Why Should IPs be Involved with Bacteremia and Stewardship?

#1 Prevent Antimicrobial Resistance

Antimicrobial resistance - growing public health threat

• MDROs infections: • Increased risk of mortality and morbidity • Increase in associated costs

• Antimicrobial resistance strongly correlated with: • incorrect antimicrobial prescribing patterns • lack of consistent diagnostic procedures to identify the pathogens

• Solution: Active and Robust Antimicrobial Stewardship Programs (ASPs)

• improve patient outcomes: mortality, morbidity, side effects, isolation, length of stay, progression to sepsis, readmissions

• reduce the incidence of MDRO infections • Reduce the use of empiric therapy and de-escalate

• Requires team work - more stakeholders involved in ASP: in addition to IP, ID, Pharm, Micro - bedside doctors, nurses, boards of directors and diagnostic laboratory directors who are responsible for providing microbiologic services and financial resources

Resistance is Spreading Across Countries

• A real global crisis

• December 2015

• Pan-Resistant Enterobacteriaceae seen in 19 countries

• mcr-1 >> Colistin resistant • Plasmid mediated • Easily passed between

organisms (E. coli/Klebsiella)

• Pan Resistance = No drugs work

For Example: Antibiotic Resistance from NNIS – Taiwan 2015 report

• (CRAB) - Acinetobacter baumannii isolates • 64.3% resistant to carbapenem

• (CRKP) - K. pneumoniae isolates • 22.5% resistant to carbapenem (CRPA)

• Pseudomonas aeruginosa isolates • 17.4% resistant to carbapenem

• (VRE) – Vancomycin • 37.6%

• (MRSA) - Staphylococcus aureus isolates • 68.6% resistant to oxacillin

• http://www.cdc.gov.tw/

Challenges in Infection Management of Antimicrobial Resistance Spread

• Patients move within areas of the hospital but also between different hospitals and other healthcare institutions as part of a comprehensive healthcare network

• Infection management will affect patients throughout the entire network

• Additionally, recent developments in cross-border patient care have even extended current healthcare networks to different countries

• Accountability for infection management is the responsibility of all stakeholders – not just the IP

Another Area IP Can Affect Positive Outcomes: Sepsis Care

• www.cdc.gov/sepsis

Saving patients from sepsis is a race against time

• CDC calls sepsis a medical emergency; encourages prompt action

for prevention, early recognition

• “Sepsis Knows No Boundaries; It Can Happen To Anyone”

• “When sepsis occurs, it should be treated as a medical emergency,” said CDC Director Tom Frieden, M.D., M.P.H.

• “Doctors and nurses can prevent sepsis and also the devastating effects of sepsis, and patients and families can watch for sepsis and ask, ‘could this be sepsis?’”

• CDC is working to increase awareness of sepsis among the public, healthcare providers, and healthcare facilities, including the need to prevent infections that lead to sepsis and urgently treat suspected sepsis

• www.cdc.gov/sepsis

CDC on Sepsis

• Sepsis remains the leading cause of death in U.S. hospitals. Across the country, a person receives a sepsis diagnosis every 20 seconds, accounting for 1.6 million people in the U.S. per year. Some 258,000 people die from the disease. That’s one sepsis-related death every 2 minutes

• Sepsis begins outside of the hospital for nearly 80% of patients.

• CDC evaluation found 70% patients with sepsis recently used health care services or had chronic diseases requiring frequent medical care.

• More than 90% of adults and 70% of children who developed sepsis had a health condition

• Sepsis occurs most often in people 65 years or older or younger than 1 year, with weakened immune systems, or with chronic medical conditions (e.g., diabetes)

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Infection Prevention and Antimicrobial Stewardship

Antimicrobial Stewardship

Program

Members

Medical Executive

Comm.

Pharmacy and

Therapeutics Comm.

Infection Control

Prevention Comm.

ADM Support

Challenges from IP perspective

No one “owns” the Epidemiology of Bacteremia

Who in a Hospital is the “Owner”of Bacteremia Data?

“Data drives your program”

• No one routinely collects or does surveillance on bacteremia and sepsis

• IPs are overwhelmed with NHSN and only enter hospital associated MRSA bacteremias and HAIs (that may have a secondary bacteremia) into NHSN

• Lack of retrospective data for use with new molecular diagnostic decisions

Challenges from IP perspective:Surveillance

• Surveillance system for bacteremia and sepsis? • NHSN MRSA bacteremia surveillance • Primary and secondary bacteremia may be on HAI dashboards • Secondary bacteremia due to HAIs may be on HAI dashboards • Sepsis readmissions reported as a healthcare acquired condition (HAC) • Progression from sepsis to septic shock reported as a HAC

What Additionally Should be Collected: Epidemiology of Bacteremia and Sepsis Demographics, risk factors, unique positive blood cultures, bacteremia

types, locations, organisms, antibiotic therapy, length of stay, mortality rate due to bacteremia/sepsis, sepsis readmissions, progression from septic shock to sepsis, C difficile in bacteremia patients on long-term empiric antibiotic therapy, MDROs in bacteremia patients, adverse side effects, cost and loss in revenue due to HACs

Challenges for direct care givers

Devastating Effects of Bacteremia and Sepsis: Rapid ID and AST are Paramount to Effective Antibiotic Therapy

Sepsis Treatment Paradigm

Kumar et al. Crit Care Med. 2006 Jun;34(6):1589-96.

• Early and effective antimicrobial therapy for bloodstream infections improves clinical outcomes

• Each hour delay associated with 7.6% reduction in survival

• Unnecessary antimicrobial use is costly and harmful

• C. difficile infection • Adverse drug events • Selection of drug-resistant

organisms

Legal Implications

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Legal Implications: Jury decides Aiken Regional Medical Center, SC has to pay $13.75M to triple amputee

• AIKEN, S.C. (WRDW/WAGT) -- An Aiken County jury has decided Aiken Regional Medical Centers has to pay a triple amputee $13.75 million in damages in a medical malpractice case, court documents state.

• The lawsuit states Seletha Gartrell, of Aiken, lost both her legs above the knee, her left arm below the elbow and fingers from her right hand.

• According to court records, Aiken Regional Medical Centers must pay Gartrell $10 million in economic damages and $3.75 million of non-economic damages totaling at $13.75 million. The judgement was issued on March 1, 2017.

• Aiken Regional said Thursday: "The patient entered our facility with two life-threatening conditions, one of which caused her to have cardiac arrest. We strongly disagree with the jury's decision. Our nursing staff and physicians gave her the best of care that saved her life."

• The original complaint said Seletha Gartrell went to the emergency room at Aiken Regional Medical Centers on Dec. 6, 2012 with severe sepsis which is a dangerous and sometimes deadly infection.

• Source: http://www.wrdw.com/content/news/Jury-decides-Aiken-Regional-Medical-Centers-has-to-pay-1375M-to-triple-amputee-415256743.html

Case in Point: Jury decides Aiken Regional Medical Center, SC has to pay $13.75M to triple amputee

• AIKEN, S.C. (WRDW/WAGT) –

• It claims her initial nurses didn’t properly triage her and did not give adequate fluids or prescribe

antibiotics. According to the complaint, Gartrell wasn’t given antibiotics until 14 hours after being

admitted.

• “Mrs. Gartrells’ care was below the standard of care in pretty much all of the particulars above,” the

complaint said.

• Gartrell was transferred to MUSC and had both her legs amputated, her left arm below the elbow and

fingers from her right hand. According to the complaint, “the injuries to Mrs. Gartrell were the direct

and proximate result of and were caused and occasioned by the negligence, carelessness, recklessness,

willfulness and wantonness on the part of the defendants.”

• Source: http://www.wrdw.com/content/news/Jury-decides-Aiken-Regional-Medical-Centers-has-to-pay-1375M-to-triple-amputee-415256743.html

Interdisciplinary Sepsis Management Advisor – “Sepsis Alerts”

Example of a Sepsis Alert

Sepsis Cloud Algorithm

Cerner Database

Cerner Database

Action

What is the Process in Cerner?

Nurse receives alert

Physician receives alert

Sepsis teams Sepsis Coordinators

Electronic Sepsis Initiative Increases CDI

Studied over 127,346 total patient days increased antibiotic use and HCFO CDI during sepsis care bundle implementation period directly following the implementation phase accounting for the highest rate of antibiotic

use 50.4 days of therapy per 1,000 patient days

HCFO CDI rates were decreasing before sepsis care bundle implementation (1.4 events per 10,000 patient days/month) they began to increase during (1.6 events per 10,000 patient days/month) and following (10.8 events per 10,000 patient days/month) implementation.

Over the three-year timeframe - HCFO CDI increased to 14.4 per 10,000 patient days/month

Cefepime was the most commonly used antibiotic

Levofloxacin, which was not part of the sepsis care order set, was the main driver of increased antibiotic use

In the period directly following sepsis care bundle implementation phase (compared to the period before implementation) levofloxacin increased by 32.7 DOT per 1,000 patient days.

Hiensch R, et al. Impact of an electronic sepsis initiative on antibiotic use and health care facility-onset Clostridium difficile infection rates. American Journal of Infection Control, Volume 45, Issue 10 (October 2017)

Sepsis Cloud

Algorithm

Association Between Antibiotic Exposure and CDI

Avoiding Broad Spectrum Antibiotics Decreases CDI Cases

•COST OF HAIS

29

30

HAI Est Annual % Est Direct Cost Avg Length of Stay

Attributable Mortality

Surgical Site Infection (SSI)

33.7% $20 785 ~11.days

~4%

MRSA SSI $42 300 ~23 days

Central Line Associated Bloodstream Infection (CLABSI)

18.9% $45 814

~10 days

~26%

MRSA CLABSI ~16 days

Ventilator Associated Pneumonia (VAP)

31.6% $40 144 ~13 days ~24%

Catheter Associated Urinary Tract Infection (CAUTI)

<1% $896 < 1 day <1%

Clostridium difficile Infection (CDI)

15.4% $11 285 ~ 3 days ~4%

Zimlichman. Et al: “Health Care–Associated Infections A Meta-analysis of Costs and Financial Impact on the US Health Care System” JAMA Intern Med. September 2013

What percentage of mortality with CLABSIs and VAPs were due to delayed antibiotic sensitivity results for effective therapy?

www.vdh.virginia.gov/epidemiology/surveillance/hai/cdiff.htm

What Are Your Costs for Treating Patients with CDI?

www.vdh.virginia.gov/epidemiology/surveillance/hai/cdiff.htm

What is Your Mortality Rate and Readmission Rate for Patients with CDI?

Nurses Role in ASP

ANA and CDC: Nurses role in Antimicrobial Stewardship Program • Obtain appropriate cultures, using proper technique, before antibiotics are started

• Educate staff on how the microbiology laboratory processes those samples

• Use microbiology results to help guide the optimal selection of antibiotics and guide decisions to stop therapy in cases where culture results represent colonization, rather than infection

• Help inform decisions to start antibiotics promptly at the time early signs of likely bacterial infections, including sepsis, are identified

• Help ensure that practices to ensure good antibiotic use are embedded in other quality improvement efforts. For example, for sepsis, help ensure that antibiotics are started promptly and then reviewed once additional data, especially cultures, are available

• Prompt, and participate in, discussions about antimicrobial usage including antibiotic de-escalation by evaluating each patient’s clinical status and readiness for change from intravenous to oral therapy, when possible.

• Take a more detailed allergy history, especially around penicillin allergy. Help educate patients and families about what constitutes an accurate antibiotic allergy history

Role of IP/Pharm/Micro/ID in Collaboration with Nurses and ASP

• Microbiology education and training on how to both obtain cultures and interpret the results

• Education about infection versus colonization

• Assertiveness training to engage in discussions with the health care team

• Information on IV-PO switch criteria

• Use The Joint Commission’s Medication Management standard and proposed Centers for Medicare and Medicaid Services Condition(s) of Participation on antimicrobial stewardship to guide nurse-relevant antibiotic stewardship tools and products

• Bring stewardship issues to C Suite attention

ASP METRICS AND DASHBOARD

• Stewardship programs are encouraged to monitor outcomes

• antibiotic use –cost of antibiotics, antibiotic usage, days of therapy, stratified by nursing unit and hospital department (ED, ICU)

• C. difficile infections

• MDRO antibiotic resistance

• MRSA bacteremias

• Bacteremias by primary, secondary, HA and CA

• Bacteremias by HA sources

• Bacteremias by organisms

• Bacteremias by nursing units and departments

12 Steps to Prevent Antimicrobial

Resistance: Hospitalized Adults

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

12 Break the chain 11 Isolate the pathogen 10 Stop treatment when cured 9 Know when to say “no” to vanco 8 Treat infection, not colonization 7 Treat infection, not contamination 6 Use “local” data 5 Practice antimicrobial control 4 Access the experts 3 Target the pathogen 2 Get the catheters out 1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose & Treat Effectively

Prevent Infections

Conclusion - How Infection Preventionists can Contribute to ASP

1. Provide healthcare associated infection data for the ASP proposal to garner C-Suite support. 2. Assist ASP team members with data analysis and (data) presentation 3. Partnering with the responsible department, work to ensure the antibiogram is published timely and accessible to providers 4. Get frontline staff on board, listen to their concerns, and help to address the issues 5. Educate nursing services personnel 6. Assist with and develop educational material for providers and staff 7. Observe practice while rounding 8. Round with the ICU teams to prevent inappropriate antibiotic use 9. Report HAI surveillance data (e.g. MDRO trends over time) and practice measures to the ASP team 10. Share health department outbreak alerts with the ASP team 11. Assist with the development of algorithms, order sets, or order entry criteria to decrease antibiotic use.

Luci Perri – Role of IP in ASP - Infection Control Today – October 2017

The End Question?