1. Identifying Targets for Improving Antibiotic Use Acute Care
AHRQ Safety Program for Improving Antibiotic Use
Identifying Targets for Improving Antibiotic Use Acute Care 

2. Presenter — Sara Cosgrove
Sara Cosgrove, MD, MS
Title: Professor of Medicine, Division of Infectious Diseases, Director, Antimicrobial Stewardship Program, Associate Hospital Epidemiologist
Place of work: Johns Hopkins Medical Institutions
Program address:

3. Housekeeping Keep phone on mute
Use ‘chat’ feature in WebEx if you need to speak
Please hold off questions until the end during Q&A

4. Objectives
Understand how to identify defects related to antibiotic prescribing.
Understand how to leverage frontline wisdom to guide safety improvement efforts around antibiotic prescribing.
Understand how to recognize defects using the Four Moments of Antibiotic Prescribing framework.

5. Recap CUSP — 3 methods to eliminate unnecessary harm —
Improves the culture of safety
Provides frontline staff with tools / support to identify and tackle hazards that threaten their patients
Strives to eliminate preventable harm!
3 methods to eliminate unnecessary harm —
Standardize practices
Create independent checks
Learn from each new opportunity

6. Examples of defects related to antibiotic use
What is a Defect?
A defect is anything you do not want to have happen again.
Examples of defects related to antibiotic use
Unnecessarily broad spectrum empiric antibiotic therapy
Delayed antibiotic initiation in patients with sepsis
Forgetting to obtain needed cultures
Forgetting to narrow antibiotic therapy based on clinical data
Forgetting to discontinue antibiotics when they are not needed
Forgetting to discontinue surgical prophylaxis
Forgetting to convert from IV to PO therapy
Accidentally miscounting days of therapy during transitions of care
Prescribing excess durations of antibiotic therapy
Development of a C. difficile infection

7. How Can you Identify Defects?
Seek input from a diverse group of healthcare workers
Staff Safety Assessment —
Describe the next patient scenario for which antibiotics may not be prescribed optimally
Describe what you think can be done to prevent this from happening

8. How Can you Identify Defects?
The AS team
Unit physician lead
Unit pharmacist lead
Unit nurse lead
Any frontline staff
Prioritize top three opportunities
Identify all the factors that could lead to this opportunity
Technical factors
Adaptive factors

9. Potential Solution(s)
Technical Problems
Have potentially clear solutions.
Usually require a checklist or protocol to guide implementation of the evidenced-based best practice
Problem
Potential Solution(s)
House staff are unaware that the recommended duration of therapy for community-acquired pneumonia is generally 5 days
Develop pocket-guides for house staff
Automatic pop-ups in the EHR

10. Potential Solution(s)
Adaptive Problems
Require a change in attitudes, beliefs and behaviors.
Problem
Potential Solution(s)
Physicians feel uncomfortable discontinuing vancomycin when a colleague decided to start it the previous day
Clinicians should feel comfortable adjusting antibiotic therapy initiated by colleagues as clinical pictures evolve

11. First order problem solving
Solves one problem in one particular instance.
Generally does not help prevent future harm from occurring.
Second order problem solving
Uses adaptive interventions to change culture and beliefs.
Identifies system opportunities to prevent them from occurring again.

12. The Four Moments of Antibiotic Stewardship

13. Four Moments Review
1. Does my patient have an infection that requires antibiotics?
2. Have I ordered appropriate cultures before starting antibiotics? What empiric therapy should I initiate?
3. A day or more has passed. Can I stop antibiotics? Can I narrow therapy or change from IV to oral therapy?
4. What duration of antibiotic therapy is needed for my patient's diagnosis?

14. Moment 3: De-escalation
What are some of the data behind Moment 3 —
Antibiotic De-escalation
Definition: Modifying antibiotic therapy to agents considered to have a narrower spectrum of activity or stopping antibiotic therapy
Guided by —
Microbiology data
Clinical status of the patient
Goals —
Optimize therapy AND
Select agents that minimize side-effects

15. Is Antibiotic De-Escalation Safe?
28% reduced risk of death compared to no de-escalation
1. Tabah A, Cotta MO, Garnacho-Montero J, et al. A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit. Clin Infect Dis Apr 15;62(8): PMID:

16. Case #1 Example of De-Escalation
A patient with a past history of mitral valve endocarditis is admitted with high fevers, hypotension, and diffuse myalgias.
He is diagnosed with presumptive endocarditis and started on vancomycin and ceftriaxone.
By day 3 of therapy, blood cultures are growing a viridans group streptococcus susceptible to penicillin with a low MIC.
In this case, while vancomycin and ceftriaxone both have activity against the organism, penicillin is the preferred choice given its narrow spectrum, excellent activity against the organism, and low side-effect profile.

17. Case #2 Example of De-Escalation
A patient hospitalized after undergoing a spinal fusion is diagnosed with pneumonia and sepsis.
He requires intubation and is admitted to the ICU and started empirically on vancomycin and piperacillin / tazobactam.
He improves over the next few days and is extubated on day 3.
Sputum cultures grow a pan-susceptible E. coli
Not necessary to continue broad spectrum therapy. Cefazolin is preferable because there is less association with C. difficile infection.

18. Case #3 Example of De-Escalation
A patient presents to the ED.
Chest x-ray shows bilateral infiltrates vs. edema greater on the right than the left.
Initiated on ceftriaxone and azithromycin and furosemide.
The next day, he reports that his shortness of breath has resolved
A sputum culture is pending.
In this case, the diagnosis is highly likely to be heart failure.
The patient had a favorable response to diuresis so it is reasonable to stop his antibiotics. There is no need to wait for the results of a sputum culture when clinical judgment suggests he does not have an infection.

19. Your Turn! Think about antibiotic usage in your unit…
What is a defect related to antibiotic use that you have noticed?
Record your defect.

20. Summary Defects related to antibiotic-prescribing are plentiful.
It is important for frontline staff to identify observed defects by completing the Staff Safety Assessment.
Teams should review and prioritize defects.
Four Moments of Antibiotic Prescribing framework will be used to identify defects and use second-order problem solving to determine technical and adaptive solutions.

21. Program Website Access

22. Questions THANK YOU FOR PARTICIPATING!
Type in your questions using “Chat” or
Speak up on conference line
THANK YOU FOR PARTICIPATING!

23. Next Steps Behavior Change Theory for Antibiotic Stewardship Leaders
Identifying Targets for Improving Antibiotic Use (CUSP 2)
Improving Antibiotic Use by Learning from Defects
WebEx call
Questions?

24. Reference
1. Tabah A, Cotta MO, Garnacho-Montero J, et al. A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit. Clin Infect Dis Apr 15;62(8): PMID: