1. Antimicrobial Stewardship/Statewide Antibiogram
Felicia Matthews Senior Consultant, Pharmacy Specialty BD MedMined Services

2. Disclosures Employee of BD Corporation MedMined™ Services
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3. Agenda CMS and JCAHO CDC Outpatient AMS Antibiogram Antibiotics
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4. JCAHO and CMS

5. Regulatory
JCAHO MMS
Effective January 1, 2017
CMS Antimicrobial Stewardship requirement
October 4, 2016 CMS published the final rule adding AMS to the 1986 infection control condition of participation (CoP)
Hospitals must met CoP to receive payments

6. Regulatory
CMS-3295-P
Updates have been delayed because new administration has taken office
3/13 Seema Verma, MPH, confirmed as Medicare and Medicaid Administrator
3/24 House Republicans removed bill to repeal and replace the ACA from House floor vote
Although it’s not a controversial rule, it will be reviewed because it will cost money – up to $1 billion
Final ruling will be November 10th

7. Regulatory CMS-3295-P Infection Prevention Focus on prevention
Ensuring the Infection Preventionist is actually trained in Infection Prevention
Focus on transmission across the care continuum including patients, hospital personnel, visitors, environment and other outpatient facilities

8. Regulatory CMS-3295-P Antimicrobial Stewardship
Require hospitals to have policies and procedures for, and to demonstrate evidence of, an active and hospital-wide antibiotic stewardship program. 
Hospitals would be required to improve their internal coordination among all components responsible for antibiotic use

9. CDC Outpatient Antimicrobial Stewardship

10. Regulatory CDC Outpatient Antibiotic Stewardship
Developed in response to Executive Order 13676: Combating Antibiotic-Resistant Bacteria—issued by President Barack Obama on September 18, 2014
The National Action Plan outlines steps for implementing the National Strategy for Combating Antibiotic-Resistant Bacteria
3/2014
9/2015
11/2016

11. Regulatory CDC Outpatient Antibiotic Stewardship
2009 $10.7 Billion Spent on Antibiotics in US
61.5% outpatient
33.6% inpatient
4.9% long-term care settings
Suda KJ, A national evaluation of antibiotic expenditures by healthcare setting in the United States, JAC. 2013;68:715–8.

12. Regulatory CDC Outpatient Antibiotic Stewardship
Intended Audiences
Health care systems
Urgent care clinics and clinicians
Retail health clinics and clinicians
Outpatient specialty and subspecialty clinics
Primary care clinics
Emergency departments (EDs)
Dental clinics and dentists
Nurse practitioners and physician assistants

13. Regulatory CDC Outpatient Antibiotic Stewardship
Core elements
Commitment
Action for policy and practice
Tracking and reporting
Education and expertise

14. Regulatory CDC Outpatient Antibiotic Stewardship
Commitment
Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety by all healthcare team members

15. Regulatory CDC Outpatient Antibiotic Stewardship
Action for policy and practice
Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.
Diagnosis guidelines
Prescribing guidelines
Written justification in chart

16. Regulatory CDC Outpatient Antibiotic Stewardship
Tracking and reporting
Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves.
Chart review
Follow-up on initiatives

17. Regulatory CDC Outpatient Antibiotic Stewardship
Education and expertise
Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing
Communication strategies
Patient education

19. AHQI Antibiogram
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20. What is included?
Duplicate isolates removed
Significantly different susceptibility results are considered unique or non-duplicate
Includes data from 1/2016 to 12/2016
Isolates from 56 hospitals in Alabama
One isolate per organism per 365 day period
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21. Community versus Hospital
Community isolate
That which is collected from an outpatient or an inpatient within the first 3 days of an admission who has had no admissions within the past 14 days
Hospital isolate
That which is collected from a inpatient on or after day 3 of an admission or within 14 days of discharge
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22. Hospital Enterococcus Isolates (Non-Urine)
31% (29%) of Enterococcus isolates are the more resistant faecium strain
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23. Vancomycin Resistant E Faecium (Hospital Non-Urine)
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24. Hospital MRSA (Non-Urine)
Infection prevention is important
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25. MRSA All HAIs |
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26. MRSA Hospital versus Community (Non-Urine)
Infection prevention is important
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27. Klebsiella pneumonia Isolates Resistant to Meropenem (KPC)
Previous presentations have reported K. pneumonia strains tested against imipenem. A greater number of hospitals have been testing meropenem instead of imipenem. We will report meropenem moving forward.
2015 testing against imipenem showed 5549 isolates tested with 206 being resistant.
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28. Hospital Non-Urine A. baumannii Isolates Susceptible to Meropenem
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29. Carbapenms R or I Acinetobacter NATIONAL HAIs | 2011-2014
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30. MDR Acinetobacter Isolate Alabama Hospitals
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31. Hospital P. aeruginosa Non-Urine
B-Lactams
Pipercillin/Tazobactam and Cefepime are stable
Aztreonam has continued to steadily improve over the last 5 years
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32. Hospital P. aeruginosa Non-Urine
Aminoglycosides
Amikacin and Tobramycin steady at over 90%
Gentamicin continues to improve over the last 4 years
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33. Hospital P. aeruginosa Non-Urine
Carbapenems
P. aeruginosa susceptibility to imipenem at it lowest since data collection started, 68%
Meropenem declining since 2011
Concern here as this one of our last lines of defense against resistant gram negative bacteria.
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34. Hospital P. aeruginosa Non-Urine
Quinolones
Poor activity against Pseudomonas
There is a trend towards improvement over the past 3 years and since 2006
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35. Antibiogram Summary
Enterococcus faecium resistant to vancomycin or linezolid, hospital non-urine, remains stable (80%, 6%)
MRSA, hospital non-urine, trend continues to decline. Geographically, still high.
CRKP, hospital and community, declined in Monitor closely.
A. baumannii , hospital non-urine, susceptibility improved (70% vs 64%). Still a dangerous pathogen.
P. aeruginosa, hospital non-urine, resistance to carbapenems a concern with overall trend declining
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36. AHQI Antibiotic Utilization
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37. Antibiotic National Comparison
Antibiotics
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38. Antibiotic National Comparison
Carbapenems
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39. Antibiotic National Comparison
Piperacillin / Tazobactam
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40. Antibiotic National Comparison
Vancomycin, Linezolid, Daptomycin, Tigecycline
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41. Antibiotic National Comparison
Quinolones
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42. Antibiotic National Comparison
3rd/4th Generation Cephalosporins
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43. Antibiotic National Comparison
Proton Pump Inhibitors
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44. Thank you!
Thank you slide