional clinical data

3. Core elements of outpatient antibiotic stewardship include

commitment, action for policy and practice, tracking and reporting,

and education and expertise

TAKE HOME POINTS

1. https://www.cdc.gov/antibiotic-use/community/index.html

2. https://www.cdc.gov/antibiotic-use/community/pdfs/16_268900-

A_CoreElementsOutpatient_508.pdf

3. https://www.jcrinc.com/antimicrobial-stewardship-toolkit/

4. http://www.dph.illinois.gov/sites/default/files/publications/opps-

antibiotic-stewardship-toolkit-dentists-final-121217.pdf

Resources & References

Questions??

Fleming A. Penicillin's finder assays its future. New York Times. 1945 June 26;:21.

The Path of Least Resistance:

A Primer on Outpatient

Antimicrobial StewardshipJason Alegro, Pharm.D., BCPS, Infectious Diseases Clinical Specialist, Mount Sinai Hospital

Email: [email protected]

Tanya Abi-Mansour, Pharm.D., Infectious Diseases/Stewardship Clinical Specialist, IU Health

Email: [email protected]

Documents

The Path of Least Resistance: A Primer on Outpatient