AHRQ Safety Program for Improving Antibiotic Use Acute Care Improving Antibiotic Use Is a Patient Safety Issue

Presenter — Pranita Tamma Pranita Tamma, M.D., M.H.S. Assistant Professor of Pediatrics Director of Pediatric Antimicrobial Stewardship, Johns Hopkins Hospital Program email address: antibioticsafety@norc.org

Housekeeping Please keep phone on mute Use “chat” feature in WebEx if you need to speak Hold off most questions until the end during Q&A Please participate when asked

Objectives Discuss the potential harm associated with antibiotic use. Understand that patient harm is largely preventable. Understand that change efforts often require a focus on systems, not just individuals. Understand the importance of diverse input to prevent harm.

Clinical Case 50-year-old man with cerebral palsy - Known seizure history - Presented to emergency department (ED) with a seizure Chest imaging: bilateral airspace opacities at the base of his lungs Not producing sputum, so sputum cultures were not sent Initiated on piperacillin-tazobactam for presumed aspiration pneumonia Admitted to the intensive care unit (ICU) Clinical improvement within 24 hours Upon discharge from ICU, completed 7-day course of piperacillin/tazobactam and discharged home 1. Joundi RA, Wong BM, Leis JA. Antibiotics just-in-case in a patient with aspiration pneumonitis. JAMA Internal Med. 2015 Apr;175(4):489-90. PMID: 25665174.

Clinical Case, Continued One week later: Re-presented to the hospital with severe Clostridium difficile infection Day 18 of hospitalization: Died

Where Are the Defects in This Case? Click to add text 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient prematurely started on broad spectrum antibiotics in the emergency department. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient prematurely started on broad spectrum antibiotics in the emergency department. 2. Decision to continue antibiotics not revisited at time of admission to the ICU. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient prematurely started on broad spectrum antibiotics in the emergency department. 2. Decision to continue antibiotics not revisited at time of admission to the ICU. 3. Decision to continue antibiotics not revisited the next day after patient improved. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient prematurely started on broad spectrum antibiotics in the emergency department. 2. Decision to continue antibiotics not revisited at time of admission to the ICU. 4. No discussion by ICU team on discontinuing therapy prior to floor transfer. 3. Decision to continue antibiotics not revisited the next day after patient improved. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? Patient dies. Antibiotic complications likely caused this sentinel event 1. Patient prematurely started on broad spectrum antibiotics in the emergency department. 2. Decision to continue antibiotics not revisited at time of admission to the ICU. 5. No discussion by floor team on discontinuing therapy when transferred to the floor. 4. No discussion by ICU team on discontinuing therapy prior to floor transfer. 3. Decision to continue antibiotics not revisited the next day after patient improved. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

The Importance of Antibiotics Revolutionized modern medicine Saved countless lives Prompt administration of the correct antibiotics at the right dose can be critical for patients who need them However, their use is not entirely benign! 5

Antibiotic Development Is on the Decline

5% Patient can take oral therapy Antibiotic Overuse Approximately 50% of hospitalized patients receive at least one antibiotic during their hospital stay. Approximately 30% of antibiotics hospitalized patients receive are unnecessary. 5% Patient can take oral therapy 3. Magill SS, Edwards JR, Beldavs ZG, et al. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. JAMA. 2014;312(14):1438-1446. PMID: 25291579. 4. Hecker MT, Aron DC, Patel NP, et al. Unncessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003; 163(8):972. PMID: 12719208.

Antibiotic-Associated Adverse Events 5

Antibiotics Alter the Bacteria in the Gut Susceptible Bugs Resistant Bugs Bacterial Cell Number Detection Threshold Antibiotic Treatment End of Antibiotic Treatment Time 5. Jernberg C, Lofmark S, Edlund C, et al. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Microbiology. 2010;156(Pt 11):3216-3223. PMID: 20705661.

Antibiotics & Clostridium difficile Antibiotics can increase the risk of Clostridium difficile infection (CDI) Greatest risk Clindamycin (odds ratio 16.8) Third-generation cephalosporins (odds ratio 5.7) Fluoroquinolones (odds ratio 4.3) Patients are at risk while receiving antibiotics and up to at least 12 weeks later 6. Brown KA, Khanafer N, Daneman N, et al. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013; 57(5):2326-32. PMID: 23478961.

Clinical Case 76-year-old woman presents to her doctor for her annual visit Complains of difficulty falling asleep; otherwise feels well Her doctor sends a urinalysis and urine culture in case her symptoms are related to a urinary tract infection (UTI) Has ≥100,000 CFU/mL of a pan-susceptible E. coli in urine culture Another clinician sees urine culture results and prescribes a 7-day course of ciprofloxacin

Clinical Case, Continued Two months later she has fevers, dysuria, and flank pain She presents to her local ED and is hypotensive Admitted and initiated on cefepime Urine culture grows ≥100,000 CFU/mL E. coli resistant to ciprofloxacin but susceptible to a number of β-lactams Completed a 7-day course of cefepime

Where Are the Defects in This Case? 1. Patient did not have signs and symptoms consistent with a UTI at primary care office. Urine culture did not need to be sent. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient did not have signs and symptoms consistent with a UTI at primary care office. Urine culture did not need to be sent. 2. When urine culture grew E. coli, prescribing clinician should have called patient to determine if she had UTI symptoms. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient did not have signs and symptoms consistent with a UTI at primary care office. Urine culture did not need to be sent. 2. When urine culture grew E. coli, prescribing clinician should have called patient to determine if she had UTI symptoms. 3. If patient did report dysuria, a different agent and shorter course should have been prescribed. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? 1. Patient did not have signs and symptoms consistent with a UTI at primary care office. Urine culture did not need to be sent. 2. When urine culture grew E. coli, prescribing clinician should have called patient to determine if she had UTI symptoms. 4. During her hospitalization, after antibiotic susceptibility data returned, cefepime should have been narrowed. 3. If patient did report dysuria, a different agent and shorter course should have been prescribed. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Where Are the Defects in This Case? Due to antibiotic overprescribing; Patient incurred daily risks, inconveniences, and costs 1. Patient did not have signs and symptoms consistent with a UTI at primary care office. Urine culture did not need to be sent. 2. When urine culture grew E. coli, prescribing clinician should have called patient to determine if she had UTI symptoms. 5. At the time of discharge, an oral antibiotic option should have been explored. 3. If patient did report dysuria, a different agent and shorter course should have been prescribed. 4. During her hospitalization, after antibiotic susceptibility data returned, cefepime should have been narrowed. 2. Reason, J. Human Error. Cambridge: University Press, Cambridge;1990

Social Determinants of Antibiotic Prescribing Medicine is often an art, not an exact science Social influences include Relationships between clinicians Relationships between clinicians and patients Risk, fear, anxiety and emotion

CUSP — Helps Reduce Antibiotic-Associated Harm Comprehensive Unit-based Safety Program (CUSP) Strives to reduce preventable harm by identifying opportunities that cause harm to patients Opportunities can be technical, behavioral or both Encourages a team-approach to fix those opportunities

The Steps of CUSP Understand the science of safety Identify current defects causing patients harm Engage leadership for support and collaboration Learn from defects and develop solutions Improve teamwork and communication

Step 1: The Science of Safety There are three basic principles of safe design Standardize care and eliminate unnecessary steps Develop local guidelines, order sets and communication tools

Step 1: The Science of Safety Standardize care and eliminate unnecessary steps Create independent checks Input from nonprescribers, (e.g., nurses, respiratory therapists, pharmacists) Input from antibiotic stewardship team Input from consultation with infectious diseases clinicians (when available)

Step 1: The Science of Safety Standardize care and eliminate unnecessary steps Create independent checks Learn from defects What happened? Why did it happen? What did you do to reduce the risk of this occurring again in the future? How do you know it worked?

Successful CUSP Teams Composed of multidisciplinary members Suggest including a physician lead, pharmacist leader, and nurse leader Select engaged frontline staff and prescribers who take ownership of patient safety Meet regularly Have adequate resources including protected time Work together to make decisions

Summary CUSP Improves the culture of safety Provides frontline staff with tools and support to identify and tackle hazards that threaten their patients Strives to eliminate preventable harm! 3 methods to eliminate unnecessary harm Standardize practices Create independent checks Learn from each new defect

Program Website Access AHRQ-AS-SUPPORT@NORC.ORG (for technical issues, only)

Science of Safety Video

Questions THANK YOU FOR PARTICIPATING! Type in your questions using “Chat” or Speak up on conference line THANK YOU FOR PARTICIPATING!

Next Steps Improving Antibiotic Use is a Patient Safety Issue (CUSP 1) Behavior Change Theory for Antibiotic Stewardship Leaders WebEx call Questions? antibioticsafety@norc.org

References Joundi RA, Wong BM, Leis JA. Antibiotics "just-in-case" in a patient with aspiration pneumonitis. JAMA Intern Med. 2015 Apr;175(4):489-90. PMID: 25665174. Reason J. Human Error. Cambridge: University Press, Cambridge; 1990. Magill SS, Edwards JR, Beldavs ZG, et al. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. JAMA. 2014 Oct 8;312(14):1438-46. PMID: 25291579. Hecker MT, Aron DC, Patel NP, et al. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003 Apr 28;163(8):972-8. PMID: 12719208. Jernberg C, Löfmark S, Edlund C, et al. Long-term impacts of antibiotic exposure on the human intestinal microbiota. Microbiology. 2010 Nov;156(Pt 11):3216-23. PMID: 20705661. Brown KA, Khanafer N, Daneman N, et al. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013 May;57(5):2326-32. PMID: 23478961.