Antibiotic Stewardship Pharmacy Education

Antibiotic Stewardship Pharmacy Education


Hello. My name is Deb Smith. I’m an improvement consultant at House Quality
Innovators, or HQI. This educational event has been developed
in partnership with HQI, the Virginia Department of Health, and the Virginia Hospital and Healthcare
Association. I’d like you to take a minute to review the
icons at the bottom of your screen. There are two green icons to the right. One is for the resources for this education,
and the other is the post test that you will be taking after completing the education. You’ll have two chances to achieve a 70% or
higher in order to receive your certificate. I would now like to introduce your instructor
for today. Rebecca Collins serves as the interim clinical
manager, Residency Director and Education Coordinator for Bon Secour Virginia Health
System. She also practices as Antimicrobial Stewardship
team lead at Memorial Regional Medical Center and Bon Secour Health System. She currently teaches pharmacy residents and
students in the clinical area of infectious diseases and offers advanced practice professional
experiences in acute geriatric care and internal medicine. She is also a co-founder of the Stewardship
Interest Group of Virginia. Rebecca, the floor is yours. Thank you, Deb. [inaudible 00:01:33] back
to Sir Alexander Fleming when he stated in the New York Times, “that the microbes are
educated to resist penicillin and a host of penicillin-fast organisms is bred out. In such cases the thoughtless person playing
with penicillin is morally responsible for the death of a man who finally succumbs to
infections with the penicillin-resistant organism. I hope this evil can be averted.” So, basically we’ve gone from infectious disease
killing people, to people being saved by penicillin and antibiotics now back full circle to these
multi-drug-resistant organisms killing people once again. If we fast forward to 2000 [inaudible 00:02:17]
by saying, “The healthcare system needs to improve how it detects patients with drug-resistant
infections, controls the spread of such infections, prevents them from happening in the first
place, and incentivizes drug-makers to develop new antimicrobials.” So, some background statistics I’d like to
review, include that two million Americans develop resistant infections every year. This leads to 23 thousand Americans dying
from drug-resistant infections annually. Antimicrobial agents continue to be the largest
portion of pharmacy expenditures with up to fifty percent of antimicrobial use being deemed
inappropriate. This inappropriate use can lead to resistance
and other adverse events and appropriate use may actually improve patient outcomes and
reduce healthcare costs. Not only are the number of infections and
diseases and deaths rising, we also see our sequelae from overuse of antimicrobials rising. For instance, C. Diff. infections have increased
to 250 thousand illnesses annually with approximately 14 thousand deaths due to C. Diff. There are many other untoward [effects 00:03:33]
that we need to consider. These include the increase of antibiotic resistance
associated with overuse of antibiotics, increased healthcare costs with up to 30 billion dollars
spent annually, increased risk of adverse drug events with things such as hypersensitivity,
diarrhea, and as we spoke just a moment ago about Clostridium Difficile. This is the class of medications that when
you use it in one patient the effects can reach those around them. Antimicrobial resistance we see an increase
in overuse and misuse of antimicrobials and this forces the bacteria to either adapt or
die leading to selective pressure. Bacteria that can adapt and survive antimicrobial
therapy then carry genes for resistance and these genes are transmitted to future generations
of bacteria. When we further look into resistance we see
that bacteria may also colonize and infect organisms, especially if they’re becoming
more and more exposed to antibiotics. Resistant organisms can be transmitted between
patients and there are some examples here of some of our more common resistant organisms
including Methicillin-resistant Staph Aureus and Carbapenem-Resistant Organisms. The highest risk patient groups that acquire
resistant pathogens include those that are immuno compromised, our hospitalized patients
and those that have invasive devices placed such as central venous catheters or Foley
catheters. Further indirect impact to the patient includes
increased office visits, lost time from work, severity of illness, increased length of stay
if they’re hospitalized and patients having adverse events from multiple antibiotics. This can even lead to death. So why do we need to worry about antimicrobial
stewardship? We really need to improve our antimicrobial
prescribing. We also need to minimize misdiagnosis and
delayed diagnosis and the under-use of antimicrobials when needed. We also need to ensure that we’re using the
right drug, dose and duration of therapy and we can track these things overtime to make
sure that we are prescribing in an appropriate manner. We can also use this tracking to help us show
a slowing and prevention of development of resistance. The Center for Disease Control has developed
some guidelines for a core group of team members that can be part of your Antimicrobial Stewardship
program. Here is a list that is inclusive but not limited
to infectious disease providers, clinical pharmacist with infectious disease training,
clinical microbiologists, information system specialists, infection control professionals
and hospital epidemiologists. And of course you definitely require the support
and collaboration of hospital administration, your medical staff and any local providers
and pharmacists involved in the care of the patient. Some benefits of antimicrobial stewardship
include the improved clinical outcome, providing more cost effective care to our patients by
decreasing the use of costly antimicrobials and also decreasing the length of stay, especially
when they’re hospitalized, reducing readmissions to the hospital setting, and preventing hospital
and healthcare associated infections. We also can decrease adverse event rates using
antimicrobial stewardship. Some further benefits include curtailing antimicrobial
resistance such as our multi-drug resistant organisms that we mentioned earlier. Also reducing overall healthcare expenditures
and both of these regulatory bodies here require that we do this and we need to make sure that
we’re meeting those requirements from the Joint Commission and the Centers for Medicare
and Medicaid Services. Some strategies to use are core strategies,
which include perspective audit with interventions and feedback. This is basically your perspective review
of a patient on a daily basis to make sure they’re receiving the most appropriate therapy. You also can use formula restriction and pre-authorization. This would restrict those agents that you
would only wanna use in a setting of resistance or intolerance for the patient. And then, supplemental strategies include
education, guideline and pathways to help direct therapies, streamlining and de-escalation
of therapy, dose optimization, IV to PO conversion and computer assisted decision support for
different infection types. Antibiotic use definitely can lead to resistance
as we’ve mentioned earlier. So we definitely want to look at patients
with a history of antimicrobial use and monitor their risk for resistance. We also wanna look at antibiograms and determine
if regions have a prevalence of antimicrobial resistance. We can definitely change our prescribing patterns
to help to curtail resistance or to also lead to resistance so we need to be monitoring
that with some of our metrics. And then we want to look at dose-response
relationships and making sure that we’re optimizing the dose for the antimicrobial and for the
patient. What can we do as pharmacists to help improve
this scenario? There are several things that we have listed
here. We definitely can review culture data and
de-escalate therapy when appropriate. We can help optimize our dosing strategies
both based on the drug and also the pharmacodynamic effect of the antimicrobial in the patient’s
body. We can also do medication use evaluations
and look for trends in prescribing that may be leading to resistance. We can look for drug allergy information and
we can also promote our antibiograms and make sure they’re readily available when prescribing
is occurring. And definitely helping the patient to know
what the adverse drug events are and to help with monitoring of those. So for example [inaudible 00:10:07] antibiotic
allergy history most people who believe that they are allergic to an antibiotic can take
that antibiotic without a problem and they may not even have a true allergy. So a good patient antibiotic history can help
sort out whether or not these patients can actually receive that antibiotic in question. So here we have a list of questions that you
can ask your patients. This would include does the parent remember
having an allergy or was it just told to them by a parent or grandparent? How many years ago was the reaction? Was the reaction with the first dose? How was it treated? What occurred when the action happened? And did the patient take other medications
at the same time that could have led to that reaction? If the patient is unsure of these questions,
you may be able to try that in a microbial and actually use it to treat an infection
for the patient. The strategies to improve antimicrobial use
include making sure that the patients are adherent to their therapy. Also making sure that the providers are adherent
to practice guidelines. We have a lot of clinical pathways that we
can use that are based on guidelines and evidence that help us streamline our therapy for our
patients once a culture is returned. Using appropriate dose and duration only when
the antimicrobial is necessary and looking for things like adverse events, symptom management
and helping with antimicrobial resistance when we’re talking with providers. An example of prevention strategies that we
can use as pharmacists is in the management of upper respiratory tract infections. These infections occur primarily in the outpatient
setting but we do see them in both the inpatient and outpatient environments and they’re associated
with about 15 million infections per year and they account for about 68 percent of all
outpatient antibiotics. However, the majority are caused by viruses
which would not need any antibiotic therapy. In fact, for Pharyngitis, only about 15 to
30 percent are actually caused by bacteria and sinusitis about 80 percent has a viral
cause and for otitis media 80 percent can resolve spontaneously without any treatment. So most cases can be treated by a watch and
wait approach with symptomatic management. So let’s look specifically at some of these
upper respiratory tract infections, the first of which is Acute Otitis Media or the common
ear infection. As we see with treatment guidelines, the lowest
risk children, those that are greater than 2 years of age, have had no recent antibiotics
and have no history of any ear infections , can actually be observed for 24 to 72 hours
before antibiotic therapy is started if it’s needed at all. Whereas those with highest risk you would
want to go ahead and treat them with antimicrobial therapy. So what does that watch and wait look like? If we look at the number needed to treat to
prevent one case of ear pain, it takes about 20 children to be treated with antimicrobial
therapy just to prevent one case of the ear pain. And 33 children needed to be treated to prevent
one perforation. Whereas, 1 in every 14 children will develop
diarrhea, rash or vomiting from antimicrobial therapy. So as you can see, it’s much more risky to
treat them with antimicrobial therapy if they don’t need it due to the adverse events associated
with that therapy. So a wait of 1-3 days before initiating antimicrobial
therapy may be warranted in Acute Otitis Media. If we look at another upper respiratory tract
infection, Pharyngitis has treatment guidelines that recommend that most of the time in children
less than 3 years of age this is going to be a viral infection so it’s rarely gonna
need antimicrobial therapy. And then you can use other strategies to determine
the risk associated with an actual bacteria pathogen, Group A Strep in the diagnosis of
Pharyngitis. So the peak incidence of this group A strep
is between 5 and 15 years of age. You definitely want to look at other non-infectious
causes such as allergies, malignancy, chemotherapy or chemical exposure, and direct trauma to
the area such as drinking something hot, that could be causing the throat pain before you
automatically jump to an antimicrobial therapy. There are some criteria for the rapid strep
test. First of all, you definitely want to determine
who to treat versus who are at the latest risk of having a strep bacterial infection. So you definitely would use that primary age
group of 4 to 15 and some of the Centor Criteria can be used to determine whether or not they
need antimicrobial therapy are a fever greater than 101, a tonsillar exudate or pus at the
back of the throat, absence of a cough or cervical lymph node involvement. If they have 2 or more of these, you probably
do wanna go ahead and test them for strep and rule out other causes if necessary. And then finally, the 3rd upper respiratory
tract infection that we wanted to discuss is Sinusitis. Treatment should only be offered to patients
who have an onset of symptoms that are lasting for greater than 10 days without improvement,
have an onset of severe symptoms or have a very high fever with a very purulent nasal
discharge or facial pain or have worsening of symptoms. And sometimes this is deemed the “double sickening,”
where they actually had a viral infection primarily, that lasted 5 to 6 days and that
trapped bacteria causing a bacterial infection which lead to the need for antimicrobial therapy. So definitely using those criteria to determine
whether or not a patient needs therapy. Some other prevention strategies are using
vaccines for vaccine preventable infections. Some of these are listed here below. The most common obviously are influenza and
pneumococcal infection but we also definitely want to vaccinate our children for some of
these others and then there’s also travel vaccines that we can use to prevent things
such as malaria, when we travel to other countries. Another promise of the pharmacist is to provide
patient counseling. We definitely want to encourage the patient
to finish their full course of antimicrobials. Also, tell them what to look out for when
they’re taking their antimicrobials, whether it be the most common adverse effects like
rash and diarrhea, or something less common that they may run across when they’re taking
therapy. Also emphasize adherence, making sure that
if they’re taking something several times a day that they take every dose. Looking at other ways to manage their symptoms,
helping with them antipyretics and analgesics. Also, providing them with tools to measure
whatever symptom management agent they’re using, especially in children. It’s really important to provide them with
an exact measuring device versus a tablespoon. Also, talking about alarm symptoms. So if you’re using that watch or wait approach,
where you’re actually watching a child for 48 to 72 hours, you want to give them parameters
by which to seek help if they start to have worsening of symptoms. Some other responsibilities of the pharmacist
include discharge planning if they’re in the hospital. Also providing education to other healthcare
providers. Performing formulary reviews of new or reformulated
antimicrobials. It’s really important to get ahead of the
prescribing pattern before it starts, so when you have a new agent to review it and make
sure that you have criteria developed for use of that agent. Precepting and mentoring pharmacy students
and helping them understand the principles of antimicrobial stewardship. Providing presentations at local, state, national
levels and then conducting research to help to control antimicrobial use, maybe restrict
use and also aide in reporting good antimicrobial stewardship practices. And then one further role, looking at colonization
vs. infection, infection suggests that the invasive microorganism, like a bacteria or
a fungi, is actually penetrating the tissues of the body and so that results in signs and
symptoms such as fever, pus, high white blood cell count, pain or organ dysfunction. Whereas colonization is just the microorganism,
whether it be a bacteria or a fungi, that actually resides in the body without invading
the tissue. So it doesn’t cause those signs and symptoms
that we just talked about. So there’s a lot of different microorganisms
that can colonize the skin, the wounds, airways, GI tract, urinary or the mouth and the nose. So it’s really important as pharmacists for
us to be able to distinguish between infection and colonization so that we can help make
good treatment choices and determine when antibiotics are needed. An example of this is asymptomatic bacteria. A bacterial urinary tract colonization should
not be treated with antibiotics. That means that unless a patient has symptoms
of a UTI, bacteria in the urine should not be treated. And so we definitely don’t wanna treat a UTI
based on urine smell or appearance. And we’re in a great position to reinforce
these principles with patients and families. More strategies that we’ve discussed earlier
but just wanted to highlight again, we definitely want to make sure that we don’t take any antimicrobials
for viral infections. That we’re obtaining culture before we’re
starting antibiotics and that we don’t treat those colonizations that we just talked about. We wanna discontinue therapy if it’s a non-infectious
diagnosis. So a good example here in the hospital is
looking at pneumonia versus heart failure. If you have an unclear chest x-ray and then
a CT is performed and it definitely shows a fusion versus a bacterial source or a pneumonia
source, then you definitely can streamline and discontinue antibiotic therapy. And then limiting the duration of therapy
to the appropriate length based on evidence with common infection types. And this is something that we’re definitely
trying to do with both the outpatient and inpatient settings. Finally, just to review the Clostridium Difficile
infection risk factors, we definitely want to decrease the use of antibiotics that are
frequently associated with this infection type and some of the more common ones are
things like broad spectrum penicillin, an example being Eosin, or a broad spectrum cephalosporins
such as ceftriaxone. These agents definitely frequently lead to
CDI and so we want to make sure that we’re limiting the use and only using them when
absolutely necessary. And although all antibiotics can cause C.
Diff, these are the ones that we want to focus on especially. And so in conclusion, by making antimicrobial
stewardship part of your daily practice, you can improve patient safety and care, reduce
the unnecessary use of valuable resources and reduce bacterial resistance. Thank you. Thank you Dr. Collins. I’d like everyone to please take time to look
at these resources on this page. You can use these in your practice. Now that you’ve completed the review of the
resources and you’ve listened to this recorded education, you’re ready to complete the post
test. Click on the green icon to the right, the
one with the pencil and complete your test. Once you’ve passed the posttest with a 70
percent or higher score, you will receive a certificate for credit in the email within
a week. We appreciate that you have used this education
and hope that it will help you in your practice.

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