U.S. Strategies to Improve Human Antibiotic Use Lauri A. Hicks, D.O. Director, Office of Antibiotic Stewardship April 13, 2016 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

Where Do We Want to Be?  Every patient gets optimal antibiotic treatment  Antibiotics only when they are needed  At the right time  At the right dose  For the right duration  Every provider and healthcare facility in America incorporates antibiotic stewardship to accomplish that goal

CDC’s Get Smart Programs  CDC launched the National Campaign for Appropriate Antibiotic Use in the Community in 1995  In 2003, the program was renamed Get Smart: Know When Antibiotics Work and coincided with a big media launch  Initial focus on outpatient settings, specifically acute respiratory tract infections  Now includes hospitals and long-term care facilities (Get Smart for Healthcare)  Additional focus on improving quality of healthcare and preventing adverse events (e.g. Clostridium difficile colitis)

Measuring and Characterizing Antibiotic Use  CDC surveys  The National Healthcare Safety Network (NHSN collects hospital antibiotic use data)  The National Ambulatory Medical Care Survey (NAMCS) and The National Hospital Ambulatory Medical Care Survey (NHAMCS)—currently setting national target to reduce inappropriate outpatient antibiotic use  Proprietary data collected for pharmaceutical marketing  Antibiotic expenditures  Population-based prescribing (based upon prescriptions filled)  Qualitative research – surveys, focus groups, etc.  Quality measure data (e.g. Healthcare Effectiveness and Information Set)  Exploring how to obtain data for nursing homes and retail/urgent care clinics

Community Antibiotic Prescribing Rates per 1000 Population — United States, 2013 Hicks CID 2015: 60(9): ; CDC. Outpatient antibiotic prescriptions — United States, Available via the internet: Lowest state: 509 per 1000 Highest state: 1274 per 1000

CDC Recommendations for Antibiotic Stewardship Implementation n/core-elements.html elements-antibiotic-stewardship.pdf

NH MA RI CT NJ DE MD DC 58% 19% 21% 50% 39% 13% 23% 44% VT 55% 36% 50% 52% 56% 54% 30% 37% 21% 24% 36% 38% 41% 24% 43% 29% 28% 21% 37% 49% 48% 41% 47% 50% 29% 30% 29% 31% 35% 33% 29% 7 – 28% 29 – 35% 36 – 48% 49 – 58% 42% HI PR 33% 28% 58% 30% 27% 49% 50% 13% 7% 25% AK Percent of Hospitals Meeting all Core Elements, by State Overall percentage was 39.2% (1642 of 4,184 hospitals) Data: NHSN 2015 Annual Facility Survey

 Released March 27, 2015  Outlines steps to implement the National Strategy  Significant outcomes expected by 2020  Establishment of antimicrobial stewardship programs in all acute care hospitals and improved antimicrobial stewardship across all healthcare settings  Reduction of inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings National Action Plan for Combating Antibiotic- Resistant Bacteria (CARB) 8

White House Forum on Antibiotic Stewardship  CDC proposed the White House Forum on Antibiotic Stewardship  An opportunity to highlight the problem of antibiotic resistance, underline the critical importance of antibiotic stewardship, and garner public support and commitments from outside organizations  Over 150 organizations across human and animal health made commitments to improve antibiotic use

Improving Antibiotic Use Lessons Learned  Tackle antibiotic misuse in all healthcare settings  Measure antibiotic use to guide implementation and track progress  Set national targets to improve antibiotic use  Conduct research to expand implementation and develop new interventions  Pair education with provider-level interventions and policy levers to speed change  Engage a variety of stakeholders, including policymakers  Changing behavior and culture requires perseverance