Notes for IDWeek 2016 Day 3
IDSA/SHEA Guidelines: Implementing an Antibiotic Stewardship Program
- learning “how the sausage was made”
- newer IDSA guidelines use the “GRADE” system to rank suggestions, factors in more than just evidence quality (old system)
- new guidelines no longer prefer prospective audit and feedback over preauthorization
- restrictive prescribing worked better and faster but strategies become equivalent at 12 mo
- switching preauth to PAF showed inreased DOT and length of stay
- PAF only has an impact if implemented in an existing ASP
- comparison table available in the guidelines
- TL;DR: implement one or both and keep doing it consistently
- syndrome -specific: new guidelines emphasize the benefit of this approach (eg SSTI, CAP, asymptomatic bacteruria)
- rapid testing in micro lab has no ASP benefit unless the ASP team is directly involved in real time
- results will just sit there without ASP intervening
- limited study for procalcitonin; may not even do that much
- DDDs are less good than DOTs but way easier to calculate
- DOT are not consistent in q2d dosing
- antibiotic costs ideally measured based on rx or actual administrations rather than by purchasing data and normalized by patient census
- cost savings wane as asp continues so measure what costs would be if you didn’t have a stewardshiop program
- apparently there are metrics and guidelines available to calculate what costs would be without a stewardship program. F/U!!
Impact of Clinical Practice Guidelines on Antimicrobial Stewardship
- Value = (Quality + Service) / Cost
- service relates to patient perspective
- HICPAC: ASP workshop, july 2016 - guidelines are helpful for defining abx use but have not routinely incorporated stewardship principles
- Guidelines don’t factor in cost effectiveness
- wholesale prices of abx in the states are crazy (dapto like $500/day?)
- issues with restricted drugs being cheaper than non-restricted (like linezolid vs vanco)
- Wachter et al. public reporting of antibiotic timing in patients with pneumonial ann intern med 2008
- focus on patients interests above all else
- 1 hour rule in sepsis has become the 3 hour rule as of 2015
- HAP/VAP guidelines 2016: only include MRSA drug in pts with risk factor for MRSA infection or at high risk for mortality
- only in pts with an increased likelyhood of pseudomonas/resistant GNR do you need an antipseudomonal
- a good stewardship-based guideline
Impact of Core Measures on Antimicrobial Stewardship Programs
- measures come from NQF (National Quality Forum), non profit organization
- SCIP - surgical care improvement project
- retired now due to great compliance… except for the 24 hrs stop recommendation
- the CAP measures have a very confusing pseudomonas section, taken out of guidelines but should not be included as a core measure
- beta-lactam + FQ for ICU CAP is probably excessive and unnecessary
- sepsis: recent meta analysis did not find an association with antibiotic timing and increased mortality in severe sepsis and septic shock
- all retrospective studies
- Kumar study 2006 (study where most of our guidelines come from) is actually an outlier in the meta-analysis
- CMS has put out new release notes commenting on pts with sepsis with known pathogen or with c diff
- jointcommission.org
- also have de-escalation release notes that came out a few days ago
Who Really Needs Antimicrobials? Rapid Diagnostics & BioMarkers
- pathogen specific tests: hard to tell colonizers, test site inaccessible/unknown, etc
- biomarkers: no info on etiology, can tell if infection is present, can’t generalize to special populations
- current rapid tests: GAS, influenza
- quicker resp panels
- limited biomarkers: procalcitonin, urinalysis
- more robust biomarker panels in the works
- point of care pathogen tests: molecular tests coming with excellent sensitive and specificity (even compared to PCR)
- currently available CLIA-waived molecular tests:
- Alere i inflenza A&B, Roche Cobas Liat influenza A/B
- 15-20 min, roche 99.2% sensitive and 100% specific vs Simplexa PCR
- will people still rx Abx “just in case”
- POC tests have risks of contamination, huge user manual with checklist to mitigate risk. Will be a challenge
- New direct from blood pathogen test T2
- works like a tiny MRI for bacteria, works on magnetic fields
- Covers top 6 bacteria; SA, E faecium, ecoli, kleb, pseudo, acintobacter; still missing a lot
- No info on susc so may not be super useful for ASP
- Forthcoming tests:
- DNAe: similar to T2 but will give some sus data
- Qvella FAST ID BSI panel: 15 species/genus pathogens in blood, 96% sens and 99% spec. 45 minutes from blood draw
- Biomarkers - what’s available today
- c reactive protein, ESR, lactate, urinalysis, procalcitonin (show host response)
- some others exist for showing presence of microorganisms
- procalcitonin: secretion starts 4 hrs post stimulus, peaks at 32 hrs. produced by tissues during infection
- nonspecific and can be affected by other conditions
- may help with differentiating bacterial vs viral and duration of abx
(huh?)
- Randomized Trial of Rapid Multiplex PCR - based Blood Culture Indetification and Suceptibility Testing
- 2015 Clin Infect Dis (Banerjee R et al)
- Proescptive RCT; grp 1 (Control) = standard BC processing; grp 2 = rapid multiplex PCR with templated comments; grp 3 = grp 1 + grp 2 process + stewardship intervention
- ID physician or pharmacist paged with the result 24/7
- 3 groups were similar, about 200 people each
- stewardship group had the best results in terms of deescalation - seemed to be an independent effect with ASP
- Langford BJ et al J clin microbiol toronto 2016
- suppressed cipro reporting on enterobacterecia when other things were sensitive
- showed a steep decline in cipro use over time (statistically significant)
- non statistically significant possible rise in cirpo Sus for ecoli and pseudo
- epstein et al infect control hosp epidemiol 2016
- Sarg et al infect control hosp episdemiol 2016
- studies looking to try and reduce unnecessary uine cultures in ICU
- screening proceudre to precede urine culturing will reduce lab testing
Studies that will Impact your Practice
Antimicrobial Agent Shortages and Concerns for Adverse Patient Outcomes are Now Part of Everyday Practice: 2016 Follow-up Survey of Infectious Diseases Physicians
- Obtained opinions regarding shortages from ID docs in 2011 and follow up in 2016
- not much change from 2011 to 2016.
- US had shortages of piptazo, mero, doyxycycline tabs…
- lots of places developed guidelines relating to shortages
- “we are lucky to have great antimicrobial stewardship pharmacists” :)
Budgetary Impact of Compliance with STI screening Guidelines in Persons Living with HIV
- It’s a pretty darn big impact.
Location, Location, Location: A Change in Urine Testing Order Sets on Culturing Practices At and Academic Emergency Department
- one study found 8% of admitted medicine patients had asymptomatic bacteruria
- CPOE based set modification (from “frequent orders” area) to see if that would reduce unnecessary cultures (unlinking the culture from the UA on the frequent sets)
- 46% decrease
- didn’t track abx ordering changes
The Successful Use of Telemedicine with Virtual Face to Face Evaluation for Inpatient Infectious Diseases Consulation
- Telemedicine is a thing that you can do. Saves a 30 minute drive.
The Impact of Infectious Disease Consultation On Clinical Management and Outcome of Patients with Bacteremia in China: A retrospective cohort study
- Chinese hospitals can be very crowded
Clindamycin vs Trimethoprim-Sulfamethoxazole vs Placebo for Uncomplicated Skin and Soft Tissue Abscesses
- The >5 cm arm of the study did not use placebo. already published in NEJM
- got I&D, then wound check at 48hrs, then fu at dat 12, 20, and 40
- excluded patients with significant comorbities
- cultures were obtained in 99% of patients
- abx were the same outcome; both were better than placebo
- clinda was bad at SA
- non SA bugs: abx were no better than placebo
- resistance for clinda wasn’t too bad for pus in the ER compared to other infection sites (10-15%) apparently
Healthcare Epidemiology and Antimicrobial Stewardship in Community Hospitals: Musings about the Present and Future
- US has 800-1000 teaching hospitals
- Data collecting for ASP is very lacking in community hospitals
- 2009 study: empicircal antimicorbail therapy for bloodstream infections due to MRSA - >50% pts received inappropriate empiric abx
- many community hospitals do not have good hand hygiene programs
- community hospitals in the US do not have real time active interventions
- new focus on training physicians in ASP formally
Stewardship in Community Hospitals - Optimizing Outcomes and Resources (SCORE)
- 5000 hosps in US, 72% have less than 200 beds
- 38% have ASPs
- new US mandate that all hospitals have ASPs by Jan 2017
- looked at 3 different stewardship program types in 15 small hospitals over 15 months
- basic stewardship education, infectious diseases hotline (ID) => program 1
- program 2 = program 1 + advanced AS education, “light” prospective AF, local restrictions (controlled by local pharmacy staff)
- program 3 = program 1+2 + ID resriction, FULL PAF, ID review of designated cultures
- sorted 5 categories of antibiotics (cat 5 = broadest or most expensive/fancy)
- program 3 crushed it compared to program 1; program 1 and 2 were similar
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