Christopher A Czaja MD MPH Antimicrobial Stewardship Medical Epidemiologist

1. Antimicrobial stewardship in nursing homes: introducing the antibiogram,increasing physician engagement Christopher A Czaja MD MPH Antimicrobial Stewardship Medical Epidemiologist Healthcare-Associated Infections Program December 4, 2018 christopher.czaja@state.co.us

2. Objectives • Describe the uses of an antibiogram and access the Colorado Antibiogram for antibiotic stewardship • Recognize the need for physician input and involvement in nursing home antibiotic stewardship programs

3. SECTION 1 The nursing home antibiogram

4. Antibiogram definition and uses • Definition • Facility-specific summary of antibiotic susceptibility of organisms cultured from clinical isolates (local data) • Uses • To inform choice of initial antibiotic therapy • To inform antimicrobial stewardship program planning

5. Antibiogram example—Colorado Antibiogram https://www.colorado.gov/pacific/cdphe/hai-data

6. Organizations recommend antibiogram use • Centers for Disease Control and Prevention (CDC. The core elements of antibiotic stewardship for nursing homes. 2015) • Centers for Medicare & Medicaid Services (CMS. State operations manual. Appendix PP-Guidance to surveyors for long term care facilities (F881). 2017.) • Infectious Diseases Society of America (Barlam et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. 2016)

7. Evidence for antibiograms • Antibiograms improve choice of “active” initial therapy (Boggan. Pediatrics 2012.) • Choice of “appropriate” therapy requires knowledge of additional principals of antibiotic use (Boggan. Pediatrics 2012.) • Improvement in antibiotic use requires that data and knowledge be incorporated into practice (Furuno. ICHE 2014.; Tallman. ICHE 2018.)

8. Antibiogram preparation • Analyze and present data annually • Include only final, verified results • Include only species with at least 30 isolates tested • Include diagnostic, not surveillance, isolates • Include only the first isolate per patient (no duplicates) • Include results only for drugs that are routinely tested • Calculate the percentage susceptible CLSI. M39-A4 2014; Hindler and Stelling. CID 2007.

9. Antibiogram quality • Variable adherence to guidelines for preparation • Breakpoints for susceptibility testing may not be up to date • Small facilities have too few isolates Zapantis. JCM 2005; Boehme. Public Health Reports 2010; Heil. JCM 2016; Moehring JCM 2015.

10. Approach to reading an antibiogram • What is the quality of the data? • What organisms are you trying to cover? • What are the preferred antibiotics (based on proven effectiveness)? • What antibiotics are likely to be active (based on the antibiogram)? • What are the opportunities for stewardship?

11. Pathogens of common infections and preferred antibiotics *Not a comprehensive list; †IDSA Practice Guidelines: https://www.idsociety.org/PracticeGuidelines/.

12. Nursing home antibiogram (cystitis example)

13. Guidance for use • Choose antibiotics based on activity, proven effectiveness, potential for antibiotic resistance or adverse events, and use clinical judgement • Consider principles of antibiotic stewardship, including appropriate initial use of broad-spectrum antibiotics, de-escalation to targeted therapy, and limited duration • Be aware of limited ability to generalize findings from a small number of isolates

14. https://www.colorado.gov/pacific/cdphe/hai-data

15. Objectives of the Colorado Antibiogram • To be a publicly available tool for antibiotic stewardship • Increase public knowledge of antibiotic resistance • Inform allocation of resources to improve antibiotic use • Demonstrate antibiotic resistance patterns by region

16. Antibiogram components Antibiotics Organisms No. of Isolates %Susceptible

17. Gram negative bacteria—nursing facilities https://www.colorado.gov/pacific/cdphe/hai-data

18. Limitations • Use requires knowledge of appropriate pathogen-directed therapy • Non-standard quality and content of source antibiograms • Regional differences are multifactorial; no statistical tests of comparison • High quality, facility-specific data will better represent facility-specific antibiotic susceptibility patterns

19. SECTION 2 Engaging physicians in antibiotic stewardship in nursing homes

20. Long-term goals of antibiotic stewardship • Improve patient outcomes (including mortality) • Fewer adverse events • Lower rates of C. difficile • Reduced antimicrobial resistance Schuts Lancet Infect Dis 2016.

21. Immediate goals of antibiotic stewardship • Right indication • Right drug • Right duration • Right dose • Right route •  first, make the right diagnosis • most effective, narrowest spectrum • evidence-based shorter courses • most effective, safest dose • Intravenous vs. oral/other

22. Targets for antibiotic stewardship

23. Approach to antibiotic stewardship

24. Antibiotic prescribing decision making requires physician expertise Antibiotic Review Diagnostic Stewardship Crnich. Drugs Aging 2015.

25. Antimicrobial Stewardship Assessments

26. Call for physician input • Please contact me if you are interested in participating in an antimicrobial stewardship assessment at your facility with attendance by the antimicrobial stewardship team including physician staff • E-mail: christopher.czaja@state.co.us • Tele: 303-692-3561 • Engage your antimicrobial stewardship team!