1. The What and Why of Antimicrobial Stewardship Kelly Kauber, MPH Antimicrobial Stewardship in LTC, May 12th, 2016

2. What is AMS? Antimicrobial Stewardship Stewardship (noun) 1. the position and duties of a steward. 2. the responsible overseeing and protection of something considered worth caring for and preserving antibiotics/antimicrobials

3. What is AMS? Antimicrobial Stewardship Right Diagnosis Right Drug Right Dose Right Duration

4. Why focus on AMS? Increasing antimicrobial resistance No new drugs

5. Targeting virulence: a new paradigm for antimicrobial therapyTargeting virulence: a new paradigm for antimicrobial therapy Anne E Clatworthy, Emily Pierson & Deborah T Hung. Nature Chemical Biology 3, 541 - 548 (2007) Published online: 20 August 2007

6. Why focus on AMS?

7. Daneman N. JAMA Int Med 2013;173:673-82 Benoit. JAGS 2008;56:2039-2044 Nicolle LE. ICHE 2000;21:537-545 Why focus on AMS?

8. REHAB SNF

9. Harms Side effects, drug interactions and adverse events Major risk factor for C difficile infections Infection w/ antibiotic resistant bacteria NH with HIGH AU 24% increase in antibiotic related complications What is considered high use? Range: 20.4 - 192.9 ABX day/1000 resident days High Use: >62 ABX days/ 1000 resident days Daneman N. JAMA Int Med 2013;173:673-82 Antibiotics can help…and harm patients

10. Challenges of Prescribing Antibiotics Richards. J Am Med Dir Assoc 2001;6(2):109-12 How do prescribers make decisions about abx order? Limited documentation of assessments Data/Labs Other pressures Rely on assessments made by someone else 67% of antibiotics ordered over the phone Influence of resident, family and other nursing home staff on the decision to start antibiotics Difficulty obtaining and interpreting laboratory and diagnostic data to inform prescribing 43% of NH initiated antibiotic courses had no documentation of infection in medical record

11. Chang et al. ICHE 2007;28(8):926-931. Hensgens et al. J Antimicrob Chemother 2012;67(3):742-748. Lessa et al. NEJM 2015;372(9):825-834. Clostridium difficile Single most important risk factor for CDI? Antibiotic exposure has lasting impact on the gut bacteria CDI risk 7-10 fold 3 months after tx with ABX 85-90% of CDI occurs within 30 days of ABX exposure

12. How many of 104,000 nursing home-onset CDI cases reported in 2011 could have been prevented by improved abx use? Clostridium difficile

13. 201320142015 2016 June 2015: White house forum on AMS to highlight healthcare partner commitments included several NH partner organizations July 2015--CMS proposed new federal regulations for LTCF including new IP and AMS activities Sept 2015--CDC released Core Elements of AMS in NH Spotlight on AMS in NH

14. “Call to Action”

18. “Call to action” “Call to Action”

19. “Call to action” “Call to Action”

20. 1. Leadership Commitment Formal statement, resources for AMS 2. Accountability Physician, nursing and pharmacy leads 3. Drug Expertise establish consultant pharmacist, partners 4. Action Action or practice to improve ABX use 5. Tracking Track at least one process, outcome measure 6. Reporting Report back to providers and nursing staff 7. Education Provide AMS education Summary of Core Elements of Antimicrobial Stewardship for Nursing Homes

22. Edwards R et. al., Covering more territory to fight resistance: Considering nurses’ role in antimicrobial stewardship. J Infect Prev 2011;12(1):6- 10 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083718/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083718/ Aspect of Management Associated RickPotential Nurse Contribution Treatment Specificity Broad spectrum antibiotics are major risk for CDI and resistance; avoid when possible. Ensure treatment is adjusted based on microbiology results; engage prescribers in discussion of limiting use of broad spectrum or high risk antibiotics. Duration of Treatment Prolonged duration of antibiotics is risk for CDI and resistance. Ensure antibiotics are prescribed for appropriate duration. Route of Administration Early switching from IV to PO antibiotics decreases length of hospital stay, reduces risk of resistance and decreases workload. Monitor IV antibiotics and engage prescribers in discussion of de-escalation. Surgical Prophylaxis Lack of adherence to best practices for timing and duration of antibiotics for surgical prophylaxis may decrease intended effectiveness and may increase risk of resistance, CDI and other adverse events. Ensure antibiotics are prescribed for appropriate duration and are administered on time. Timing of Administration Lack of timely antibiotics for infections may be associated with decreased survival. Improve timeliness of antibiotic administration. Therapeutic Drug Monitoring Suboptimal antibiotic concentrations promote resistance and may not be effective; higher than recommended concentrations increase risk of adverse events. Consider standing orders or nurse-activated orders for monitoring therapeutic drug concentrations. Outpatient Antibiotic Therapy Outpatient antibiotics can decrease length of stay; earlier discharge reduces risk of transmission of HAIs and decreases costs. Identify opportunities for outpatient therapy.

23. Key nursing activities include: Triage, and initial infection control precautions Medication allergy assessment and reconciliation Timely ordering and administration of antibiotics Early and appropriate collection and submission of specimens for culture Antibiotic timeout and de-escalation Implementation of quality and safety bundle measures Central communicator among prescribers, pharmacy, lab, discharge planners and consultants Olans RN et.al, The critical role of the staff nurse in antimicrobial stewardship—unrecognized but already there. Clin Infect Dis 2016;62(1):84-89. http://cid.oxfordjournals.org/content/62/1/84.full.pdf+htmlhttp://cid.oxfordjournals.org/content/62/1/84.full.pdf+html

24. DECREASE  ANTIBITOIC RESISTANCE  C. DIFFICILE INFECTIONS  COSTS ANTIBIOTIC STEWARDSHIP IN YOUR FACILITY WILL… IMPROVE  OUTCOMES FOR RESIDENTS

25. Thank you! Kelly Kauber 206-418-5589 kelly.kauber@doh.wa.gov