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

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

3. 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

4. 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.

5. 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 Apr;175(4): PMID:

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Antibiotic Development Is on the Decline

15. 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 JAMA. 2014;312(14): PMID:
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:

16. Antibiotic-Associated Adverse Events5

17. 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): PMID:

18. 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): PMID:

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

31. 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?

32. 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

33. 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

34. Program Website Access
(for technical issues, only)

35. Science of Safety Video

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

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

38. References
Joundi RA, Wong BM, Leis JA. Antibiotics "just-in-case" in a patient with aspiration pneumonitis. JAMA Intern Med Apr;175(4): PMID:
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 JAMA Oct 8;312(14): PMID:
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 Apr 28;163(8): PMID:
Jernberg C, Löfmark S, Edlund C, et al. Long-term impacts of antibiotic exposure on the human intestinal microbiota. Microbiology Nov;156(Pt 11): PMID:
Brown KA, Khanafer N, Daneman N, et al. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother May;57(5): PMID: