Identifying Targets for Improving Antibiotic Use Acute Care AHRQ Safety Program for Improving Antibiotic Use Identifying Targets for Improving Antibiotic Use Acute Care 

Presenter — Sara Cosgrove Sara Cosgrove, MD, MS Title: Professor of Medicine, Division of Infectious Diseases, Director, Antimicrobial Stewardship Program, Associate Hospital Epidemiologist Place of work: Johns Hopkins Medical Institutions Program email address: antibioticsafety@norc.org

Housekeeping Keep phone on mute Use ‘chat’ feature in WebEx if you need to speak Please hold off questions until the end during Q&A

Objectives Understand how to identify defects related to antibiotic prescribing. Understand how to leverage frontline wisdom to guide safety improvement efforts around antibiotic prescribing. Understand how to recognize defects using the Four Moments of Antibiotic Prescribing framework.

Recap CUSP — 3 methods to eliminate unnecessary harm — Improves the culture of safety Provides frontline staff with tools / 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 opportunity

Examples of defects related to antibiotic use What is a Defect? A defect is anything you do not want to have happen again. Examples of defects related to antibiotic use Unnecessarily broad spectrum empiric antibiotic therapy Delayed antibiotic initiation in patients with sepsis Forgetting to obtain needed cultures Forgetting to narrow antibiotic therapy based on clinical data Forgetting to discontinue antibiotics when they are not needed Forgetting to discontinue surgical prophylaxis Forgetting to convert from IV to PO therapy Accidentally miscounting days of therapy during transitions of care Prescribing excess durations of antibiotic therapy Development of a C. difficile infection

How Can you Identify Defects? Seek input from a diverse group of healthcare workers Staff Safety Assessment — Describe the next patient scenario for which antibiotics may not be prescribed optimally Describe what you think can be done to prevent this from happening

How Can you Identify Defects? The AS team Unit physician lead Unit pharmacist lead Unit nurse lead Any frontline staff Prioritize top three opportunities Identify all the factors that could lead to this opportunity Technical factors Adaptive factors

Potential Solution(s) Technical Problems Have potentially clear solutions. Usually require a checklist or protocol to guide implementation of the evidenced-based best practice Problem Potential Solution(s) House staff are unaware that the recommended duration of therapy for community-acquired pneumonia is generally 5 days Develop pocket-guides for house staff Automatic pop-ups in the EHR

Potential Solution(s) Adaptive Problems Require a change in attitudes, beliefs and behaviors. Problem Potential Solution(s) Physicians feel uncomfortable discontinuing vancomycin when a colleague decided to start it the previous day Clinicians should feel comfortable adjusting antibiotic therapy initiated by colleagues as clinical pictures evolve

First order problem solving Solves one problem in one particular instance. Generally does not help prevent future harm from occurring. Second order problem solving Uses adaptive interventions to change culture and beliefs. Identifies system opportunities to prevent them from occurring again.

The Four Moments of Antibiotic Stewardship

Four Moments Review 1. Does my patient have an infection that requires antibiotics? 2. Have I ordered appropriate cultures before starting antibiotics? What empiric therapy should I initiate? 3. A day or more has passed. Can I stop antibiotics? Can I narrow therapy or change from IV to oral therapy? 4. What duration of antibiotic therapy is needed for my patient's diagnosis?

Moment 3: De-escalation What are some of the data behind Moment 3 — Antibiotic De-escalation Definition: Modifying antibiotic therapy to agents considered to have a narrower spectrum of activity or stopping antibiotic therapy Guided by — Microbiology data Clinical status of the patient Goals — Optimize therapy AND Select agents that minimize side-effects

Is Antibiotic De-Escalation Safe? 28% reduced risk of death compared to no de-escalation 1. Tabah A, Cotta MO, Garnacho-Montero J, et al. A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit. Clin Infect Dis. 2016 Apr 15;62(8):1009-1017. PMID: 26703860

Case #1 Example of De-Escalation A patient with a past history of mitral valve endocarditis is admitted with high fevers, hypotension, and diffuse myalgias. He is diagnosed with presumptive endocarditis and started on vancomycin and ceftriaxone. By day 3 of therapy, blood cultures are growing a viridans group streptococcus susceptible to penicillin with a low MIC. In this case, while vancomycin and ceftriaxone both have activity against the organism, penicillin is the preferred choice given its narrow spectrum, excellent activity against the organism, and low side-effect profile.

Case #2 Example of De-Escalation A patient hospitalized after undergoing a spinal fusion is diagnosed with pneumonia and sepsis. He requires intubation and is admitted to the ICU and started empirically on vancomycin and piperacillin / tazobactam. He improves over the next few days and is extubated on day 3. Sputum cultures grow a pan-susceptible E. coli Not necessary to continue broad spectrum therapy. Cefazolin is preferable because there is less association with C. difficile infection.

Case #3 Example of De-Escalation A patient presents to the ED. Chest x-ray shows bilateral infiltrates vs. edema greater on the right than the left. Initiated on ceftriaxone and azithromycin and furosemide. The next day, he reports that his shortness of breath has resolved A sputum culture is pending. In this case, the diagnosis is highly likely to be heart failure. The patient had a favorable response to diuresis so it is reasonable to stop his antibiotics. There is no need to wait for the results of a sputum culture when clinical judgment suggests he does not have an infection.

Your Turn! Think about antibiotic usage in your unit… What is a defect related to antibiotic use that you have noticed? Record your defect.

Summary Defects related to antibiotic-prescribing are plentiful. It is important for frontline staff to identify observed defects by completing the Staff Safety Assessment. Teams should review and prioritize defects. Four Moments of Antibiotic Prescribing framework will be used to identify defects and use second-order problem solving to determine technical and adaptive solutions.

Program Website Access ANTIBIOTICSAFETY@NORC.ORG

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

Next Steps Behavior Change Theory for Antibiotic Stewardship Leaders Identifying Targets for Improving Antibiotic Use (CUSP 2) Improving Antibiotic Use by Learning from Defects WebEx call Questions? antibioticsafety@norc.org

Reference 1. Tabah A, Cotta MO, Garnacho-Montero J, et al. A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit. Clin Infect Dis. 2016 Apr 15;62(8):1009-1017. PMID: 26703860