Deemed exempt from IRB due to quality improvement project Presentation Number: 264 Category: A1. Infectious Diseases - Anti-infective Agents Retrospective Review And Analysis of the Clinical Impacts of an Antimicrobial Stewardship Program Katie Gordon PGY1 Pharmacy Resident Providence Alaska Medical Center Anchorage, Alaska Deemed exempt from IRB due to quality improvement project

Disclosure Statement Katie Gordon, Pharm.D. Potential Conflicts of interest: None Sponsorship: None Proprietary information or results of ongoing research may be subject to different interpretations. Presentation of this slide indicates my agreement to abide by the non-commercialism guidelines provided on the CE Requirements page.

Learning Objectives Describe the components of an antimicrobial stewardship program Explain the criteria for health care associated pneumonia versus community-acquired pneumonia Target audience: Pharmacists

Providence Alaska Medical Center Location: Anchorage, Alaska Population Estimate: 300,549 as of 2014 1 of 3 hospitals in Anchorage Largest hospital in Alaska Highest level of acuity of care in Alaska Demographics: 394 bed, tertiary care, community hospital Level 2 Trauma Center Level 3 NICU Safety net hospital Decentralized pharmacy model http://labor.state.ak.us/research/pop/popest.htm

Background IDSA recommended components for AMS program includes: Secondary Supplements to AMS Programs Essential Education Infectious disease physician Guidelines and clinical pathways Clinical pharmacist with infectious disease training Antimicrobial cycling Antimicrobial order forms Optimal Combination therapy Clinical microbiologist Information system specialist Streamlining or de-escalation of therapy Infection control professional Dose optimization Hospital epidemiologist Hospital administrative support Parenteral to oral conversion Primary Core Strategies EMR, CPOE, and clinical decision support Prospective audit with intervention and feedback Computer based surveillance Clinical microbiology support Formulary restriction and preauthorization Process measures Despite this established goal, few studies have addressed clinical impacts, such as mortality and length of stay, after initiation of an antimicrobial stewardship program.

Background PAMC’s AMS program was initiated August 26, 2013 The objective of this study is to evaluate clinical outcomes of patients admitted with community-acquired pneumonia in relation to the start of an antimicrobial stewardship program in order to assess: Inpatient mortality 30-day readmission rate Rate of C. difficile infection during admission Length of stay Duration of antimicrobial agents While the program has shown positive impacts on antimicrobial expenditure and utilization of antimicrobials, clinical outcomes of the program have not been evaluated.

Methodology Retrospective analysis Assessed for non-inferiority Year prior to AMS program initiation Year one post-AMS program initiation Inclusion: Primary ICD-9 code of 486.0 consistent with CAP August 26, 2012-August 26, 2014

Methodology Exclusion: Met criteria for HCAP Pregnant Incarcerated Immunocompromised Antibiotics in preceding 90 days Incarcerated <18 years of age Hospitalization of 5 days or more Admitted for <24 hours Chronic dialysis within 30 days Concurrent infection requiring antibiotics Home infusion therapy Residence in extended care facility LOS >60 days Hospitalization for ≥2 days in preceding 90 days

Methodology 1180 Patients (Excluding LOS <1 day, age <18 yo) Exclusion Criteria 790 Patients 390 Patients Included

Results p 0.221 p 0.734 p 0.440 p 0.360 p 0.784 p 0.229 p 0.375

Results p 0.425 p 0.571 p 0.425 http://www.medicare.gov/hospitalcompare/compare.html#cmprTab=3&vwgrph=1&cmprID=020001%2C020026%2C020017&cmprDist=11.5%2C10.9%2C11.9&dist=200&loc=99504&lat=61.2010981&lng=-149.5425156 p 1.0

Results

Results

Results

Results

Results p 0.001 p <0.001 p <0.001 Common CAP Abx (Days inpatient antibiotics/Total duration inpatient antibiotics) Zosyn- 0.09466 vs 0.06985 (P 0.054); Vancomycin 0.06472 vs 0.08615 (P 0.078); Clinda- 0.0623 vs 0.03027 (P <0.001); Augmentin 0.03236 vs 0.03376 (0.858); Amox 0.00243 vs 0.01281 (P 0.006); Amp/Sul 0.02751 vs 0.01164 (P 0.012); Cefepime 0 vs 0.00116 (P 0.41)

Conclusions The antimicrobial stewardship (AMS) program at PAMC has not had negative impacts on clinical outcomes as related to community- acquired pneumonia Decrease in mean length of stay and duration of antimicrobials Fluoroquinolone usage has decreased Ceftriaxone and azithromycin usage has increased Future directions for continuation of this project include: Analysis after initiation of the community-acquired pneumonia clinical pathway Analysis of other commonly intervened upon disease states Integration of procalcitonin levels and rapid diagnostics (Biofire® Viral Panel)

References Dellit TH, Owens RC, McGowan JE, et al. Infectious disease society of America and the society for healthcare epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. CID. 2007;44:159-177. CDC. Vital signs: Improving antibiotic use among hospitalized patients. MMWR. March 2014;63(09):194-200. Ibrahim OM, Polk RE. Antimicrobial use metrics and benchmarking to improve stewardship outcomes. Infect Dis Clin N Am. 2014;28:195-214. Schmitt S, McQuillen DP, Nahass R, et al. Infectious disease specialty intervention is associated with decreased mortality and lower healthcare costs. CID. 2014;58(1):22-28. The Joint Commission: Specifications Manual for Joint Commission National Quality Core Measure (2010B). https://manual.jointcommission.org/releases/archive/TJC2010B1/Pneumon ia.html. Accessed August 10, 2014.