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 Annual excess direct healthcare cost: $20 billion Addi#onal annual costs of lost produc#vity: >$35 billion CDC. An*bio*c resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/
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? Represents unnecessary risks to pa*ents of adverse drug events, Clostridium difficile infec*ons and development of an*bio*c resistance Fleming-Dutra et al. JAMA 2016;315(17): 1864-1873.
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 annually 2 § 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*on 3 § >70% of pediatric C. difficile infec*ons are community-associated 4 § 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 pneumonia 1 § 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 disease 4 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 only 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 § Commitment: demonstrate dedica*on to and accountability for op*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 hNps://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpa*ent-stewardship.html
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 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.
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