Improving Outpa#ent An#bio#c Use through An#bio#c Stewardship - - PowerPoint PPT Presentation

Na#onal Center for Emerging and Zoono#c Infec#ous Diseases

Improving Outpa#ent An#bio#c Use through An#bio#c Stewardship

Katherine Fleming-Dutra, MD

Office of An*bio*c Stewardship Division of Healthcare Quality Promo*on Na*onal Center for Emerging and Zoono*c Infec*ous Diseases Centers for Disease Control and Preven*on

An#bio#c Resistance

• CDC. An*bio*c resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/

Annual excess direct healthcare cost: $20 billion Addi#onal annual costs of lost produc#vity: >$35 billion

An#bio#c Use Drives Resistance

hNp://www.cdc.gov/drugresistance/about.html

How CDC and Public Health Are Comba#ng An#bio#c Resistance

An#bio#c Expenditures in United States by Treatment SeSng: Total $10.7 billion in 2009

Suda et al. J An*microb Chemother 2013; 68: 715–718 hNps://www.gov.uk/government/uploads/system/uploads/aNachment_data/file/362374/ESPAUR_Report_2014__3_.pdf. hNps:// www.folkhalsomyndigheten.se/pagefiles/20281/Swedres-Svarm-2014-14027.pdf.

How many outpa#ent an#bio#cs are prescribed in the United States?

§ 269.4 million an#bio#c prescrip#ons were dispensed in community pharmacies in 2015 § 838 an#bio#c prescrip#ons dispensed per 1000 persons in 2015 § On average for 5 out of every 6 people in the United States to receive one an*bio*c prescrip*on in 2015.

hNps://www.cdc.gov/getsmart/community/programs-measurement/measuring-an*bio*c-prescribing.html

Outpa#ent an#bio#c prescribing rates vary markedly by state—map

hNps://www.cdc.gov/getsmart/community/programs-measurement/measuring-an*bio*c-prescribing.html

Outpa#ent an#bio#c prescribing rates vary markedly by state—chart

hNps://www.cdc.gov/getsmart/community/programs-measurement/measuring-an*bio*c-prescribing.html hNps://gis.cdc.gov/grasp/PSA/AUMapView.html

Diagnoses leading to an#bio#c prescrip#ons from doctors’ offices and emergency departments — United States, 2010–11

URI = Upper respiratory infec*on

Fleming-Dutra et al. JAMA 2016;315(17): 1864-1873.

How much an#bio#c use is unnecessary?

Fleming-Dutra et al. JAMA 2016;315(17): 1864-1873.

Represents unnecessary risks to pa*ents of adverse drug events, Clostridium difficile infec*ons and development of an*bio*c resistance

Clostridium difficile infec#ons: serious consequence of an#bio#c use

§ CDC es*mates that C. difficile causes 453,000 infec*ons and 15,000 deaths in the US annually2 § At least 20% of adult C. difficile infec*ons are community- associated, meaning the pa*ent had no overnight healthcare stay within the 12 weeks prior to infec*on3 § >70% of pediatric C. difficile infec*ons are community-associated4

§ Many of these community-associated C. difficile infec*ons are

associated with outpa*ent an*bio*c use § C. difficile infec*ons can recur, leading to even more morbidity and risk of mortality for the pa*ent. § C. difficile infec*on is a severe and poten*ally fatal consequence of an*bio*c use. § Preven*on of C. difficile infec*on is key.

• 1. CDC. An*bio*c resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/
• 2. Lessa NEJM 2015;372(9):825-34
• 3. KuNy et al. EID 2010, 16(2):197-204.
• 4. Wendt et al. Pediatrics 2014: 133(4)651-8.
• 5. Zhang, S., et al. BMC Infec9ous Diseases 2016;16(1): 447.

It’s a Maber of Pa#ent Safety Case Study: Viral Upper Respiratory Infec#ons (URIs)

§ Weighing the benefits: What is the number needed to treat?

§ An*bio*cs do not provide symptom relief for viral URIs § Over 4400 pa*ents with viral URIs need to be treated to prevent 1 case of pneumonia1

§ Weighing the risks: What is the number needed to harm?

§ An*bio*c adverse events can be severe

• Life-threatening allergic reac*ons (e.g., anaphylaxis)
• An*bio*c-associated diarrhea (e.g., C. difficile infec*on)
• 1 in 1000 an*bio*c prescrip*ons leads to an ER visit for an adverse event, or ~200,000

es*mated ER visits/year in U.S (not including C. difficile infec*ons)2,3

§ An*bio*cs may have long-term consequences: disrup*on of microbiota and microbiome has

been associated with increased risk of chronic disease4

1. Petersen et al. Bri9sh Medical Journal. 2007;335(7627): 982. 2. Shehab, et al. Clin Infect Dis. 2008 Sep 15;47(6):735-43. 3. Shehab et al. JAMA 2016:316:2115-25. 4. Vangay, et al. Cell host & microbe 2015; 17(5): 553-564.

What about an#bio#c selec#on?

§ Among 3 most common diagnoses leading to an*bio*cs —sinusi*s, acute o**s media, and pharyngi*s, 52% received first-line therapies § At least 80% should receive first- line therapy, accoun*ng for allergies and treatment failures

Hersh et al. JAMA Int Med 2016;315(17): 1864-1873. The Pew Charitable Trusts. May 2016.

Have we made any progress?

hNps://gis.cdc.gov/grasp/PSA/indexAU.html

What can we do? Answer is An#bio#c Stewardship.

§ An*bio*c stewardship is the effort to: – Measure an*bio*c prescribing – Improve an*bio*c prescribing so that an*bio*cs are

• nly prescribed and used when needed

– Minimize misdiagnoses or delayed diagnoses leading to underuse of an*bio*cs – Ensure that the right drug, dose, and dura*on are selected when an an*bio*c is needed

CDC’s Core Elements of An#bio#c Stewardship for Hospitals, Cri#cal Access Hospitals, Nursing Homes, Outpa#ent SeSngs

hNps://www.cdc.gov/getsmart/healthcare/implementa*on/core-elements.html; hNps://www.cdc.gov/longtermcare/preven*on/an*bio*c-stewardship.html hNps://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpa*ent-stewardship.html hNps://www.cdc.gov/getsmart/healthcare/implementa*on/core-elements-small-cri*cal.html

The Core Elements of Outpa#ent An#bio#c Stewardship

hNps://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpa*ent-stewardship.html

§ Commitment: demonstrate dedica*on to and accountability for

• p*mizing an*bio*c prescribing and pa*ent safety

§ Ac#on for policy and prac#ce: implement at least one policy or prac*ce to improve an*bio*c prescribing, assess whether it is working, and modify as needed § Tracking and Repor#ng: monitor an*bio*c prescribing prac*ces and offer regular feedback to clinicians or have clinicians assess their own an*bio*c use § Educa#on and Exper#se: Provide educa*onal resources to clinicians and pa*ents on an*bio*c prescribing and ensure access to needed exper*se on an*bio*c prescribing

For more informa*on, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official posi*on of the Centers for Disease Control and Preven*on.

For more informa#on, contact CDC 1-800-CDC-INFO (232-6348) TTY: 1-888-232-6348

www.cdc.gov/getsmart An#bio#cUse@cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily

represent the official posi#on of the Centers for Disease Control and Preven#on