PACCARB Meeting Part 3: Working Group on Antibiotic Stewardship

PACCARB Meeting Part 3: Working Group on Antibiotic Stewardship


GOOD AFTERNOON, LADIES AND GENTLEMEN.
OUR PUBLIC MEETING IS BACK IN SESSION. THIS AFTERNOON WE’RE GOING TO BEGIN WITH A
REPORT FROM THE FIVE PACCARB WORKING GROUPS. EACH OF THE WORKING GROUPS WAS FOCUSED ON
ONE OF THE MAJOR GOALS OF OF THE NATIONAL ACTION PLAN.
WE’RE GOING TO HAVE REPORTS FROM THE CHAIR AND VICE CHAIR OF EACH OF THE WORKING GROUPS
IN TURN. THERE WILL BE A REPORT, TIME FOR DISCUSSION,
AND WE’LL PROCEED, AND THEN THERE WILL BE A FINAL THERE WILL BE A FINAL SUMMATION.
I WOULD LIKE TO POINT OUT TO THE PUBLIC THAT THE WORKING GROUPS WORKED INTENSIVELY.
EACH OF THE WORKING GROUPS HAD AT LEAST EIGHT CONFERENCE CALLS.
THESE CALLS INVOLVED A NUMBER OF DIFFERENT EXPERTS WHO PROVIDED TESTIMONY.
THERE WAS ACTIVE DISCUSSION, AND THERE WERE I’LL JUST SAY INNUMERABLE CALLS AN E MAILS
IN BETWEEN THAT ENABLED EACH OF THE WORKING GROUPS TO PROVIDE A REPORT.
THIS WAS A VERY HARD WORKING SERIES OF GROUPS AND CERTAINLY DR. KING AND I REALLY COMMEND
THEM FOR THEIR GREAT WORK. IN THE PUBLIC SERVICE.
SO LET’S BEGIN WITH WORKING GROUP 1, ON ANTIBIOTIC STEWARDSHIP, THE REPORT WILL BE GIVEN BY DR.
SARA COSGROVE, AND DR. MICHAEL APLEY. I’M PLEASED TO PRESENT OUR RECOMMENDATIONS
AND FINDINGS FROM OUR WORK GROUP, NUMBER 1, ON THE SLIDE TITLED ANTIBIOTIC STEWARDSHIP
IS A VERY VAST TOPIC, AND WE ADDRESSED U.S. GOVERNMENT APPROACHES AND PROGRESS TO DATE
TO INCREASE ANTIBIOTIC STEWARDSHIP CAPACITY AS WELL AS TO TRACK AND PREVENT THE SPREAD
OF ANTIBIOTIC RESISTANCE IN BOTH HUMANS AND ANIMALS.
I’LL JUST START WITH A DEFINITION OF ANTIBIOTIC STEWARDSHIP, AS WE MOVE FORWARD SO WE’RE ON
THE SAME PAGE. WE ESSENTIALLY DEFINED IT AS SYSTEMATIC APPROACHES
TO ENSURE THAT ANTIBIOTICS ARE USED OPTIMALLY AND ONLY WHEN THEY ARE NEEDED.
SO THIS FIRST SLIDE IS ELUCIDATING OUR BROAD RECOMMENDATIONS, THAT WILL PROBABLY COME UP
WITH EVERY WORK GROUP. BUT SPECIFIC TO OUR WORK GROUP, WE DO RECOMMEND
ENSURING THAT THERE’S SUSTAINED AND ENHANCED FUNDING FOR THE ACTIVITIES AND STEWARDSHIP
AND SURVEILLANCE. THERE ARE HUGE CHANGES THAT HAVE TO HAPPEN
IN HOW PHYSICIANS, VETERINARIANS, AND ALL OTHER PRESCRIBERS USE ANTIBIOTICS TO MAKE
TO MOVE THE NEEDLE IN THIS AREA. AND THIS CAN NOT HAPPEN IN ISOLATION, AND
WILL REQUIRE SPECIFIC ATTENTION TO FUNDING THAT’S DIRECTED BOTH AT RESEARCH TO KNOW THE
BEST WAYS TO DO THIS AND ACTUAL IMPLEMENTATION ITSELF.
AND SO WE DON’T JUST SAY THAT TO SAY THAT. WE REALLY BELIEVE THAT MULTI YEAR FUNDING
IS CRITICAL FOR THIS WORK. AND SECOND, BROAD RECOMMENDATION IS TO COORDINATE
THIS WORK ACROSS ALL FEDERAL AGENCIES THAT INCLUDE CDC, DoD, USDA, FDA AND V.A. AND OTHER
FEDERAL AGENCIES WORKING IN THIS AREA, AND CONSIDERATION WOULD BE TO ESTABLISH DEPARTMENTAL
AND INTERDEPARTMENTAL LEVEL LEADS FOR HUMAN AND VETERINARY MEDICINE TO MOVE THIS WORK
FORWARD AND AVOID DUPLICATING WORK WHENEVER POSSIBLE.
WITH REGARD TO A ONE HEALTH APPROACH FOR GOAL 1, ONE THING WE FOUND IN COMMON WITH HUMAN
AND ANIMAL MEDICINE WAS IN ORDER TO MAKE THIS CULTURE CHANGE HAPPEN WE HAVE TO FOCUS ON
HOW WE EDUCATE OUR TRAINEES AND HAVE TO FOCUS ON HOW WE EDUCATE OUR CURRENT PRACTITIONERS
IN THE AREA. THIS HAS TO SPAN ALL OF HUMAN AND VETERINARY
MEDICINE AND I THINK THE MESSAGES ARE VERY SIMILAR IN HUMAN HEALTH AND ANIMAL HEALTH,
BECAUSE OUR END GOAL AS I SAID IS STEWARDSHIP OF ANTIBIOTICS.
WE HAD THREE OBJECTIVES IN OUR GOAL 1. I WILL DISCUSS 1.1, IMPLEMENT PUBLIC HEALTH
PROGRAMS AND REPORTING POLICIES THAT ADVANCE ANTIBIOTIC RESISTANCE PREVENTION PROGRAM AND
FOSTER STEWARDSHIP, AND THEN MIKE WILL ADDRESS 1.2, ELIMINATE USE OF MEDICALLY IMPORTANT
ANTIBIOTICS FOR GROWTH PROMOTION AND FOOD PRODUCING ANIMALS AND BRING UNDER VETERINARY
OVERSIGHT INFEED AND IN WATER USES OF ANTIBIOTICS THAT ARE MEDICALLY IMPORTANT AND 1.3, IDENTIFY
AND IMPLEMENT MEASURES FOSTER STEWARDSHIP IN ANIMALS.
THERE’S BEEN NOTABLE ACTIVITIES IN THIS AREA, OUR GROUP APPLAUDS THE FEDERAL GOVERNMENT.
I’LL HIGHLIGHT A FEW ACTIVITIES, CMS HAS IN THE WORKS A CONDITION OF PARTICIPATION THAT
WOULD REQUIRE ANTIBIOTIC STEWARDSHIP PROGRAMS IN IN PATIENT SETTINGS ACROSS THE UNITED STATES.
AND ALREADY HAS SET FORTH NEW INFECTION CONTROL STANDARDS THAT REQUIRE ANTIBIOTIC STEWARDSHIP
PROGRAMS IN LONG TERM CARE FACILITIES. THIS IS THE FIRST TIME WE’RE SEEING A BROAD
REQUIREMENT THEY WILL NEED TO ADDRESS STEWARDSHIP AMONG ALL PRESCRIBERS, CDC HAS DONE THINGS
TO SUPPORT THIS WORK. THEY HAVE DEVELOPED CORE ELEMENTS DOCUMENTS,
THEY HAVE A SURVEY THAT ALLOWS AN ANNUAL ASSESSMENT OF THE UPTAKE OF ANTIBIOTIC STEWARDSHIP PROGRAMS
ACROSS THE COUNTRY. SO THIS IS VERY GOOD WORK IN THE AREA OF ANTIBIOTIC
STEWARDSHIP. THERE’S GOOD WORK BEING DONE IN THE AREA OF
EXPANDING OUR ABILITY TO DO SURVEILLANCE FOR ANTIBIOTIC USE AND RESISTANCE.
AND DOING SOMETHING ABOUT IT, WHICH IS CRITICAL, BECAUSE YOU CAN DO SURVEILLANCE ALL YOU WANT,
IF YOU’RE NOT GOING TO ACT ON THE INFORMATION WHAT’S THE POINT OF DOING THE SURVEILLANCE?
ELIZABETH JUNGMAN FROM GROUP 2 IS GOING TO TALK ABOUT SURVEILLANCE ACTIVITIES GOING ON.
IN ADDITION WE’RE DOING WORK, THE CDC IS DOING WORK TO TEN HANS OUR ABILITY TO COLLECT INFORMATION
ABOUT ANTIBIOTIC USE ACROSS THE COUNTRY. AGAIN, YOU WOULD THINK THAT SUCH A LARGE COUNTRY
WOULD HAVE THIS INFORMATION AT ITS FINGERTIPS BUT INDEED IT DOES NOT.
AND THERE’S A LOT OF WORK TO BE DONE WITH THAT INFRASTRUCTURE IN PLACE TO MAKE IT HAPPEN,
BUT WE HAVE TO DO A LOT OF WORK TO GET HOSPITALS TO REPORT IN TO THIS.
AND AS WE HEARD THIS MORNING, THERE HAVE BEEN GOOD INCREASES IN BUDGETS TO FEDERAL AGENCIES
AND THIS HAS INCLUDED EXPANSION OF FUNDING TO CDC, AHRQ AND NIH FOR RESEARCH TO DEVELOP
AND IMPLEMENTED INTERVENTION TO PROMOTE STEWARDSHIP AND PREVENT RESISTANCE.
THE NEXT THREE SLIDES ADDRESS ADDITIONAL RECOMMENDATIONS IN THE AREA OF STEWARDSHIP, SURVEILLANCE,
AND RESEARCH. I THINK FIRST AND FOREMOST IN THE AREA OF
ANTIBIOTIC STEWARDSHIP, NOW THAT WE ARE WORKING TOWARDS REQUIREMENTS TO HAVE STEWARDSHIP WE
NEED TO PAY A LOT OF ATTENTION THAT THESE ARE NOT JUST STEWARDSHIP PROGRAMS ON A CHECK
BOX, THESE ARE STEWARDSHIP PROBLEMS THAT DO SOMETHING TO REDUCE RESISTANCE.
A CRITICAL COMPONENT IS INTERPRETIVE GUIDELINES FOR WHAT THESE CONDITIONS OF PARTICIPATION
LOOK LIKE, NEED TO BE VERY SPECIFIC AND WE NEED TO TRAIN THE SURVEYORS WHO ASSESS THAT
AT INDIVIDUAL HOSPITALS AND LONG TERM CARE FACILITIES ABOUT WHAT IS REALLY STEWARDSHIP
BECAUSE WE DON’T WANT CHECK BOX STEWARDSHIP. WE WANT ACTUAL WORKING STEWARDSHIP. PART OF THIS WILL ALSO INCLUDE MAKING SURE
WE CONTINUE TO HAVE ADEQUATE PHYSICIANS AND PHARMACISTS WITH APPROPRIATE TRAINING IN INFECTIOUS
DISEASES, IT DEPENDS ON EXPERTISE IN THIS. IN ADDITION WE RECOMMEND ENHANCED COLLABORATION
BETWEEN CMS QUALITY IMPROVEMENT NETWORKS AND HOSPITAL ENGAGEMENT NETWORKS AS WELL AS THE
NEW CDC PROGRAMS THAT ARE GOING TO BE ESTABLISHED AT THE STATE LEVEL TO PREVENT RESISTANCE,
WE THINK THE MORE THE GROUPS CAN WORK TOGETHER AND SHARE, THE MORE EFFECTIVE THE WORK WILL
BE. WE NEED INCREASED ATTENTION, A PARTICULAR
CHALLENGE IN THE UNITED STATES, NEED TO INVESTIGATE WHAT EDUCATIONAL MESSAGES ARE MOST LIKELY
TO LEAD TO BEHAVIOR CHANGE NOT ONLY IN PRESCRIBERS BUT ALSO IN PATIENTS REGARDING ANTIBIOTIC
USE IN BOTH HUMANS AND ANIMALS, AND I SAID WE’LL TALK ABOUT SUSTAINED FUNDING AGAIN WE
HAVE TO ENSURE SUSTAINED FUNDING FOR ALL THESE ACTIVITIES.
REGARDING SURVEILLANCE, SUSTAINED FUNDING IN THIS AREA IS OF PARTICULAR IMPORTANCE,
A YEAR OF SURVEILLANCE DATA DOES NOT GET YOU VERY FAR.
WE HAVE TO KNOW WHAT’S HAPPENING OVER MULTIPLE YEARS TO LOOK FOR IMPROVEMENT, TO KNOW WHAT
AREAS TO FOCUS ON, AND I THINK IT WOULD BE HELPFUL TO COORDINATE WHAT DATA ARE COLLECTED,
ANALYZED AND ACTED UPON BY THE CDC AS THE STATE PROGRAMS MOVE OUT SO WE DON’T HAVE INDIVIDUAL
STATES MAKING INDIVIDUAL DECISIONS ABOUT WHAT BUG THEY WOULD LIKE TO DO SURVEILLANCE FOR.
WE NEED A MORE COORDINATED EFFORT. WE HAVE TO ADDRESS OTHER CHALLENGES OF GETTING
INFORMATION FROM HOSPITALS AND OTHER FACILITIES TO THE STATES, TO REALLY HAVE ROBUST DATA. WE NEED TO INCREASE THE NUMBER OF HOSPITALS
REPORTING ANTIBIOTIC USE DATA TO THE NHSN, AUR MODULE AND DEVELOP MORE ROBUST METHODS
TO ASSESS APPROPRIATE ANTIBIOTIC USE, HALF ARE PRESCRIBED IN THE OUTPATIENT SETTING YET
WE DON’T HAVE A GREAT WAY TO ASSESS APPROPRIATENESS OF THOSE ANTIBIOTICS.
FINALLY WITH REGARD TO RESEARCH RECOMMENDATIONS, WE STRONGLY ENCOURAGE CONTINUED RESEARCH FUNDING
IN THE AREA OF UNDERSTANDING EFFECTIVE APPROACHES TO ANTIBIOTICS STEWARDSHIP, ESPECIALLY WAYS
TO INFLUENCE HOW PRESCRIBERS THINK ABOUT ANTIBIOTICS, IN ADDITION RESEARCH IN THE AREA OF PREVENTION
OF THE SPREAD OF ANTIBIOTICS ANTIBIOTIC RESISTANCE ACROSS ALL HEALTH CARE.
WE ALSO NEED TO MAKE SURE RESEARCH DOESN’T JUST END UP IN JOURNALS.
RESEARCH NEEDS TO END UP AS TOOLS THAT ARE TRANSLATED FOR EVERYONE TO USE, TO REALLY
MOVE THIS FORWARD. AND WE NEED TO NOT FORGET THAT WE NEED TO
TRAIN YOUNG PEOPLE TO ALSO PERFORM THIS KIND OF RESEARCH SO THEY CAN TAKE CARE OF US WHEN
WE GET OLD. SO I’LL TURN IT OVER TO MIKE. THANK YOU, SARA.
GOAL 1.2 AGAIN IS ON SPECIFICALLY A VERY SPECIFIC GOAL IN ELIMINATING USE OF MEDICALLY IMPORTANT
ANTIBIOTICS FOR GROWTH PROMOTION AND LITTLE ALSO INTERTWINED WITH WORKING GROUP NUMBER
2’S FOCUS ON MONITORING OR SOME INTERTWINING HERE.
THE ACTIVITY THAT’S BEEN IN PLACE BY THE FDA WITH GUIDANCE FOR INDUSTRY 209 AND 213 IS
UNDERWAY AND IS ANTICIPATED TO BE COMPLETED THIS DECEMBER WITH ROLLING OUT OF THOSE NEW
CONDITIONS FOR USE, JANUARY 1, 2017. AND THEN THE USE OF THE DRUGS FOR PREVENTION
CONTROL OR TREATMENT THAT ARE MEDICALLY IMPORTANT WILL BE UNDER VETERINARY CONTROL.
ANOTHER SPOT IN THIS WAS TALKING ABOUT ESTABLISHING METRICS FOR THE APPROPRIATENESS OF ANTIBIOTIC
USE AND WE DID ADDRESS THIS SOME BECAUSE WE’RE GOING TO BE LOOKING AT ANTIBIOTIC USE IN RELATIONSHIP
TO THIS SPECIFIC INITIATIVE AND THEN EVALUATING FURTHERANCE OF THIS INITIATIVE DOWN THE ROAD. I THINK IN COMING UP WITH THIS LANGUAGE, I
THINK ONE OF THE THINGS THAT’S REALLY CLEAR IS THERE WOULD BE WIDELY DIFFERING OPINIONS
ON LEVEL OF EVIDENCE FOR WHICH DRUG SHOULD STAY AND WHICH SHOULD GO, AND THE DEGREE TO
WHICH OR SURETY TO WHICH WE HAVE REASONS FOR MOVING AHEAD TODAY AND SO THESE ARE REALLY
STATEMENTS WE COULD AGREE ON THAT SAID WE NEED TO CONTINUE TO WORK ON THESE, THESE ARE
REALLY BIG PRIORITIES AND MOVING AHEAD AND MAKING ADVANCEMENTS ON THESE AREAS. THE LAST ONE, GOAL 1.3 AGAIN WAS IDENTIFYING
AND IMPLEMENTING MEASURES TO FOSTER STEWARDSHIP OF ANTIBIOTICS IN ANIMALS, AND ONE OF THE
THINGS WE DIDN’T ACTUALLY PUT IN HERE ON THE SLIDE, QUALITY ASSURANCE PROGRAMS, EDUCATIONAL
OUTREACH STRATEGIES, EXPANSION OF ANTIBIOTICS STEWARDSHIP, INITIATIVES AND VETERINARY CURRICULA,
CONTINUING EDUCATION PROGRAMS, JUDICIOUS USE GUIDELINES HAVE BEEN BEING INITIATED BY PRODUCERS
AND VETERINARY GROUPS IN ASSOCIATION WITH FEDERAL AGENCIES FOR SOME TIME AND OUR RECOMMENDATIONS
ARE THAT USDA AND FDA SHOULD GIVEN THE MEANS TO ENSURE FINANCIAL AND EDUCATIONAL SUPPORT
OF THESE OUTREACH EFFORTS AND CONTINUE THOSE UNDERTAKEN BY AG EXTENSION N.G.O.s, ET CETERA,
AND THESE ARE A WORTHY START AND SHOULD BE SUPPORTED, AND THEN ALSO IT’S BEEN MADE CLEAR
BY SOME OF THE MEMBERS OF THE COUNCIL WE SHOULDN’T JUST FOCUS ON FOOD ANIMAL STEWARDSHIP BUT
ALL STEWARDSHIP IS IMPORTANT INCLUDING COMPANION ANIMALS WHO ARE CLOSELY ASSOCIATED WITH HUMAN
HOSTS. THAT BROADENS THE SCOPE BEYOND THINKING OF
FOOD ANIMALS AND PUTS IT TOWARD ALL VETERINARY MEDICINE.
WITH THAT, WE’D LIKE TO THANK ALL OUR WORKING GROUP MEMBERS WHO WORKED HARD AND THE REST
OF THE COUNCIL FOR THEIR VALUABLE INPUT ON OUR SECTION.
WE’LL TAKE QUESTIONS, MR. CHAIR. THANK YOU BOTH FOR YOUR REPORT.
I WOULD LIKE TO IN BEGINNING THE QUESTIONS, GO BACK TO AN EARLIER POINT.
I MENTIONED THAT THE COUNCIL MEMBERS SPENT A LOT OF TIME ON WORKING GROUPS.
EACH COUNCIL MEMBER SERVED ON TWO WORKING GROUPS SO THEY HAD A LOT OF WORK TO DO, AND
NOW I PARTICULARLY WANT TO INVITE MEMBERS OF OUR COUNCIL WHO DID NOT SERVE ON WORKING
GROUP 1 FOR QUESTIONS THAT MIGHT REFER TO WORKING GROUP 1 AND THEN WE CAN DEAL WITH
OTHERS ON THE COUNCIL. ARE THERE QUESTIONS?
TOM? AND PLEASE IDENTIFY YOURSELF. TOM SHRYOCK.
NICE JOB ON WORKING GROUP 1, STEWARDSHIP. IT OCCURS TO ME STEWARDSHIP IS CONNECTED IN
MANY CASES TO THE OTHER WORKING GROUPS, IN TERMS OF SETTING A TEMPLATE FOR ANTIBIOTIC
USE NOT JUST NOW BUT IN THE FUTURE, SO DID THE WORKING GROUP CONSIDER THINGS LIKE NEW
ANTIBIOTIC USE, DIAGNOSTIC TOOLS THAT COULD BE USED OR MAYBE WE DO NEED, AND RESEARCH
THAT COULD FOSTER ADDITIONAL STEWARDSHIP RECOMMENDATIONS? I’M TRYING TO BE FORWARD LOOKING HERE RATHER
THAN SAY, YEAH, WE’VE GOT THESE THINGS TODAY BUT OPEN IT UP TO SAY WHAT DO WE NEED IN THE
FUTURE AND HOW CAN WE GET THERE? WORKING GROUP 4 ADDRESSED A LOT OF THOSE ISSUES
AND SOME OF THE OTHER WORKING GROUPS SO WE TRIED TO MAKE SURE WE DIDN’T TRACK DOWN THE
SAME ROAD, BUT YOUR POINTS ARE WELL TAKEN AND THE MISSION ON PART OF WORKING GROUP 1
IS NOT THAT THEY ARE NOT IMPORTANT BUT RECOGNITION OTHER GROUPS DEALT WITH THOSE ISSUES. THIS AREA OF IMPLEMENTATION OF STEWARDSHIP,
AS YOU SAID, AS WE BOTH SAID, IS OF CRITICAL IMPORTANCE, AND THERE IS LIKELY A ROLE FOR
RAPID DIAGNOSTIC TESTS IN STEWARDSHIP BUT AS YOU’LL HEAR FROM WORK GROUP 3, THOSE TESTS
CANNOT EXIST IN THE ABSENCE OF AN ANTIBIOTIC STEWARDSHIP PROGRAM.
THEY MUST BE HAND IN HAND, SO THAT CLINICIANS MAKE THE BEST USE OF THOSE TESTS.
I OFTEN SPEAK FROM THE HUMAN PERSPECTIVE BUT I THINK THAT’S TRUE IN THE ANIMAL WORLD ALSO
BECAUSE THESE ARE NEW TECHNOLOGIES, AND NEW TECHNOLOGIES TAKE TIME TO BE ADOPTED APPROPRIATELY.
JOHN REX. THANKS FOR A NICE REPORT.
MY QUESTION IS ABOUT THE CONDITIONS OF PARTICIPATION REQUIREMENT THAT’S COMING INTO PLAY WITH RESPECT
TO HAVING TO HAVE A PROGRAM END. WHAT’S THE TIME LINE FOR THAT?
AND AS I UNDERSTAND IT CORRECTLY, THAT WOULD APPLY ONLY TO HOSPITAL LIKE FACILITIES OR
DOES IT ALSO APPLY TO CLINICS AND OTHER LEVELS, AND IF NOT THE LATTER THEN DO WE NEED TO DO
SOMETHING ABOUT THAT? DO OUR CMS COLLEAGUES WANT TO ADDRESS THAT?
SURE. SO, YES
IDENTIFY YOURSELF. MARJORIE CANNON, CMS.
BOTH OF THOSE SETTINGS AS YOU KNOW HAVE COME INTO PLAY IN RECENT CONDITIONS OF PARTICIPATION,
THE LONG TERM CARE ANTIBIOTIC STEWARDSHIP IN LONG TERM CARE IS MORE OF A FASTER TIME
LINE. THE PUBLIC COMMENT PHASE ENDED A COUPLE MONTHS
AGO. THERE WERE OVER 9000 COMMENTS RECEIVED AND
CMS IS ADDRESSING ALL OF THOSE. SO THAT IS IN THE WORK TOWARD FINAL PROPOSALS.
WE CAN’T SAY TOO MUCH ABOUT THE CONDITIONS OF PARTICIPATION IN HOSPITALS YET.
THAT’S MORE IN ITS INFANCY AND PROPRIETARY INFORMATION BUT WE’RE TRACKING ALONG THOSE
LINES AND USING THAT MECHANIC, AS WE WILL FOR INTERPRETIVE GUIDANCE. I DID NOT MENTION, BUT THE JOINT COMMISSION
HAS ALSO HAS A DRAFT STANDARD FOR ANTIBIOTIC STEWARDSHIP AND THAT COVERS ALL HEALTH CARE
SETTINGS INCLUDING OUTPATIENT, AND THAT HAD A PUBLIC COMMENT PERIOD AND THEY ARE LOOKING
AT THOSE COMMENTS NOW. SO WOULD IT BE USEFUL TO STATE A TARGET YEAR
FOR ANY OF THIS? BECAUSE THAT’S WHAT I’VE NOT HEARD IS BY TWO
THOUSAND X WE’LL HAVE Y% DOING Z? I’M SPEAK FOR CMS QUICKLY. WITHIN OUR PROCESS OF RULE MAKING, THAT KIND
OF DEFINES THE TIME LINE AND SO THERE’S NOT REALLY A SPECIFIC TIME THAT WE CAN SET BECAUSE
THAT PROCESS HAS A LOT OF DIFFERENT MECHANISMS AND IS INFLUENCED, BUT IT IS CERTAINLY ON
EVERYONE’S MIND AND THERE’S A LOT OF WORK GOING TOWARD IT. EILEEN MARTY.
SARA, FANTASTIC. YOU AS WELL, MIKE.
IN SARA’S PRESENTATION, YOUR COMMENT ON SURVEILLANCE FOR ACTION, WHICH IS ABSOLUTELY KEY, I WAS
WONDERING IF WE TURNED THIS WHOLE THING A LITTLE BIT ON ITS HEAD AND INSTEAD OF THINKING
STRICTLY ABOUT STEWARDSHIP FROM THE PROVIDER, THE HOSPITAL, THE VETERINARIAN, ET CETERA,
AND SEE IF THERE WAS SOME WAY TO DO SURVEILLANCE AT THE LEVEL OF THE PATIENT, WHEN YOU GET
YOUR ANTIBIOTIC YOU GET A QUESTIONNAIRE, DO YOU WHY YOU’RE GETTING THIS, HOW IT’S GOING
TO BE USED, WAS THAT DONE IN YOUR CONVERSATION? IT’S A GREAT IDEA. WE DID NOT HAVE THOSE CONVERSATIONS.
ELIZABETH, DID YOU TALK ABOUT THAT IN IT DIDN’T COME UP IN OUR GROUP. THANKS VERY MUCH. GREAT JOB.
I WAS PLEASED AND I’VE HEARD CONVERSATIONS IN YOUR GROUP ABOUT STRESSING EDUCATION AND
JUST COMING FROM A UNIVERSITY WITH SEVEN HEALTH SCIENCE COLLEGES AND PUTTING THEM TOGETHER
THERE’S NO STANDARDIZATION. THERE’S NO BASIC CURRICULUM.
I WAS LOOKING AT THE CORE ELEMENTS CDC HAS REALIZING STEWARDSHIP IS IMPORTANT, IF YOU
HAVE A FLOCK, HERD, OR INDIVIDUAL. HAVE YOU GIVEN THOUGHT OR FURTHER CONVERSATIONS
ABOUT HOW TO DO THAT? IS THERE A BASIC EDUCATION STRATEGY OR CURRICULUM
THAT YOU CAN PUT FORWARD OR HAD YOU THOUGHT ABOUT THAT?
I REALLY THINK IT’S AN AREA THAT NEEDS MORE WORK, IN THE HUMAN SIDE AND VETERINARY SIDE.
WE ON THE HUMAN SIDE JUST AS ONE EXAMPLE IN MEDICAL SCHOOL, THERE’S BEEN A DECREASE IN
INFECTIOUS DISEASED INDICATION, OVERALL. IT GETS LUMPED INTO SYSTEM BASED EDUCATION,
SO WHEN YOU’RE DOING CARDIOLOGY I GUESS YOU’VE LEARNED ENDOCARDITIS, BUT THAT HAS TAKEN AWAY
FROM LOOKING AT INFECTIOUS DISEASE AS ITS OWN WHOLE, AND STEWARDSHIP IS INTEGRATED INTO
INFECTIOUS DISEASES, SO I’M CONCERNED EVEN FOR THE MEDICAL STUDENT CURRICULUM STEWARDSHIP
GETS LEFT BEHIND BECAUSE OF THE WAY THEY ARE DEVELOPED RIGHT NOW AND WOULD LOVE TO SEE
INCREASED ATTENTION IN THAT AREA. I THINK THAT’S PROBABLY TRUE FOR NURSE PRACTITIONER
TRAINING, PHYSICIAN ASSISTANT TRAINING, VETERINARY TRAINING, AND ALL THE OTHER PEOPLE WHO PRESCRIBE
ANTIBIOTICS. DEEPER IN THE TEXT OF OUR REPORT IS THE DISCUSSION
OF THAT THAT THERE’S VALUABLE LESSONS TO BE TAKEN FROM WHAT WE LEARNED IN BOTH HUMAN AND
VETERINARY MEDICINE. I SIT HERE TODAY, I THINK ONE OF THE MOST
VALUABLE THINGS THAT HAPPENED FOR ME IN THIS SELFISHLY WAS HEARING DETAILED DESCRIPTIONS
OF THE CHALLENGES AND REACTIONS ON THE HUMAN SIDE AND I THINK SARA WOULD SAY SHE’S HAD
SOME BIG DISCOVERIES OF THINGS WE DO IN CHALLENGES AND WE IN THE VETERINARY SIDE.
IN A CURRICULUM, THE IMPORTANCE TO ME OF HAVING IT START WITH YOUR PHYSIOLOGY INSTRUCTORS
AND WORK UP THROUGH REINFORCEMENT BY THE CLINICIANS, I PERSONALLY HAD THE EXPERIENCE OF HAMMERING
ON ANTIBIOTIC RESISTANCE FOR AN HOUR IN OUR CLINICAL PHARMACOLOGY HOURS AND A STUDENT
SAID THAT’S INTERESTING, THE CLINICIAN WHO JUST FINISHED BEFORE YOU SAID THEY WEREN’T
SURE RESISTANCE WAS REALLY A REAL ISSUE. YOU GO … OKAY. WELL, AT LEAST I GOT MY LICKS IN.
[LAUGHTER] STANDARDIZATION ACROSS THE CURRICULUM GETTING
EVERYONE IN, ONE OF THE THINGS THAT REALLY STRUCK ME WITH SOME OF OUR DISCUSSIONS IN
OUR WORKING GROUP WAS IF I RECALL CORRECTLY ONE OF THE HIGHEST THINGS CORRELATED WITH
MAKING ADVANCEMENTS ON STEWARDSHIP IN HUMAN HOSPITALS WAS HAVING SOMEONE WHO WAS A FULL
TIME DESIGNATED EMPLOYEE THAT WAS THEIR JOB, NOT VOLUNTARY, NOT ADDED ON, I THINK THERE’S
A LESSON FIRST IN VETERINARY EDUCATION A SIMILAR THING.
THAT’S ONE OF THE THINGS THAT REALLY STUCK WITH ME. ALICIA COLE.
WE HAD HAVE SOME DISCUSSION ABOUT CURRICULUMS IN ONE OF OUR WORKING GROUP CALLS, AND THE
NEED FOR PROMOTING AND ADVANCING, AND I KNOW AT ONE POINT I SHARED WITHIN THE STATE OF
CALIFORNIA ONE THING THAT WE ARE DOING WITHIN OUR PUBLIC HEALTH COMMITTEE AT THE STATE LEVEL,
WE PASSED UNANIMOUSLY A MOTION WITH OUR ANTIBIOTIC STEWARDSHIP PROGRAM WHERE WE WOULD DO A SURVEY
OF ALL OF THE RESIDENCY PROGRAMS, PODIATRY PROGRAMS, DENTAL PROGRAMS, EVERY SCHOOL WHERE
THERE ARE WHERE THERE WILL BE PROVIDERS WHO HAVE THE ABILITY TO PRESCRIBE WHAT THEY ARE
CURRENTLY DOING TO GET A BASELINE, TO GET AN ASSESSMENT OF WHAT’S BEING DONE AND WHAT’S
BEING TAUGHT IN THE WAY OF ANTIBIOTIC STEWARDSHIP AND APPROPRIATE PRESCRIBING.
AND THEN FOLLOWING THAT, THE SECOND PHASE OF WHAT WE’RE GOING TO BE DOING IS REQUIRING
THAT 10% OF ALL CMEs THAT ARE DONE IN THE STATE OF CALIFORNIA WILL HAVE TO BE IN SOME
AREA OF ANTIBIOTIC STEWARDSHIP AND ANTIBIOTIC RESISTANCE, COMBATING ANTIBIOTIC RESISTANCE,
AND SO THESE ARE SOME THINGS WE TALKED ABOUT IN ONE OF OUR WORKING GROUP MEETINGS THAT
IN DOING A DEEPER DIVE THAT WE WOULD LOOK AT TRYING TO SCALE UP IN A NATIONAL WAY. DO YOU WANT TO COMMENT ABOUT THAT? HELEN BOUCHER. THAT WAS GREAT, SARA AND MIKE.
FROM AN EDUCATIONAL PERSPECTIVE ISSUE, THE WORKFORCE ISSUE IS REALLY REAL.
WE HAVE CURRICULUM IN THE TRAINING OF INFECTIOUS DISEASE FELLOWS, AND THERE IS DEDICATED TRAINING
FOR PharmD.’S AS WELL, IN THE BOARD EXAMS TO MAKE YOU BOARD CERTIFIED FOR INFECTIOUS
DISEASES WHICH IS GOOD NEWS. THE BAD NEWS IS WHAT SARA ALLUDED TO, THAT
WE HAVE A WORKFORCE PROBLEM AND IT HAS NEVER BEEN WORSE IN INFECTIOUS DISEASE IN TERMS
OF THE POOL OF PEOPLE COMING WHO ARE SPECIALTY AND WE THINK ONE REASON FOR THAT HAS TO DO
WITH WHAT’S CHANGED IN MEDICAL EDUCATION THAT SARA ALLUDED TO. THERE ARE A LOT OF OTHER ISSUES INCLUDING
FINANCIAL ISSUES AND HOW INFECTIOUS DISEASE DOCTORS REMUNERATED, BUT IT IS KEY
THE MESSAGES IN THE EXECUTION AND IMPLEMENTATION ARE IMPORTANT.
THE CURRICULUM HAS KEY CONCEPTS, INCLUDING THE KEY NOTION OF TRAINING LEADERS WHO CAN
INFLUENCE CONSTITUENCIES ON THE IMPORTANCE OF STEWARDSHIP, A REALLY IMPORTANT ASPECT
OF THIS
AS WELL. THIS IS A TEAM SPORT AND WE NEED MORE INFECTIOUS
DISEASE PHARMACISTS WHO PLAY A CRITICAL ROLE IN STEWARDSHIP PROGRAMS BECAUSE THEY DO A
LOT OF THE ACTUAL INTERVENTIONS ACROSS HEALTH CARE.
SO WE NEED MORE I.D. PHYSICIANS AND PHARMACISTS. I’VE GOT SEVERAL QUESTIONS, AND LET ME START
WITH THE FIRST ONE, AND THAT IS WELL, FIRST TO THANK YOU AND YOUR WORKING GROUP FOR A
SPLENDID REPORT, VERY COMPLICATED AREA AND YOU DID A GREAT JOB.
A LOT OF THE EMPHASIS ON STEWARDSHIP HAS BEEN IN HOSPITALS BECAUSE THE PROBLEM OF RESISTANCE
IS OBVIOUS THERE, AND SOME OF THE TOOLS LIKE CMS AND JCOH ARE THERE AS WELL.
BUT MOST OF THE ANTIBIOTICS USED IN PEOPLE ARE IN OUTPATIENTS, AND HOW ARE WE GOING TO
DEVELOP OR HOW CAN WE ADVISE THE GOVERNMENT TO DEVELOP BETTER WAYS TO IMPROVE STEWARDSHIP
IN THE OUTPATIENT PRACTICES? THAT’S A TOUGH QUESTION. IT’S ONE THAT WE HIGHLIGHTED IN OUR REPORT.
ONE IMPORTANT ASPECT IS GETTING SOME INFORMATION ABOUT WHAT THE EXTENT OF USE IS IN THE OUTPATIENT
SETTING FOR HUMANS, AND ACTUALLY ALSO FOR ANIMALS BUT THAT’S PROBABLY SIGNIFICANTLY
HARDER, AND THEN UNDERSTANDING IF THAT USE IS APPROPRIATE OR NOT BECAUSE THE GOAL OF
STEWARDSHIP IS NOT TO DENY ANTIBIOTICS TO PEOPLE WHO HAVE BACTERIAL INFECTIONS.
IT’S TO MAKE SURE WE’RE NOT GIVING ANTIBIOTICS TO PEOPLE WHO HAVE A VIRAL INFECTION OR NO
INFECTION AT ALL. AND CDC IS WORKING AND, BETH, IF YOU WANT
TO COMMENT FURTHER, WORKING IN SOMEWHAT CONSTRAINED ENVIRONMENT IN THE UNITED STATES TO GET DATA
ON OUTPATIENT PRESCRIBING TO AT LEAST ESTABLISH A BENCHMARK OF WHERE WE ARE WITH OUTPATIENT
PRESCRIBING AND WHAT PROPORTION WE THINK IS INAPPROPRIATE.
I DO THINK HAVING SOME DATA IS ALWAYS HELPFUL UPON WHICH TO BENCHMARK MOVING FORWARD AND
CREATE A SENSE THAT YOU’RE BEING WATCHED, WHICH IS NOT WHAT WE CURRENTLY HAVE IN THE
OUTPATIENT SETTING. I DON’T KNOW IF YOU WANT TO ADD TO THAT. ONLY TO SAY I THINK THIS IS SOMETHING WE’RE
ADDRESSING FROM MULTIPLE FRONTS. THERE ARE SOME CONDITIONS THAT, YOU KNOW,
LIKE BRONCHITIS FOR EXAMPLE WHERE I THINK WE CAN CLEARLY SHOW THAT THERE ARE SOME INTERVENTIONS
WE CAN MAKE PROGRESS, SOME OF THE LARGE MANAGED CARE ORGANIZATIONS CAN REALLY BE CHAMPIONS
AND SORT OF, YOU KNOW, MOVE THE DIAL A LITTLE BIT AND THEN AFTER THAT I THINK TO AGAIN ECHO
WHAT YOU SAID, SARAH, JUST MAKE THE POINT ABOUT THE IMPORTANCE OF INFORMATION FOR ACTION,
WHICH IS REALLY, YOU KNOW, A PARADIGM WE’VE BEEN APPLYING IN ALL OF OUR WORK ON BOTH A
R AND HEALTH CARE ASSOCIATED INFECTIONS, AND I THINK TO GET DOWN TO THAT AT THE OUTPATIENT
LEVEL WE’RE STARTING WITH SOME CONDITIONS WE KNOW HOW TO ADDRESS AND WE’VE BEEN COLLABORATING
WITH PARTNERS TO FIGURE OUT WHAT MEASURES, METRICS WOULD WORK.
AND IT IS A BIT MORE COMPLICATED, WE HAVE PRINCIPLES MOVING FORWARD ON IMPLEMENTING
AND WE’LL GET THERE EVENTUALLY. GREAT. BRONCHITIS IS A COMMON CONDITION.
I JUST WANT TO ASK MARTY, CAN I FOLLOW UP ON THAT QUICKLY IF
YOU’RE MOVING TO SOMETHING DIFFERENT? ONE THING I MIGHT DISAGREE WITH ABSENCE OF
DATA. WE HAVE DATA.
CDC PUBLISHED THIS. WE HAVE STATE LEVEL DATA.
WE KNOW FOR INSTANCE PER CAPITA ANTIBIOTIC PRESCRIBING IN ALASKA IS HALF OF THE SOUTHEAST
OR U.S., THERE ARE CLEAR SOLID AND REGIONAL TRENDS OVER TIME AND WE KNOW WHAT MOVED THE
TRENDS IN THE COMMUNITY. IT’S BEEN THE INTRODUCTION OF THE CONJUGATE
VACCINE, REDUCING NEED FOR ANTIBIOTICS, AND I THINK SETTING TARGETS AND PROBABLY GEOGRAPHICALLY
FOCUSING MIGHT GET US TO SOME OF THESE PLACES BUT THERE ARE DATA AND THEY ARE BEING PUBLISHED. IF I COULD JUST ADDRESS THAT, AND CERTAINLY
OUR MAPS ARE QUITE COMPELLING, DR. BLASER IS A GREAT CHAMPION OF OUR MAPS BUT I THINK
THAT’S LIKELY THAT THE DRIVERS OF ANTIBIOTIC PRESCRIBING ARE SOMETHING WE NEED TO UNDERSTAND
PROBABLY AT LESS SMALLER DESIGNATIONS THAN THE STATEWIDE LEVEL, WE’RE WORKING ON GETTING
INFORMATION AT A MUCH LOWER LEVEL AND THEN WE REALLY DO NEED TO I THINK UNDERSTAND A
LOT MORE ABOUT THE DRIVERS IN ORDER TO HAVE INTERVENTIONS THAT ARE ACTUALLY GOING TO BE
MOST EFFECTIVE. I CERTAINLY, YOU KNOW WE’RE QUITE HAPPY THAT
WE’VE BEEN ABLE TO HIGHLIGHT THE PROBLEM AS WE HAVE, AND I THINK THAT DRAWS ATTENTION,
ALLOWS US TO HAVE SORT OF MOMENTUM MOVING FORWARD BUT I DO THINK THERE ARE SOME DATA
GAPS THAT ARE IMPORTANT IN ORDER FOR US TO LIKE PRIORITIZE OUR PREVENTION STRATEGIES.
WE’RE RUNNING OVER TIME BUT I’LL JUST TAKE THE CHAIR’S PREROGATIVE TO ASK ONE MORE QUESTION.
THAT IS, ON DECEMBER 31 VETERINARY FOOD DIRECTIVE IS GOING TO COME INTO PLAY.
THE QUESTION IS, WHAT KIND OF STEWARDSHIP PROGRAMS ARE IN PLACE TO HELP US PREPARE FOR
THAT? AND DO WE NEED TO DO MORE? INTERTWINED IN OUR EDUCATIONAL INITIATIVES
THAT I’M INVOLVED IN, BOTH THROUGH THE AMERICAN ASSOCIATION OF BOVINE PRACTITIONERS, ACADEMY
OF VETERINARY CONSULTANTS, STATE ORGANIZATION, EXTENSION, ET CETERA, LIVESTOCK ASSOCIATIONS
IS THAT WE ARE COMBINING THE INs AND OUTS OF HOW TO DO THE VFD, WE’RE STARTING DOWN
THE ROAD OF SHOULD WE, AND THE SHOULD WE IS THAT ANOTHER WAY OF SAYING SUREDSHIP.
THE VFD AND THE IMPLEMENT ACHES WITH NEW DRUGS THAT WILL HAVE THOSE LABELS HAS BEEN A REAL
INSTIGATOR OF HAVING THOSE CONVERSATIONS ABOUT WHEN SHOULD WE, SHOULD WE, HOW SHOULD WE,
ET CETERA. SO IT’S BEING ADDRESSED TOGETHER.
GREAT. THANK YOU. THANK YOU TO WORKING GROUP 1 AND TO ITS REPRESENTATIVES. THANK YOU TO WORKING GROUP 1 AND TO ITS REPRESENTATIVES.

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