Evidence Based Guidelines at PHD related to Infectious

DiseaseEdward L. Goodman, MD

Outline

• Standing Orders for Vaccinations– The problem

– Evidence for guidelines

– Federal Guidelines

• Comprehensive Antimicrobial Management Program– Evidence in the literature

– Components of Program

– Outcomes to date

Standing Orders for Influenza and Pneumonia Vaccine

• Background

• Interventions in the literature

• Federal support

• Implementation

Background: http://www.cms.hhs.govhealthyaging/2a.asp

• Influenza and pneumonia represent 5th leading cause of death in elderly– 20,000 to 40,000 influenza related deaths

annually– 90% occur in those >65 years old– Influenza vaccine effective

• Reduces hospitalizations by 27-57%

• Reduces deaths by 27-30%

Underutilization

• Influenza/pneumococcal vaccines are underutilized for persons >65– Overall, 66%/35%– Nursing Homes 68%/38%

• National Center for Health Statistics. Early release of selected estimates from the 2002 National Health Interview Surveys. http://www.cdc.gov/NCHS/about/major/nhis/released200209.

Cost effectiveness of Influenza vaccination. Leavenworth, G. The costly toll of vaccine-

preventable disease. Business and Health 1995;(13)(3)16

• Minnesota health plan, three flu seasons

• Vaccinated 45-58% of those >64 years

• Lower hospitalization rates for flu, pneumonia, CHF

• Average savings of $117 per vaccinated member

Standing Orders Improve Rates• Task Force on Community Preventive Services. Recommendations

regarding interventions to improve vaccination coverage in children,adolescents, and adults. Am J Prev Med 2000;18:92—140

• . Health Care Financing Administration. Evidence report andevidence-based recommendations: interventions that increase the utilizationof Medicare-funded preventive service for persons age 65 and older.Baltimore, Maryland: U.S. Department of Health and Human Services, HealthCare Financing Administration, October 1999; HCFA publication no.HCFA-02151.

• Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-basedstrategies for improving influenza vaccination rates. J Fam Prac 1994;38:258--61.

• Stevenson KB, McMahon JW, Harris J, Hilman JR, Helgerson SD.Increasing pneumococcal vaccination rates among residents of long-term-carefacilities: provider-based improvement strategies implemented by peer-revieworganizations in four western states. Infect Control Hosp Epidemiol2000;21:705--10.

Government Regulations to Promote Standing Orders

• Centers for Medicare and Medicaid Services. Medicare and Medicaidprograms: conditions of participation: immunization standards for hospitals,long-term care facilities, and home health agencies. Washington, DC: U.S.Department of Health and Human Services, Centers for Medicare and MedicaidServices, 2002. Available athttp://www.cms.gov/providerupdate/regs/cms3160fc.pdf<http://www.cms.gov/providerupdate/regs/cms3160fc.pdf> .

Centers for Medicare and Medicaid Services, Center for Medicaid andState Operations. Program memorandum: change in requirement for signedphysician's order for influenza and pneumonia vaccine. Washington, DC: U.S.Department of Health and Human Services, Centers for Medicare and MedicaidServices, 2002; publication no. S&C-03-02.

Comprehensive Antimicrobial Management Program

Rationale

• Antibiotic use (appropriate or not) leads to microbial resistance

• Resistance results in increased morbidity, mortality, and cost of healthcare

• Appropriate antimicrobial stewardship will prevent or slow the emergence of resistance among organisms (Clinical Infectious Diseases 1997; 25:584-99.)

• Antibiotics are used as “drugs of fear” (Kunin et al.Annals 1973;79:555)

Antibiotic Misuse

• Surveys reveal that:– 25 - 33% of hospitalized patients receive

antibiotics (Arch Intern Med 1997;157:1689-1694)

– 22 - 65% of antibiotic use in hospitalized patients is inappropriate (Infection Control 1985;6:226-230)

Changes in Resistance Rates at a University Hospital

• A university hospital had an increase in multidrug-resistant K. pneum.

• Physicians were educated about the association between ceftazidime use and MDR K. pneum.

• Education occurred through grand rounds, attending rounds and consultations by ID physicians and clinical pharmacists.

Infect Control Hosp Epidemiol. 2000;21: 455-458.

Changes in Resistance Rates at a University Hospital

Parameter Pre- Intervention Post- Intervention Ceftaz ( gms)4,3011,248Pip/ taz ( gms)12,455 17,464 Imipen ( gms)14060Abx tot cost $68,027 $59,166 K. pneumo Resistance Ceftaz Pip/ taz22%36%15%19% Infect Control Hosp Epidemiol. 2000;21: 455-458.

Resistance Changes in a Community Hospital

• Increase resistance among GNR with C-I beta-lactamases, staph and enterococcus

• An antimicrobial task force was formed (ID physicians, pharmacists, microbiologists, and infection-control.)

• Consultations were triggered by 3rd generation cephalosporins, carbapenems, and vancomycin.

• Extended spectrum penicillins/beta-lactamase inhibitor and aminogycosides were encouraged.

• Costs were reduced by $650,000/year. Pharmacotherapy 1999;19(8 pt 2):129S-132S

Resistance Changes in a Community Hospital

Selected Bacteria

% of Resistance 1994 1998

VRE E. cloacae*

16 61

6 28

E. aerogenes* Acinetobacter sp*

63 17

11 0

S. marcescens* MRSA

20 34

0 23

Pseudomonas sp* 13 17 *resistance to pip/tazo Pharmacotherapy 1999;19(8 pt 2):129S-132S

Changes in Resistance at an Urban Teaching Hospital

• Epidemic in the surgical ICU of bacteremia due to Acinetobacter sensitive only to imipenem

• Prior-authorization from ID faculty for selected antibiotics (amikacin, aztreonam, ceftaz, cipro, imipenem, ticar/clav) was required.

• Acquisition cost for antimicrobial drugs were reduced by $863,100/year.

• Survival rates, LOS, and length of ICU stay were not impacted.

Clinical Infectious Diseases 1997;25:230-9.

Changes in Resistance at an Urban Teaching Hospital

Organism Tic/ clav Pre Post Imipen Pre Post Ceftaz Pre Post Ceftriax Pre Post P. aerug Inpt Outpt ICU 1721111317355172434812697488283136K. pneum Inpt Outpt ICU 201676162123Clinical Infectious Diseases 1997;25:230-9.

Components of PHD Program

• Intravenous (IV) to oral conversion for well absorbed (highly bioavailable) antimicrobials

• Discontinuation of preoperative antibiotic prophylaxis at 24h

• Restricted antibiotic therapy

Components of the Program 1• IV to Oral Conversion for Highly Bioavailable

Antimicrobials– Patient Criteria

• Able to take oral medications and diet• No persistent nausea, vomiting, or diarrhea• No medical condition that could decrease drug absorption

– IV to oral conversions became automatic on July 1, 2001

• Pharmacists consult with nurse about how well the patient is eating and taking medications

Components of the Program 2

• Discontinuation of Preoperative Surgical Prophylaxis at 24 Hours– Strong support in the medical literature

– Undergoing a “clean” procedure• Open heart• Artificial joint insertion• Many others

Components of the Program 3a

• Restricted Antimicrobial Therapy– Antimicrobial Criteria

• High risk• High cost• High potential to select resistance• Drugs of “last resort”

Components of the Program 3b

• Restricted Antimicrobial Therapy– Antimicrobials restricted to ID physicians

• Quinupristin/Dalfopristin (Synercid®)

• New Antifungal Agents

– Antimicrobials restricted after 48 hours – require Infectious Disease consult to continue

• Vancomycin

• Imipenem/Meropenem

• Cefepime

• Ceftazidime

• Linezolid

Results of CAMP

• April 2001 inception and partial implementation

• July 1, 2001 full implementation

Antimicrobial Program Interventions(April 3, 2001 - December 31, 2002)

IV to PO Conversion Surgical Prophylaxis Restricted Antimicrobials Total Interventions 2914483251064Accepted 264(91%)261(58%)286(88%)811(76%)Rejected 2718739253

Table 1

Team Activities To Date Including 2003

• 30 - 60 antimicrobial orders screened daily

• > 1400 antibiotic recommendations have been made since April 1, 2001

• Recommendations are communicated through notes on charts and phone calls

• Overall acceptance rate is 79%

Surgical Prophylaxis Antibiotic Doses / Day

p=.010p=.003

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Doses/Census Day

2000

20012002

IV vs. OralTotal Antibiotic Cost / Day

$0

$2

$4

$6

$8

$10

$12

$14

IV Abx

Cost/Census Day

PO Abx

Cost/Census Day

200020012002

Restricted Antibiotics Doses / Day

p=.007p=.016

0

0.020.040.060.08

0.10.120.140.160.18

0.2

Doses/Census Day

200020012002

Vancomycin

0.0780.08

0.0820.0840.0860.0880.09

0.0920.0940.0960.098

0.1

Doses/Census Day

2000

20012002

IV and PO Fluoroquinolones

00.01

0.02

0.030.04

0.05

0.060.07

0.08

0.090.1

IV Dose/Census Day Oral Doses/Census Day

1999200020012002

Total Antibiotic Doses / Day

p=.001p=.000

0

0.5

1

1.5

2

2.5

Doses/Census Day

200020012002

Facility Census Days

155000

160000

165000

170000

175000

180000

2000

20012002

Annual Antibiotic Expenditure

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

2000

20012002

Total Antibiotic Cost / Census Day

$0

$2

$4

$6

$8

$10

$12

$14

Cost/Census Day

Cost Savings for 2001 = $399,238Cost Savings for 2002 = $659,812Total Cost Savings = $1,059,050

2000

20012002

Changes in Bug/Drug Susceptibility Patterns

0%

5%

10%

15%

20%

25%

30%

1999 2000 2001 2002% Bug/Drug combinations having > or = 5% increase in resistance%Bug/Drug combinations having > or = 5% decrease in resistance