Evidence Based Guidelines at PHD related to Infectious Disease

1. Evidence Based Guidelines at PHD related to Infectious Disease Edward L. Goodman, MD

2. Outline • Standing Orders for Vaccinations • The problem • Evidence for guidelines • Federal Guidelines • Comprehensive Antimicrobial Management Program • Evidence in the literature • Components of Program • Outcomes to date

3. Standing Orders for Influenza and Pneumonia Vaccine • Background • Interventions in the literature • Federal support • Implementation

4. Background: http://www.cms.hhs.govhealthyaging/2a.asp • Influenza and pneumonia represent 5th leading cause of death in elderly • 20,000 to 40,000 influenza related deaths annually • 90% occur in those >65 years old • Influenza vaccine effective • Reduces hospitalizations by 27-57% • Reduces deaths by 27-30%

5. Underutilization • Influenza/pneumococcal vaccines are underutilized for persons >65 • Overall, 66%/35% • Nursing Homes 68%/38% • National Center for Health Statistics. Early release of selected estimates from the 2002 National Health Interview Surveys. http://www.cdc.gov/NCHS/about/major/nhis/released200209.

6. Cost effectiveness of Influenza vaccination. Leavenworth, G. The costly toll of vaccine-preventable disease. Business and Health 1995;(13)(3)16 • Minnesota health plan, three flu seasons • Vaccinated 45-58% of those >64 years • Lower hospitalization rates for flu, pneumonia, CHF • Average savings of $117 per vaccinated member

7. Standing Orders Improve Rates • Task Force on Community Preventive Services. Recommendationsregarding interventions to improve vaccination coverage in children,adolescents, and adults. Am J Prev Med 2000;18:92—140 • . Health Care Financing Administration. Evidence report andevidence-based recommendations: interventions that increase the utilizationof Medicare-funded preventive service for persons age 65 and older.Baltimore, Maryland: U.S. Department of Health and Human Services, HealthCare Financing Administration, October 1999; HCFA publication no.HCFA-02151. • Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-basedstrategies for improving influenza vaccination rates. J Fam Prac 1994;38:258--61. • Stevenson KB, McMahon JW, Harris J, Hilman JR, Helgerson SD.Increasing pneumococcal vaccination rates among residents of long-term-carefacilities: provider-based improvement strategies implemented by peer-revieworganizations in four western states. Infect Control Hosp Epidemiol2000;21:705--10.

8. Government Regulations to Promote Standing Orders • Centers for Medicare and Medicaid Services. Medicare and Medicaidprograms: conditions of participation: immunization standards for hospitals,long-term care facilities, and home health agencies. Washington, DC: U.S.Department of Health and Human Services, Centers for Medicare and MedicaidServices, 2002. Available athttp://www.cms.gov/providerupdate/regs/cms3160fc.pdf<http://www.cms.gov/providerupdate/regs/cms3160fc.pdf> . Centers for Medicare and Medicaid Services, Center for Medicaid andState Operations. Program memorandum: change in requirement for signedphysician's order for influenza and pneumonia vaccine. Washington, DC: U.S.Department of Health and Human Services, Centers for Medicare and MedicaidServices, 2002; publication no. S&C-03-02.

9. Comprehensive Antimicrobial Management Program

10. Rationale • Antibiotic use (appropriate or not) leads to microbial resistance • Resistance results in increased morbidity, mortality, and cost of healthcare • Appropriate antimicrobial stewardship will prevent or slow the emergence of resistance among organisms (Clinical Infectious Diseases 1997; 25:584-99.) • Antibiotics are used as “drugs of fear” • (Kunin et al.Annals 1973;79:555)

11. Antibiotic Misuse • Surveys reveal that: • 25 - 33% of hospitalized patients receive antibiotics (Arch Intern Med 1997;157:1689-1694) • 22 - 65% of antibiotic use in hospitalized patients is inappropriate (Infection Control 1985;6:226-230)

12. Changes in Resistance Rates at a University Hospital • A university hospital had an increase in multidrug-resistant K. pneum. • Physicians were educated about the association between ceftazidime use and MDR K. pneum. • Education occurred through grand rounds, attending rounds and consultations by ID physicians and clinical pharmacists. • Infect Control Hosp Epidemiol. 2000;21: 455-458.

13. Changes in Resistance Rates at a University Hospital

14. Resistance Changes in a Community Hospital • Increase resistance among GNR with C-I beta-lactamases, staph and enterococcus • An antimicrobial task force was formed (ID physicians, pharmacists, microbiologists, and infection-control.) • Consultations were triggered by 3rd generation cephalosporins, carbapenems, and vancomycin. • Extended spectrum penicillins/beta-lactamase inhibitor and aminogycosides were encouraged. • Costs were reduced by $650,000/year. • Pharmacotherapy 1999;19(8 pt 2):129S-132S

15. Resistance Changes in a Community Hospital

16. Changes in Resistance at an Urban Teaching Hospital • Epidemic in the surgical ICU of bacteremia due to Acinetobacter sensitive only to imipenem • Prior-authorization from ID faculty for selected antibiotics (amikacin, aztreonam, ceftaz, cipro, imipenem, ticar/clav) was required. • Acquisition cost for antimicrobial drugs were reduced by $863,100/year. • Survival rates, LOS, and length of ICU stay were not impacted. • Clinical Infectious Diseases 1997;25:230-9.

17. Changes in Resistance at an Urban Teaching Hospital

18. Components of PHD Program • Intravenous (IV) to oral conversion for well absorbed (highly bioavailable) antimicrobials • Discontinuation of preoperative antibiotic prophylaxis at 24h • Restricted antibiotic therapy

19. Components of the Program 1 • IV to Oral Conversion for Highly Bioavailable Antimicrobials • Patient Criteria • Able to take oral medications and diet • No persistent nausea, vomiting, or diarrhea • No medical condition that could decrease drug absorption • IV to oral conversions became automatic on July 1, 2001 • Pharmacists consult with nurse about how well the patient is eating and taking medications

20. Components of the Program 2 • Discontinuation of Preoperative Surgical Prophylaxis at 24 Hours • Strong support in the medical literature • Undergoing a “clean” procedure • Open heart • Artificial joint insertion • Many others

21. Components of the Program 3a • Restricted Antimicrobial Therapy • Antimicrobial Criteria • High risk • High cost • High potential to select resistance • Drugs of “last resort”

22. Components of the Program 3b • Restricted AntimicrobialTherapy • Antimicrobials restricted to ID physicians • Quinupristin/Dalfopristin (Synercid®) • New Antifungal Agents • Antimicrobials restricted after 48 hours – require Infectious Disease consult to continue • Vancomycin • Imipenem/Meropenem • Cefepime • Ceftazidime • Linezolid

23. Results of CAMP • April 2001 inception and partial implementation • July 1, 2001 full implementation

24. Antimicrobial Program Interventions(April 3, 2001 - December 31, 2002) Table 1

25. Team Activities To Date Including 2003 • 30 - 60 antimicrobial orders screened daily • > 1400 antibiotic recommendations have been made since April 1, 2001 • Recommendations are communicated through notes on charts and phone calls • Overall acceptance rate is 79%

26. Surgical Prophylaxis Antibiotic Doses / Day

27. IV vs. OralTotal Antibiotic Cost / Day

28. Restricted Antibiotics Doses / Day

29. Vancomycin

30. IV and PO Fluoroquinolones

31. Total Antibiotic Doses / Day

32. Facility Census Days

33. Annual Antibiotic Expenditure

34. Total Antibiotic Cost / Census Day

35. Changes in Bug/Drug Susceptibility Patterns