1. Downstate Illinois Partnership Against Antibiotic Resistance Wayne Mathews, MS, PA-C Justin Parker, MD SIU Department of Family and Community Medicine The presenters have no disclosures to make.

2. Focus: Regional Outpatient Antimicrobial Stewardship Initiative Web- based, online November 2014: www.siumed.edu/antibioticresistance www.siumed.edu/antibioticresistance Medical Education impacts training future primary care physicians: based in five downstate Family Medicine residencies. Purpose: analyze regional outpatient resistance patterns, educate providers on improving prescribing and patients on understanding scope of problem.

4. Scope and Partners State and National -- Illinois Department of Public Health Carbondale, IL -- Memorial Hospital of Carbondale -- SIU Family and Community Residency Decatur, IL -- Decatur Memorial Hospital -- SIU Family and Community Residency -- St. Mary's Hospital Quincy, IL -- Blessing Hospital -- SIU Family and Community Residency Springfield, IL -- Memorial Medical Center -- SIU Family and Community Residency -- St. Mary's Hospital Urbana, IL -- Carle Family Medicine Residency -- Carle Foundation Hospital -- Presence Hospital

5. THE PROBLEM: HOSPITAL VS. AMBULATORY ENVIRONMENT Hospital : High Tech Tools, Surveillance, Infection Control Measures

6. THE PROBLEM: HOSPITAL VS. AMBULATORY ENVIRONMENT Ambulatory: Lax monitoring, prescribing often by patient choice.

7. CURRENT STATE OF AMBULATORY ANTIBIOTIC PRESCRIBING Estimated 50% current antibiotic prescriptions unnecessary- CDC MMWR 2011 833 antibiotic Rx per 1000 persons in US in 2010- NEJM, April 2013 Azithromycin most frequently prescribed antibiotic- highest in age 65 High Regional variation

8. Regional Resistances Analyzed local hospital antibiograms for past 4 years for presence and trend of resistances. Criteria for analysis: 1. Bacteria which would likely be treated in the out-patient setting, where most antibiotic prescriptions occur. Example is Strep Pneumonia to Macrolides (Zithromax is the most frequently prescribed antibiotic in the US). 2. Bacteria which could be influenced by prescribing in the outpatient setting and test as resistant in the hospital. Example is Strep. Pneumonia to Ceftriaxone (Ceftriaxone is one of the first line antibiotics used to treat community acquired pneumonia), or Methicillin-resistant Staph Aureus. 3. Bacteria that evidence a trend of increasing resistance. Example is E. coli to Sulfas. 4. Bacteria with resistances mentioned by guidelines from the Infectious Disease Society of America, which should be used to guide empiric treatment. Example is caution using Sulfa in UTI: ‘avoid if resistance prevalence is known to exceed 20 %, or if used for UTI in previous 3 months’.

9. Regional Resistances of Concern 2014 West Central: # IsolatesBacteriaAntibiotic SusceptibilityResistance Trend 118Strep. PneumoniaCeftriaxone 89%Less Susceptible 118Strep. PneumoniaMacrolides 43%Less Susceptible 819E. ColiTMP/SMX 76%Less Susceptible 357Staph Aureus MRSAClindamycin 49%Less Susceptible 149Proteus M.Quinolones 56%Less Susceptible Bacteria# IsolatesAntibiotic SusceptibilityResistance Trend Strep Pneumonia88Macrolides 56% Less Susceptible E. Coli1341Quinolones 78% Less Susceptible E. Coli1340TMP/SMX 78% Less Susceptible Staph aureus1115MRSA rate 54% Less Susceptible Proteus M.99Quinolones 54%Stable East Central:

10. Regional Resistances of Concern West: Bacteria# IsolatesAntibiotic SusceptibilityResistance Trend E. coli1363Quinolones 79% Less Susceptible E. coli1363TMP/SMX 76% Less Susceptible Enterococcus302Vancomycin 90% Less Susceptible Staph Aureus539 Inducible Clindamycin resistance 89% Unknown Staph Aureus144MRSA Rate 52%Less Susceptible Proteus M.188Quinolones 59%Stable Bacteria# IsolatesAntibiotic SusceptibilityResistance Trend E. Coli552TMP/SMX 76%Stable E. Coli552Quinolones 72% Less Susceptible Strep Pneumonia26Macrolides 36% Less Susceptible Staph aureus1040MRSA Rate 57%Less Susceptible Bacteria# IsolatesAntibiotic SusceptibilityResistance Trend E. Coli552TMP/SMX 76%Less Susceptible E. Coli552Quinolones 72%Less Susceptible MRSA162Clindamycin 70%Less Susceptible Strep Pneumonia26Macrolides 36%Less Susceptible East: South:

11. Projects Underway Partner with IDPH on Precious Drugs and Scary bugs Campaign using method of Meeker at al: nudging guideline concordant antibiotic prescribing. JAMA Internal Medicine 2014. Survey on Antibiotic Stewardship to US Family Medicine Program Directors. Educate ED providers on AS issues. Study Effects of LTC prescribing for Asymptomatic Bacteruria on UTI resistance patterns. News Releases, participated in Get Smart with Antibiotics Week.

12. Family Medicine Program Directors Survey Survey to 288 FM PD’s 98% identified Antibiotic Stewardship as Important to Extremely Important. 67% stated program involvement of Infectious disease faculty physician. 73% stated program had no plans to change curriculum for AS in next year. Only 14% had an AS quality improvement metric in place.