1. 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

2. 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.

3. 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

4. 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

5. 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.

6. 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.

7. 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 consistent with CAP
August 26, 2012-August 26, 2014

8. 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

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

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

11. Results
p 0.425
p 0.571
p 0.425
p 1.0

12. Results

13. Results

14. Results

15. Results

16. Results
p 0.001
p <0.001
p <0.001
Common CAP Abx (Days inpatient antibiotics/Total duration inpatient antibiotics)
Zosyn vs (P 0.054); Vancomycin vs (P 0.078); Clinda vs (P <0.001); Augmentin vs (0.858); Amox vs (P 0.006); Amp/Sul vs (P 0.012); Cefepime 0 vs (P 0.41)

17. 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)

18. 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:
CDC. Vital signs: Improving antibiotic use among hospitalized patients. MMWR. March 2014;63(09):
Ibrahim OM, Polk RE. Antimicrobial use metrics and benchmarking to improve stewardship outcomes. Infect Dis Clin N Am. 2014;28:
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) ia.html. Accessed August 10, 2014.