>> Thank you for joining.
We would, well, we would like to welcome you to our annual CDC
and Federal Office of Rural Health Policy webinar,
celebrating U.S. Antibiotic Awareness Week
and National Rural Health Day This year,
we are also partnering with the Agency for Healthcare, Research
and Quality, to showcase how the AHRQ Safety Program Toolkit can
be implemented in critical access hospitals.
My name is Linda Neuhauser, and I am the pharmacist
and acute care lead for CDC's Office
of Antibiotic Stewardship, and I'll be the moderator today.
And at this time, I would like to introduce our speakers.
Very thrilled to be joined by Natalia Vargas,
who is program lead for the Medicare Beneficiaries Quality
Improvement Program in HRSA's Federal Office
of Rural Health Policy, who will discuss the recent efforts
to support improvements
in antibiotic use in rural facilities.
Next, we'll discuss the four moments
of antibiotic prescribing in critical access hospitals
with Dr. Melissa Miller, who is a physician in the Division
of Healthcare Associated Infections in the Agency
for Healthcare, Research and Quality.
Dr. Pranita Tamma is an infectious disease physician
and director of the Pediatric Antimicrobial Stewardship
Program at the Johns Hopkins Hospital.
And then Dr. Sara Cosgrove is also an infectious diseases
physician and director
of the adult Antimicrobial Stewardship Program
at the Johns Hopkins Hospitals.
At this time, I would like to introduce Natalia
to provide her presentation.
>> Thank you, Linda.
I really appreciate the introduction.
And would like to thank CDC
for the opportunity to be here today.
I will be presenting our recent efforts to support improvements
in antibiotic use in rural facilities.
So, my goal with today's presentation is to set the stage
for what you will hear next from the presenters
that we have lined up today.
And we have three objectives to cover
in this portion of the webinar.
And that is first I would like to review the national reach
and overarching goals
of our Medicare Beneficiaries Quality Improvement Program.
And then provide an overview of the healthcare delivery
and quality improvement context in rural facilities.
And then end with a short discussion on how we aim
to collaborate across levels of the healthcare system
so that we can reach these program goals
and improve quality of care for rural populations.
This is just to give you a snapshot of what it's
like to serve the hospitals across the country, we have,
where you see on the right side, all of those dots,
the colored dots on the map,
are the critical access hospitals that we serve.
They comprise over 75%
of overall hospitals in the United States.
We, through, and equip, are able to support these hospitals
in providing high quality care to rural populations.
These small hospitals are limited to only 25 beds.
So, unlike traditional hospitals pay it
through the perspective payment system,
Medicare pays critical access hospitals based on each
of the hospitals' reported costs.
Therefore, with this context, you can, you can see that,
you know, we tried to really provide the support
for this small rural hospitals to report measures
so that we can, we can use those measures to improve quality
of care for populations.
The primary goal of our program is to enhance the reporting
of quality data, and then have the hospitals use that data
for quality improvement activities,
and support quality improvement measurements
and quality improvement activities
across all of those hospitals.
We have about 1,350 hospitals
that are currently participating in our program.
And through our program,
we established this national tracking system
for the first time so that these hospitals
that are voluntarily report quality measures to CMS are able
to be supported through our program,
and have additional access to funds
that support quality improvement activities.
So, we work at the intersection of various levels
of the healthcare system.
The national, state, and facility levels.
And antibiotic stewardship is one of those successful examples
of how we have used one of the measures to enhance reporting,
that then drives improvements at the local level,
at the hospital level,
by expanding those activities for quality.
So, the healthcare delivery context in rural facilities is
that essentially we have a mandate to serve
over 60 million people with very little resources.
And unfortunately these are competing priorities
that we have access, quality and costs,
are always competing in rural settings.
So, what we hear most in terms of challenges
from our hospitals is that there is scarcity
of infectious disease physicians and pharmacists.
There is a little bit of lack of provider engagement
in antimicrobial stewardship due
to the competing priorities that I mentioned.
We have also come across deficiencies
in staff understanding
of antibiograms sensitivity reports, drug classes,
how to use antibiotics properly.
And also we have limited capabilities
of EMRs to man data for QI.
Despite all of these challenges,
we have some real implementation come examples here
that I have linked for you.
We are really focused on pushing the accountability
for optimizing antibiotic use in critical access hospitals
and increasing the number of interventions
at the hospital per week.
Some hospitals have also reported
that through the implementation
of antibiotic use focused activities,
they have reported decreases in cases,
but also they have decreased the costs
of purchasing antibiotics at the hospital.
Underpinning all of these efforts is actually the
collaboration approaches that they have used
for antibiotic stewardship, such as sharing education, resources,
and tools to better equip the providers.
And that strategy has been one of the most successful ones
to be used in critical access hospital facilities
to overcome those challenges
and support those implementation outcomes
that I have outlined above.
So, with that is of key importance to our program
that we better collaborate across the levels
of the healthcare system.
And that is what brings this presentation today.
As you can see, we have joined efforts with our CDC colleagues,
with our, with agency for healthcare research
and quality colleagues,
to really address the improvement goals that we have
in our program that we see, you know,
through this chart you can see there is a microlevel,
a mesolevel, and a macrolevel.
This is adopted from a pediatric,
from an academic pediatrics journal article.
And basically what it does is that it shows the connection
for why it is important to have,
to connect those dots across the systems.
We set priorities at the federal level, but we most work together
in order to reach those goals.
We have to better understand the role of managed care delivery
at the mesolevel in order to really impact what happens
at the microlevel, to provide evidence,
evidence based treatments, and services
that support patient care
and improve health outcomes in rural areas.
So, as we look ahead in our program goals, we are hoping
to identify all the rural relevant measures
that establish, in order
to establish a curated measure sent one
of the broad priority areas
that we have is actually patient safety.
So, the work that we're doing in this space is very important.
We also hope to continue supporting critical access
hospitals to report measures that align with CMS IPP rules.
And one of the priority areas will involve antibiotic use.
We also hope to continue supporting the states
in building capacity for conducting QI, building the work
that space has completed so far as part of QI projects
that they are implementing, and co designing
with the critical access hospitals,
including antibiotic stewardship.
And also integrating a systems level approach to the work
that we do to the strategies that we implement
at the program level, which involves this type
of collaboration today.
So, today I'm just really pleased to be here
in celebrating what we call National Rural Health Day,
that is actually tomorrow.
And the theme for this year is driving change,
going the extra mile.
And that's what we're hoping that this presentation brings
to you today is just driving changes
in critical access hospitals in a way
that helps contextualize the care that we support
in this rural communities.
So, with that, I will leave my contact information here,
and I will pass it onto my colleague at AHRQ
who will be speaking and introducing herself next.
So, Dr. Miller, thank you.
>> Thank you, Natalia.
And thank you to HRSA and to CDC for having us here today.
We are looking forward
to sharing our toolkit and work with you.
Oh, and so today we're going to review the overarching goals
of the AHRQ safety program for improving antibiotic use.
We'll provide an overview of the safety program,
and review the findings from the one year acute care AHRQ
safety program.
And discuss how to apply the four moments
of antibiotic decision making
in clinical practice using a case based approach
for community acquired pneumonia and urinary tract infections.
So, first, to review the overarching goals, next,
antibiotic stewardship, or antibiotic stewardship programs,
or ASPs, have traditionally used a top down approach
to improve antibiotic use in acute care settings.
For example, an administrative decision to use one antibiotic
versus another, or a service that guides the antibiotic use,
such as, you know, a traditional antibiotic stewardship program,
our AHRQ safety program
for improving antibiotic use challenges this approach
by equipping frontline clinicians with tools
to incorporate stewardship practices
into their daily decision making.
So, the AHRQ safety program
for improving antibiotic use aimed initially
to improve antibiotic use in acute care, long term care,
and ambulatory care settings, in a phased approach.
What we're presenting today represents the experiences
of the first large cohort of over 400 acute care hospitals,
including critical access hospitals.
The goals were to assist facilities with establishing
or strengthening ASPs to provide frontline clinicians with tools
to incorporate stewardship principles
into routine decision making by underscoring the importance
of communication and teamwork around antibiotic prescribing,
and to equip frontline clinicians with best practices
in the diagnosis and treatment of common infectious processes.
So, next I'm going to hand it over to my colleague,
Dr. Pranita Tamma, to provide you with an overview
of the safety program.
>> Thanks so much, Melissa.
And I'm excited to talk a little more in depth
about the acute care portion of the AHRQ safety program.
So, just very briefly, this was a one year program.
It occurred in the calendar year 2018.
And the goal was to include at least 250 acute care facilities
across the United States.
And recruitment efforts included social media campaigns,
engagement of federal partners, including the CDC and HRSA
and professional societies.
And we invited either retired hospitals,
which was generally the case for critical access hospitals,
or individual units within a hospital, to participate.
And Sara Cosgrove and I delivered all the webinars.
It was usually about two webinars per month,
each delivered about three times
to accommodate different work schedules,
and time zone differences.
And we invited all members of the healthcare team
to participate, including physicians, mid level providers,
pharmacists, nurses, and anyone else who was involved
in the process of antibiotic decision making.
We also included two office hours every month
where participants had the opportunity to ask questions
about implementing stewardship programs,
or even just management questions related
to particular patients.
And we were very fortunate to partner
with quality improvement experts that came
from health quality innovators,
health services advisory group, and stratus health.
And one quality improvement expert was assigned
to each participating hospital to assist them with some
of the day to day stewardship implementation work.
So, I'm going to go a little further
into what actually took place during the one year period.
And fortunately, AHRQ did a very nice job on their website
of developing a toolkit where the material can be accessed
so that even for sites that didn't participate
in this one year program, they would have the ability
to access all of the content developed for the program.
And on the website, there's some guidance
on how you could implement the toolkit locally
to emulate the one year program.
So, just very briefly, there were three general domains
as part of this acute care safety program.
The first was assisting sites
with developing stewardship programs.
Some sites did already have a stewardship program
that was maybe in its early phases, and we assisted them
with how they could sort of take it to the next level.
Part of this involved identifying a
leadership structure.
Ideally we preferred a clinician and a pharmacist lead.
Not necessarily trained in infectious diseases, because,
of course, that's just not feasible in many sites.
And how they could identify senior leadership
to Garner the support amongst other healthcare practitioners
within that facility.
We also assisted them with identifying how
to develop metrics to collect data for metrics,
which I'll talk about.
And to use these metrics by tracking them over time
to guide intervention.
So, for example, if you notice
that Vancomycin uses extremely high in an ICU,
what kinds of interventions can you think
about to help reduce that use.
The second main domain was trying to develop a culture
of safety around antibiotic prescribing.
We realize that a lot of times there's a social etiquette
involved around prescribing
or perhaps one prescriber starts an antibiotic,
and another clinician comes on
and might feel strange stopping an antibiotic
if a colleague started it,
because it might be deemed disrespectful.
Or perhaps during clinical rounds, a physician is rounding,
assessing the patient, and a nurse might feel a little,
might not feel as empowered to mention
that the patient is still on Vancomycin.
Is this really still necessary?
So, we wanted to help with improving teamwork
and communication between healthcare providers,
as well as between healthcare providers and patients
and families who might be expecting an antibiotic.
And finally, the third domain dealt
with teaching frontline providers
with learning best practices in the management and the diagnosis
and management of common infectious diseases syndromes.
And we've decided to focus on syndromes and nonantibiotics
because clinicians are generally much more excited
if you say would you like to learn about the latest data
in managing community acquired pneumonia versus would you
like to learn how to use Vancomycin more appropriately.
And for all of the syndrome based content,
we organize the material using a framework we developed as part
of this program called the four moments
of antibiotic decision making, which I'll summarize.
So, this is a snapshot of, from the AHRQ website.
In the develop and improve stewardship content that's
really targeting the stewardship leader, so, again,
ideally a clinician and a pharmacist, a physician,
and if a physician's not available, a mid level provider,
like a nurse practitioner or physician assistant,
along with a pharmacist, and we have content in how
to develop the program, how to effective,
make behavior /KHAEUFPBLGZ around prescribing.
And after the program is developed,
have a sustained stewardship activities
so that this program will continue
to exist and be impactful.
And these content are available
as PowerPoint slides on the website.
There's also what we call facilitator guide,
which includes a detailed script for each slide,
so that the content can be used locally.
In terms of the developing culture of safety
around prescribing, there's four targeted PowerPoint slides
with facilitator guides.
For each of these, and these are targeting mostly frontline
providers, for each of these, we used case based approaches,
because we think that that's probably most engaging
to healthcare providers.
And finally, for best practices, as you can see here,
we target a variety of syndromes
that we think are common problems,
both in large academic facilities,
as well as small critical care access hospitals.
And for all of these, again, we have slides available,
as well as the facilitator guide.
And we also have several other types of content available,
which I'll show you in the next few slides.
But for all of these best practices topics,
we Lutz what we call the four moments
of antibiotic decision making.
So, these are the four moments
when we think clinicians should review when deciding
if a patient needs antibiotics,
and if antibiotics need to be continued.
So, very briefly, the first moment asks,
does my patient have an infection
that requires antibiotics?
And this might just be stopping and thinking about the patients.
Maybe the patient has a cough.
Maybe they're having a little bit of chest pain.
But is this a pulmonary embolism?
Is this congestive heart failure?
Doesn't necessarily have to be bacterial pneumonia.
So, it's really asking clinicians to stop
and think about, is it more likely than not
that this patient has a bacterial infection.
The second moment has two questions.
Have I ordered appropriate cultures before
starting antibiotics?
For example, do I need blood cultures?
Do I need urine cultures?
Do I need a sputum culture?
And the second question asks what empiric therapy should
I initiate?
And for each of the infectious syndromes, we include guidance
on what we would consider empiric therapy
for your routine patients.
And then what about patients
who might have a severe Penicillin allergy, who might,
maybe there's concerns for MRSA or concerns for pseudomonas.
And in those patients,
the empiric therapy regimens might be different.
The third moments has three questions.
After more clinical and diagnostic data are available.
And these include can I stop antibiotics, particularly
if cultures are negative,
and an alternative diagnosis has been established.
Can I narrow therapy or change
from an intravenous to an oral agent?
And finally, the fourth question asks about the duration
of antibiotic therapy.
For all of the best practices topics, we include evidence
that supports what the available data suggests in terms
of effective durations of antibiotic therapy.
And then, again, for each of the topics as an example,
we have what we call a one page document
that summarizes some of the data.
These are editable on the website
so that local sites can include recommendations here
and make these their local treatment guidelines.
Alternatively, you could delete these sort
of place local recommendations here sections and post these
in common work areas, send them as e mails or other ways
to disseminate this knowledge
between the healthcare providers in your facility.
We also include commitments posters on the website.
And we suggest that people put the pictures of providers,
their signatures, maybe pictures and signatures of leadership.
And this is meant to show that to patients,
as well as to just all healthcare providers
within the institution, that your facility committed
to the judicious use of antibiotics.
And similar to this commitment poster, we also have posters
with the four moments, screensavers
for the four moments that are available on the AHRQ websites.
And then another document we developed
that we thought was particularly helpful in settings a lot
of critical access hospitals are what we call the team antibiotic
review forum.
So, the goal of these forums would be every month we would
ask sites to retrospectively pick five, ten patients
who are receiving antibiotics, and as a group to go
through these questions that use the format of the four moments,
so that you can look for areas for maybe
where there should be improvement for the next patient
who started antibiotics.
So, it might be caught that perhaps Vancomycin was continued
for too long, or a duration longer
than the evidence suggests is necessary might have
been prescribed.
And the hope would be that as a group, again, including nursing,
pharmacists, physicians, and anyone at a team meeting,
that lessons could be learned
to improve care for the next patient.
So, for the sites that participated
in this one year program.
We requested that they submitted antibiotic use data as days
of antibiotic therapy for per thousands patient days,
and they submitted these data on a monthly basis.
We also requested the submitted C difficile lab ID event per
10,000 patient days.
So, basically this is looking
for if a lab test indicated positive C difficile testing,
of course this is not a perfect proxy
for clinical C difficile infections,
because some patients might be colonized, but we thought
that this would still be helpful to get a sense
of if we could impact C difficile rates
by reducing antibiotic use,
or really optimizing antibiotic use, I should say.
And then we requested up to 10 team antibiotic review forums
per month.
For some hospitals, particularly critical access hospitals,
they might have actually had less
than 10 patients a month on antibiotics.
And, of course, that was perfectly acceptable too.
And for all sites, and we talk a lot about on the website how
to collect the data, how to report data to clinicians
within your institution, but we, what we would do
with the program was feedback quarterly reports
so you could compare yourself over time,
and also compare yourself to like facilities.
So, for example, for critical access hospitals,
we compared them to other critical access hospitals.
And, of course, not large academic medical centers.
I'll move on to very briefly summarized findings
of the project before I hand it over to Sara Cosgrove.
But there were 402 hospitals
that completed the one year safety program.
Over 90% of facilities that started the program,
which we were very happy to see.
And for those that weren't able to complete it was often
because they had staff turnover,
didn't have the resources to stay engaged.
In terms of the types of hospitals that participated,
about 20% were critical access hospitals.
And about 40% of hospitals had less than 100 beds.
So, it was really a variety of types of hospitals
that participated in the program.
And what we saw was that antibiotic use decreased
in that, in that first quarter,
and then this first quarter we were actually relatively
aggressive with the number of webinars
and engagement we had with sites.
And then after that antibiotic use plateaued,
and basically stayed relatively consistent.
We actually were able to compare these data with data
from premier, which included large number
of hospitals not participating in the program.
And basically that data suggested that antibiotic use
in nonparticipating programs started off high
and remained relatively consistent [inaudible] the
one year.
So, they didn't have this sort of drop in that first quarter.
Now, obviously it's not a perfect comparison,
but it just gives you a sense of what was happening nationally
in other institutions at the same time.
We did find that antibiotic use significantly decreased
when we looked at the data in various subgroups.
And I highlighted in red here critical access hospitals
where we did see a significant reduction in antibiotic use.
And also across the cohort, we saw significant reduction
in C difficile lab ID rates.
So, I'll hand is over to Sara.
And before I do so, again, I just want to stress
that we really do encourage people to go to the AHRQ website
to look at the content of this program,
because I really do think that there's, this can be sizeable,
scalable for all institutions,
including critical access hospitals.
So, thank you very much.
>> Thanks, Pranita.
We'll start the last portion of this with a clinical case.
And then basically go through this case,
showing how you could apply the four moments
in everyday decision making around antibiotics.
So, this is a case in a 54 year old man with diabetes
and hypertension who presents with two days of fever, a cough,
and left sided chest pain.
He's febrile.
His blood pressure is fairly normal.
But his heart rate is elevated.
And his respiratory rate at 24 is certainly elevated.
He has a normal oxygen saturation of 95% [inaudible].
And on other [inaudible] exam, he's tired, appearing,
and has crackles over the lower left lung field.
So, going through the four moments,
remember that the first moment is does my patient have an
infection that requires antibiotics.
So, thinking about this patient, he needs a lot of criteria
for community acquired pneumonia.
And, therefore, in him, CAP is likely.
But if some of this presentation were slightly different,
he might actually have something
that is not community acquired pneumonia, and may mimic some
of the signs and symptoms of community acquired pneumonia,
so we always say, you know,
think about other potential causes
of someone's presentation.
And just some examples of things
that would also be considerations
on the differential here are viral respiratory tract
infections, aspiration, pneumonitis,
chronic obstructive pulmonary disease exacerbation,
asthma exacerbation, congestive heart failure,
and pulmonary embolism.
I'm not saying that that's what I think he has.
But a lot of times people present with symptoms
that are a little more nonspecific than what he has.
And so these other items should certainly be
on the differential, and the majority
of them do not require antibiotic therapy.
You know, and I think our next [inaudible] management
of this patient would be to obtain a chest x ray.
And it's also important to know while you're thinking
about does the patient need antibiotics or not
that if there's no infiltrate on a chest x ray, with the patient
in general, it's much less likely
to have community acquired pneumonia.
So, moving on to moment two,
remember moment two has two questions.
Have I ordered appropriate cultures before
starting antibiotics?
And what empiric therapy should I initiate?
Remembering, of course,
that empiric therapy ideally should be based
on local empiric treatment guidelines
that have been developed by the stewardship program
in conjunction with frontline providers.
So, first with diagnostic testing
in community acquired pneumonia.
A sputum gram stain and culture is recommended
if the patient is able to produce sputum.
And blood cultures are really
at this point not recommended for all patients.
They used to be part of a core measure that led
to people getting blood cultures all the time in patients
with community acquired pneumonia.
That is no longer a requirement.
However, if the patient is quite ill,
or they have any abnormal chest imaging findings,
such as a long abscess or a parapneumonic infusion,
then it's reasonable to consider blood cultures.
But in the average patient presenting with CAP,
blood cultures are likely to be a very low yield.
It also can be useful to obtain a respiratory virus panel,
because that can be an alternative explanation
for our patient's clinical symptoms,
particularly during respiratory virus season.
And, you know, in institutions
that have the strep pneumourinary antigen test,
that can be considered.
Many institutions don't have this available.
We actually do use it in our institution, because we find
that it can be helpful if positive to say
that the patient has pneumococcal pneumonia
and not some other kind of pneumonia, and that allows us
to comfortably narrow antibiotic therapy to Amoxicillin.
And then, again, on the, on the theme of urinary antigen tests,
if Legionella urinary antigen testing is available,
it can be considered for patients with moderate
to severe symptoms, people who smoke,
immunocompromised patients, or patients over 50 years of age.
So, remember the other part of moment two is empiric therapy.
Empiric therapy for community acquired pneumonia
in the United States is largely driven by existing guidelines
from the American Thoracic Society
and the Infectious Diseases Society of America.
And these recommend coverage for typical bacterial pathogens
such as streptococcus pneumoniae and haemophilus influenzae.
And the U.S. guidelines also suggests a coverage
for atypical organisms, such as Legionella.
So, regimens to consider are Ampicillin or Ceftriaxone,
as your beta lactam agents.
Plus, either Azithromycin or Doxycycline.
The guidelines will tell us that there is more evidence
for Azithromycin than there is for Doxycycline.
However, many institutions preferentially use Doxycycline
because it is less commonly associated
with Clostridium difficile infection
than other antibiotics.
In general, and as part of the safety program,
we discouraged use of fluroquinolones for the majority
of patients, not just for patients
with community acquired pneumonia.
And one of the findings in our safety program was
that decreases in antibiotic use were driven
by reductions in fluroquinolones.
So, for community acquired pneumonia,
even though historically I think many providers have reached
for fluroquinolones, because they think, oh, it's easier,
it's just one agent, we really recommend, as do the guidelines
against these being first line agents,
and instead limiting them to patients
with severe Penicillin allergies.
And as I mentioned, you know, most antibiotics are associated
with C diff, but fluroquinolones in particular can be associated
with C diff infections.
And other side effects, such as prolonged QTC intervals,
tendinopathies, altered mental status changes.
And this is particularly an issue in the elderly population,
so I really do try to avoid quinolones in that population.
I think a common question that comes up is is it,
is it okay to cover patients
with community acquired pneumonia with all those agents
that we just discussed?
Should we be concerned about patients' risk
for Methicillin resistant staph aureus?
Or risk for pseudomonas aeruginosa?
And I just want to say, for both of these organisms,
which are the source of much handwringing and worrying
in the hospital, as we all know, that CAP is very unlikely
to be caused by MRSA, and very unlikely to be caused
by pseudomonas aeruginosa.
And frankly, patients
who ultimately do have these organisms isolated probably
didn't have what we would call community acquired pneumonia.
They probably had pneumonia that was associated with contact
with some kind of healthcare facility.
I think another interesting point for MRSA is
that there have been many studies
that both tell us it is uncommon as a cause of CAP,
and then a large study that showed
that empiric anti MRSA therapy was not associated
with reduced mortality in patients with CAP.
So, I think there's just a couple of considerations
for when you might use this agent.
And they include patients who present fairly ill
and have a cavitary or a necrotizing pneumonia
on chest x ray or chest CT.
And in patients that have MRSA risk factors,
perhaps if the sputum gram stain has gram positive cocci
and clusters on it.
You know, the standard CAP regimens don't include coverage
for MRSA, so, you know, if MRSA coverage is indicated,
this would be Vancomycin, Manazalib [phonetic],
or Trimethyl [inaudible] Mathoxazole [phonetic].
And then for pseudomonas, again,
I think I've mentioned now several times
that pseudomonas CAP is very rare.
In general, you would think about it in patients
who had a fairly severe underlying lung disease,
such as Bronchiectasis, or severe COPD,
where they have likely been exposed to multiple courses
of different antibiotics over several years.
And then the other groups of people who have this,
in general, they don't have CAP, they have some kind
of healthcare associated pneumonia,
so recent received a broad spectrum antibiotic therapy,
recent full on hospitalization,
admission from a skilled nursing facility or nursing home,
or people with significant immunocompromise.
And, of course, coverage for pseudomonas would be
with Sethapime [phonetic] or Piperacillin and Tazobactam.
So, we'll move on to moment three.
And so this is a moment that should happen every day
that a patient is on antibiotics.
So, a day or moment has passed, can I stop, can I narrow,
or can I change from IV to oral therapy.
And so for community acquired pneumonia, here we go,
transitioning to oral therapy is recommended as soon
as the patient is starting to have clinical improvement,
and able to tolerate oral medications.
So, in community acquired pneumonia,
there's no requirement for prolonged IV therapy.
So, when, you know, when their vital signs parameters are
starting to normalize, it's perfectly reasonable
to transition to oral therapy.
We, in general, transition
to an oral third generation Cephalosporin, or,
as I mentioned, if you know that the patient has pneumococcus
in general, it's safe to transition to Amoxycillin.
If the I think we've covered that.
So, now we can move on to moment four.
What is the duration of antibiotic therapy
for my patient's diagnosis?
And fortunately for community acquired pneumonia,
we now have multiple randomized control trials,
and observational trials that indicate that five days
of antibiotic therapy is sufficient for most patients
with community acquired pneumonia.
And, you know, and this should really be the standard,
five days, we should drill
that into everyone's head, five days of therapy.
There are, you know, occasionally cases
where someone has severely immunocompromised, has severe
or underlying structural lung disease,
or had inadequate clinical response,
or ended up growing an organism that you weren't covering
where you might prolong therapy to seven days.
But the vast majority of patients
with CAP should be treated for five days.
If you started a combination regimen
with the beta lactam and Azithromycin.
Remember that you don't need to give more
than three days of Azithromycin.
It has an incredibly long half life.
And so it's actually, you know, three days, sticking around in
that person's body for probably 10 days.
So, remember to encourage discontinuation of Azithromycin
after three days if it was part of the empiric regimen,
unless the patient is diagnosed with Legionella,
in which case longer courses of Azithromycin would be indicated.
Also, you know, remember, and remember to remind patients
that they may feel tired, they may have a cough that goes
on for, you know, quite a few days after a bout
with community acquired pneumonia.
And it's going to take a while for them to get better.
But don't rework them up for this, you know,
by getting chest x rays and more sputum,
because chest x rays can take a long time to improve.
And, you know, so it should be considered as part
of the natural history that cough and fatigue can go
on for a few weeks after a patient has community acquired
pneumonia, and is not a reason to prolong antibiotics.
So, I think we have time to one through quickly a second case,
just to give another idea of how you can use the four moments.
This is a case of a 31 year old woman who is healthy
and presents with dysuria, fever, rigors,
and left sided flank pain.
She, you know, also has evidence of being infected
with a temperature of 101, low blood pressure,
elevated heart rate, and is standing normally
and breathing normally.
On exam, she is ill appearing, but able to carry
on a normal conversation.
So, for this patient, the first question is does my patient have
an infection that requires antibiotics?
In this case, the patient has signs and symptoms
that are concerning for pyelonephritis.
So, in this particular case, the answer is yes.
But, in general, for urinary tract infections,
there are many situations
where patients do not necessarily have an infection,
even if they have abnormalities with their urine.
So, remember that foul smelling urine, cloudy urine,
or isolated mental status changes, in the absence
of other clinical symptoms of a urinary tract infection,
are not indications to obtain urine cultures.
And if a urine culture is obtained,
and comes back positive, it's always important to go back
to the patient and ask about symptoms, because a lot of time
in medical care, urine cultures get sent all the time,
and then no one remembers why that urine culture was sent,
and, you know, positive urine cultures can trigger antibiotic
therapy, when antibiotic therapy is not needed at all.
So, moving on to moment two.
Have I ordered appropriate cultures before
starting antibiotics?
And what empiric therapy should I initiate?
You know, just some more information about interpreting,
sending and interpreting urinalysis and urine cultures,
you know, there are, in general, in labs,
cut offs for positive UAs, you know,
and so your lab might differ.
But, you know, in general, this is usually considered greater
than or equal to 10 white cells per high powered field.
In patients with very small numbers of white cells
in their urine, a UTI is, in general, unlikely.
In our patient with pyelonephritis,
a urine culture should be obtained.
But a lot of patients get urine cultures as I, as I mentioned,
and, you know, it's really important to look
at colony counts in these urine cultures
when assessing whether they are clinically significant.
If patients do not have symptoms,
and have low colony counts, again, highly unlikely
to be a urinary tract infection.
And then with regard to blood cultures,
most patients do not need blood cultures.
Certainly patients with concern
for cystitis don't need blood cultures.
And patients being treated for pyelonephritis
as outpatients don't need blood cultures.
If patients are hospitalized for pyelonephritis,
a urine culture is still the most useful culture.
But if there's any concern about getting that urine culture,
difficult to getting that urine culture,
or if the patient has evidence of sepsis,
then blood culture should be obtained.
So, moving onto the empiric therapy part of moment two,
you know, for patients being hospitalized
with pyelonephritis, you know, currently, we recommend use
of Ceftriaxone if a patient has risk factors for pseudomonas
or structural or functional urologic abnormalities,
then Sethapime [phonetic].
And if patients have histories
of extended spectrum beta lactamase producing organisms,
particularly E. Coli, then recommend use of a Carbapenem.
For severe Penicillin allergy,
it can be either Aztreonam or Gentamicin.
If you look at national guidelines
for urinary tract infections, quinolones
and Trimethoprim sulfamethoxazole are still high
on the list for empiric treatment.
These guidelines are now over 10 years out of date.
And while fluroquinolones
and Trimethoprim sulfamethoxazole have excellent
kidney and urine penetration, the big issue with them is
that we have seen increasing resistance, particularly
in E. Coli, over the past decade.
And this is in many parts of the United States, although not
in all of the United States.
So, if resistance rates are known to be low, ideally less
than 10%, then these agents can certainly be considered
for empiric therapy.
The problem is many parts of the country, the resistance rates
for fluroquinolones and Trimethoprim sulfamethoxazole
for E. Coli are now, you know, 30 to 40%.
So, moving onto the third moment,
a day or more has passed.
Can I stop?
Can I narrow?
Can I change to oral?
So, in patients admitted with pyelonephritis,
therapy should be transitioned to oral therapy, again,
as soon as the patient is feeling better,
and whenever the patient can tolerate oral therapy.
This is one situation where we actually favor use
of quinolones.
I know I always talk about not using quinolones.
But because of their outstanding urinary penetration,
I think they are very reasonable to use in stepdown therapy
for patients with pyelonephritis,
because you can give a pretty short duration of therapy.
But it's important.
Whether using quinolones or Trim sulfa to make sure
that the organism is susceptible.
If you can't use these agents
because of susceptibility issues, then, in general,
we use oral cephalosporins.
And then finally, the fourth moment is what duration
of therapy is needed?
In this case, durations for pyelonephritis,
and as I mentioned, quinolones can be attractive
in these situations, because patients can be treated
with five to seven days of therapy.
In contrast, we don't have clinical studies
that support these short courses of therapy for other agents.
So, even for Trim sulfa, which, again,
has excellent urinary penetration,
we unfortunately don't have a lot of studies
that say we can use these shorter courses of therapy.
And then for oral cephalosporins,
there probably is a bit higher failure rate
for oral cephalosporins.
And so if you're using them, again, 10 to 14 days
of total therapy, of course including the days
that the patient received in the hospital.
And, you know, much like not repeating chest x rays
and sputum cultures in patients with CAP,
in patients who are recovering from urinary tract infections,
they also do not need repeat urine cultures.
So, I'm going to sum up the presentation
for all three of the speakers.
And I hope that we have convinced you
that implementation of the AHRQ safety program
for improving antibiotic use was, was valuable and useful
and associated with enhancing antibiotic stewardship programs
and improving antibiotic prescribing, and I want to point
out that, you know, 20%
of the participating hospitals were critical access hospitals.
And we did see reductions in antibiotic use
in these hospitals, you know, because overall the amount
of use is not as high compared to larger hospitals.
This was not a significant finding, but the magnitude
of reduction was actually greatest
in critical access hospitals.
So, I think if we'd have more critical access hospitals,
ultimately I think that finding would have been significant.
And then finally, you've heard before, but I'll say it again,
that the AHRQ safety program
for improving antibiotic use toolkits is available
at the AHRQ website.
And, you know, all the materials
that we've discussed today are available for download.
Most of them are editable
so that you can customize them for your site.
And if you're somehow also looking for materials
for nursing homes and materials for outpatient care,
we have toolkits with all these same features available
for those settings also on the website.
So, thank you for your attention.
And I think we have some time for questions.
>> Yes, thank you so much for all our speakers.
And I could just listen to Sara all day talking
about clinical pearls for infections.
So, I'll actually maybe start with you, Dr. Cosgrove.
In terms of there's a question about the three day course
of Azithromycin for CAP.
What dose is used?
>> It would be 500 for three days.
>> Okay. Great.
And in terms of the engagement for the office hours,
one of our audience members was curious
of what the engagement was like for the office hours.
>> We had a good time on the office hours.
It was actually, it was really fun to do the office hours.
I think that, and I don't mean to like toot our own horn
or something, but I think that people were excited
to have access to infectious disease stewardship positions.
And, you know, I know that there are, you know, are many places
in the country that really don't have that access.
And so it was really just a treat to be able to, you know,
just be there to answer anyone's question,
because it could be anything.
It could be programmatic stewardship stuff,
it could be I'm having this problem with this person,
can you help me solve this problem with this person, or,
you know, just stuff about the evidence behind recommendations
and so forth.
>> Yeah, absolutely.
And getting some questions about using days
of therapy per a thousand patient days, particularly
in the context of a small hospital
or critical access hospital, and some of the limitations,
for example, one of our audience members is saying
that one patient could really impact your days of therapy.
And they were wondering if you had thought about other measures
that might better capture this excellent work that you've done.
>> So, I completely agree that I think
that that is a very challenging metric.
It's actually a challenging metric for all hospitals,
because even if you have tons of antibiotic use,
it's actually hard for clinicians to understand.
You know, we've had this experience in our institution.
Well, your Vanco increased from this to this.
And they're like, what does that mean?
Why do I care if my Vanco increased
from 500 days to 600 days?
What does that mean?
And so I think we all should be thinking
about alternative metrics, you know, obviously those kind
of metrics are helpful to stewardship programs
to track things over time.
But when we are trying to engage providers,
I think it can be more challenging.
I actually think that what providers respond
to more is assessments of appropriate decision making.
Or adverse events.
And so if you have the bandwidth to look at a sample of cases,
you know, kind of like we did
with the team antibiotic review form, or, you know,
even if you say every Friday I'm going to look at everyone
on antibiotics and like just do an assessment, you know,
30% of people were guideline noncompliant,
60% of people were guideline compliant.
Here's some of the, you know, things I found.
But that, I think, is actually more valuable feedback
to the frontline than days of therapy per 1,000 patient days.
And apologies to CDC, because obviously, you know,
that is the approach for large scale surveillance.
But when we're talking to frontline,
they need something they can wrap their head around.
And, you know, and another thing is
that if you do have C diff cases that you can review,
we find that our focus really kind of like to hear about,
you know, assessments
of how well they did with managing C diff.
And that covers both the diagnostic stewardship parts
of the C diff, like should the patient have been tested
in the first place.
It covers, you know, were the antibiotics non C diff related
that the patient was on appropriate?
Or did they contribute to the C diff?
Once they found out about C diff,
did they modify the antibiotics or stop them?
And then even did they use the right approach
with the treatment of the C diff?
So, lots of stewardship stuff around C diff.
>> Absolutely.
Thank you.
Along similar lines about really tracking antimicrobial use,
we had an audience member ask if there's a comprehensive list
of antibiotics on a spectrum of broad to narrow
when this individual is doing audits,
and if a physician changes the antibiotic, not a clear guidance
in terms of if that was a deliberate move
to more narrow spectrum.
Do you want to [inaudible]?
>> I can comment real quick.
>> Yes.
>> You know, I think this is like the question of the century
in some ways, because we talk about, you know, narrowing.
And it is like a core component of stewardship.
But most of the antibiotics we use are pretty broad.
You know, when you think of what their potential impact is
on the human microbiome.
But, in general, you can, I think, have your class of agents
that have anti pseudomonal coverage and have a goal
to not be on those, and to narrow to something else
that doesn't have anti pseudomonal coverage,
if they don't have pseudomonas.
I think that, you know, for Vancomycin, you know,
most of narrowing of Vancomycin is stopping Vancomycin.
So, if they don't end up having an indication to be
on Vancomycin, no MRSA isolated, no other thing
that might be Vanco, narrowing
of Vancomycin means stopping Vancomycin.
And, you know, if you can get people on Penicillin,
that is truly a pretty narrow spectrum drug relative
to everything else.
Amoxicillin is narrower than late generation Cephalosporin.
So, if you can get people on Amoxicillin, that's good.
But it's not crazy narrow, you know, it kills plenty
of gram positives and gram negatives.
So, [inaudible] to any other thoughts?
>> No, that's good.
Okay, we have like a technical question here.
What is the recommendation for the duration of Azithromycin
if a urine Legionella is positive?
>> Yeah, so there's not actually a recommendation,
because there's not been studies performed on the duration.
What's kind of suggested and up to date and some other sort
of review articles is somewhere in the range of 7 to 14 days.
I think most people would probably treat,
until the patient's better, maybe a couple
of days more and stop.
Like Sara, I always favor shorter durations
whenever possible.
So, certainly if the patient is responding to therapy,
I think a week is probably fine.
If the patient is critically ill in the ICU, then maybe going
to like 10 days or so might make sense.
But there's not actually like traditional CAP where the large,
very nicely done RCTs, that data is just not available
with Legionella.
>> That you don't have to switch someone to a quinolone,
just because they have Legionella.
>> Correct.
>> Quinolones pretty much have the same activity.
And so if you already have them on the Azithro,
you can stop the Ceftriaxone or the [inaudible]
and just keep going with the Azithro.
>> Yeah.
>> Which is, that's one of my CAP pet peeves,
when people switch to quinolones.
Then they don't need to switch to quinolones.
[ Inaudible ]
>> We do, for the acute care program, you know,
I'm a pediatrician, we definitely, the guidance that's
in there is very generalizable to both children and adults.
And if there are exceptions, we make note of it.
So, I would say that certainly for the acute care content,
it is very generalizable to children as well.
Maybe not babies, because they're always a
little [inaudible].
>> Ambulatory is also for both.
>> Correct, yeah.
>> And nursing home one, not so much.
>> Yes, and we, just to address a housekeeping question.
This presentation will be available,
along with the recorded webinar on CDC's tune
into safe healthcare website.
And you'll be notified when that is available.
Typically takes a couple of weeks.
And then we also have it linked to the CDC's antibiotic use
and stewardship websites, specifically in the [inaudible]
and healthcare professionals website for resources.
At this time, we're at the top of the hour.
And once again, want to really thank our speakers.
I enjoyed every aspect of this presentation.
And look forward to hearing
about U.S. Antibiotic Awareness Week
and National Rural Health Day
from everyone this upcoming week.
Thanks again.