You have data. So now what?JAMIE JOHNSON, PHARM.D.

CLINICAL PHARMACIST

ANTIMICROBIAL STEWARDSHIP COMMIT TEE CHAIR

Objectives• Understand the rationale for developing an antimicrobial stewardship program

• Review antimicrobial use metrics useful for informing antimicrobial stewardship strategies

• Provide practical examples on employing antimicrobial use data to inform antimicrobial stewardship strategies

DisclosuresNone

Our DataDescending DOT / 1000 PD

Antimicrobials 12-Month Rate

Levofloxacin (all) 136.94

Ceftriaxone 120.60

Ciprofloxacin (all) 82.09

Piperacillin-Tazobactam 81.37

Cefazolin 77.37

Azithromycin (all) 63.57

Vancomycin IV 52.67

Azithromycin IV 52.31

SMX-TMP 44.32

Metronidazole (all) 38.87

Days of Therapy per 1000 Patient-Days

Antibiotics ASAP Facility 1* ASAP Facility 2* ASAP Facility 3† ASAP Facility 4* Larger Facility

Ampicillin/Sulbactam 2.30 19.98 23.17 4.48 15.91

Azithromycin 44.40 63.57 73.36 150.75 23.26

Aztreonam 6.70 0.73 0.97 -- 7.86

Cefazolin 58.10 77.37 68.53 10.45 111.25

Cefepime 3.40 -- 15.44 13.43 20.04

Ceftriaxone 109.80 120.60 108.11 291.04 66.53

Ciprofloxacin 9.60 82.09 10.62 68.66 0.34

Clindamycin 13.10 37.78 23.17 11.94 30.27

Daptomycin 10.20 1.09 -- -- 13.56

Levofloxacin 81.60 136.94 90.73 131.34 75.38

Linezolid 0.60 -- 3.86 50.75 12.49

Meropenem/Imipenem/Doripenem 8.00 9.81 8.69 38.81 25.15

Metronidazole 22.70 38.87 14.48 108.96 42.33

Piperacillin/tazobactam 55.30 81.37 54.05 76.12 109.32

SMX/TMP -- 44.32 6.76 37.31 43.37

Vancomycin IV 86.50 52.67 32.82 86.57 131.36

Group 1 -- Broad-spectrum antibacterial agents for hospital-acquired/multi-drug resistant infectionsAntibiotics ASAP Facility 1 ASAP Facility 2 ASAP Facility 3 ASAP Facility 4 Larger FacilityAztreonam 6.70 0.73 0.97 -- 7.86Cefepime 3.40 -- 15.44 13.43 20.04Ceftazidime 3.60 -- -- -- 1.99Imipenem/Meropenem/Doripenem 8.00 9.81 8.69 38.81 25.15Piperacillin/tazobactam 55.30 81.37 54.05 76.12 109.32Total 77.00 91.91 79.15 128.36 164.36

Group 2 -- Broad-spectrum antibacterial agents for community-acquired infectionsAntibiotics ASAP Facility 1 ASAP Facility 2 ASAP Facility 3 ASAP Facility 4 Larger Facility

Cefotaxime -- -- 11.58 -- 0.72

Ceftriaxone 109.80 120.60 108.11 291.04 66.53

Ciprofloxacin 9.60 82.09 10.62 68.66 0.34

Ertapenem 16.10 -- -- 2.99 16.24

Levofloxacin 81.60 136.94 90.73 131.34 75.38

Total 217.10 339.63 221.04 494.03 159.21

Areas for ImprovementFluoroquinolone usage

Cefazolin usage

Piperacillin/Tazobactam usage

Overall antibiotic usage is high

EducationProvided provider education from an ID physician◦ Great way to Kick-off our program

◦ Peer-to-Peer discussion of importance of Antimicrobial Stewardship

◦ Showed physicians our usage data

◦ Will continue with annual provider education on different areas of stewardship

2222 North Lincoln Avenue

York, Nebraska 68467

Date Collected (Specimen) - 01/01/2016 to 12/31/2016 2016 Antibiogram ReportGram Negative Organisms Gram Positive Organisms

Enterobactercloacae complex

(6)Escherichia coli

(137)Klebsiella oxytoca

(10)

Klebsiella pneumoniae ssp pneumoniae (27)

Proteus mirabilis (13)

Pseudomonas aeruginosa (30)

Enterococcus faecalis (22)

Staphylococcus aureus (62)

Staphylococcus epidermidis (24)

Staphylococcus lugdunensis (6)

Streptococcus agalactiae (15)

Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total Susceptible Total

Amoxicillin/Clavulanic Acid 0% -6 82% -137 80% -10 93% -27 100% -12 3% -30

Ampicillin 52% -137 0% -10 0% -27 92% -13 0% -28 95% -22 100% -15

Aztreonam 83% -6 94% -137 100% -10 96% -27 92% -13

Benzylpenicillin 95% -22 11% -62 0% -24 17% -6 100% -14

Beta-Lactamase 100% -22 11% -62 0% -24 17% -6 100% -13

Cefazolin 0% -6 93% -137 70% -10 89% -27 92% -13 0% -29

Cefepime 100% -6 94% -137 100% -10 96% -27 92% -13 83% -30

Ceftriaxone 83% -6 94% -137 100% -10 96% -27 92% -13 4% -28

Ciprofloxacin 100% -6 68% -137 90% -10 85% -27 54% -13 63% -30 68% -22 52% -62 58% -24 100% -6

Clindamycin 71% -62 71% -24 83% -6 0% -15

ESBL 93% -137 100% -10 96% -27

Ertapenem 100% -6 100% -137 100% -10 100% -27 100% -13

Erythromycin 14% -22 37% -62 38% -24 83% -6

Gentamicin 100% -6 93% -137 100% -10 100% -27 85% -13 79% -29 100% -62 100% -24 100% -6

Gentamicin High Level (synergy) 82% -22

Imipenem 100% -6 100% -137 100% -10 100% -27 100% -13 79% -28

Inducible Clindamycin Resistance 90% -62 83% -24 100% -6

Levofloxacin 100% -6 68% -137 90% -10 85% -27 54% -13 64% -28 68% -22 53% -62 58% -24 100% -6 93% -15

Linezolid 100% -22 100% -62 100% -24 100% -15

Meropenem 100% -6 100% -137 100% -10 100% -27 100% -13 79% -28

Moxifloxacin 68% -38 58% -24 100% -6

Nitrofurantoin 67% -6 95% -137 80% -10 11% -27 0% -13 0% -29 86% -22 98% -62 100% -24 83% -6

Oxacillin MIC 61% -62 46% -24 67% -6

Piperacillin/Tazobactam 80% -5 99% -137 100% -8 100% -27 100% -12 100% -28

Quinupristin/Dalfopristin 100% -38 100% -24 93% -15

Rifampicin 100% -62 100% -24 100% -6

Streptomycin High Level (synergy) 86% -22

Tetracycline 100% -6 78% -137 90% -10 85% -27 0% -13 4% -28 32% -22 98% -62 88% -24 83% -6 13% -15

Tigecycline 100% -22 100% -62 100% -23 100% -15

Trimethoprim/Sulfamethoxazole 100% -6 78% -137 90% -10 100% -27 77% -13 98% -62

Vancomycin 100% -22 100% -62 100% -24 100% -6 100% -13

AntibiogramPublished annually

Good local data to show providers resistance in their patient population

Educate on how to read antibiogram

Point out key changes from year to year

Use to drive standing order antibiotic selections

Standing OrdersBased on syndromes to treat the disease as an entirety

Current standing orders available at York General:◦ Pneumonia

◦ Skin and soft tissue infections

◦ Urinary Tract Infections

◦ Surgical prophylaxis

◦ Sepsis

Pneumonia Standing OrderA lot of York General fluoroquinolone use is driven by CAP

Add duration to antibiotic orders: 5-7 days

* If patient has Community Acquired Pneumonia and normal

renal function, give:

_____ Levofloxacin 750 mg IV every 24 hours.

OR

_____ Rocephin IVPB, every 24 hours (1 gram if greater than

65 years , 2 grams if less than 65 years) AND Zithromax 500

mg IVPB every 24 hours.

Skin And Soft Tissue InfectionsDeveloped standing order

Defined varying forms of cellulitis with diagnostic criteria to avoid broad spectrum antibiotics if not indicated◦ Cellulitis

◦ Cutaneous Abscess

◦ Diabetic foot infections

◦ Necrotizing fasciitis

Need to add duration 5-7 days

Adjusted based upon antibiogram

Skin and Soft Tissue InfectionsCellulitis◦ Oral- Cephalexin or TMP/SMX◦ IV- Cefazolin or Clindamycin◦ MRSA- Vancomycin per pharmacy

Cutaneous Abscess◦ I & D◦ TMP/SMX or Clindamycin or Vancomycin

Diabetic Foot Infections◦ Mild- Cefazolin or Clindamycin◦ Moderate- Ampicillin/Sulbactam◦ Severe- Piperacillin/Tazobactam◦ MRSA- Vancomycin per pharmacy

Necrotizing Fasciitis◦ Surgical intervention◦ Vancomycin + Pip/Tazo + Clindamycin

Urinary Tract InfectionsCreated standing order

Utilized ceftriaxone as 1st-line agent due to resistance to ciprofloxacin in E. coli isolates

Discuss one-on-one with provider if they order fluoroquinolone for UTI

Need to add durations to orders (3-7 days)

Surgical ProphylaxisAudited cefazolin use to determine appropriateness◦ Most in total joint procedures

Currently reviewing all surgical prophylaxis standing orders

Difficult as most surgeons are from out of town

SepsisMost patients only receive 1 dose of antibiotics in our facility

So started with empiric therapy for different sources◦ Unknown source

◦ Abdominal

◦ Urinary Tract

◦ Neutropenic Fever

◦ Pneumonia

Mismatch between current sepsis order set and syndrome order sets so needed aligned

Pharmacist InterventionsAutomatic pharmacokinetic consult on all aminoglycoside and vancomycin orders

Pharmacy to convert all pip/tazo orders to extended-infusion

Renal dose adjustments

Initiating pharmacist review for key antibiotic usage◦ fluoroquinolones, pip/tazo, carbapenems, and vancomycin

Pharmacist TrackingMotivates individuals to complete interventions◦ Educational tool for making interventions

Great way to provide feedback to individuals

Look at interventions and its impact on facility antibiotic use data

Successes and FailuresUtilization of new standing orders needs improvement◦ Staff communication is essential

Increased provider awareness of antibiogram and resistance patterns in the facility

Pharmacy interventions have been well received

Awaiting results from the past 6 months to determine if interventions have been effective

Future ABS ActivitiesCOPD order set

Required clinical staff education◦ Nursing education on obtaining cultures

Provider specific results and feedback

2017 Antibiogram released in January◦ Review standing orders

2017 Antibiotic use data available for comparison

Questions?