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Hello.
My name is Deb Smith.
I'm an improvement consultant at House Quality Innovators, or HQI.
This educational event has been developed in partnership with HQI, the Virginia Department
of Health, and the Virginia Hospital and Healthcare Association.
I'd like you to take a minute to review the icons at the bottom of your screen.
There are two green icons to the right.
One is for the resources for this education, and the other is the post test that you will
be taking after completing the education.
You'll have two chances to achieve a 70% or higher in order to receive your certificate.
I would now like to introduce your instructor for today.
Rebecca Collins serves as the interim clinical manager, Residency Director and Education
Coordinator for Bon Secour Virginia Health System.
She also practices as Antimicrobial Stewardship team lead at Memorial Regional Medical Center
and Bon Secour Health System.
She currently teaches pharmacy residents and students in the clinical area of infectious
diseases and offers advanced practice professional experiences in acute geriatric care and internal
medicine.
She is also a co-founder of the Stewardship Interest Group of Virginia.
Rebecca, the floor is yours.
Thank you, Deb. [inaudible 00:01:33] back to Sir Alexander Fleming when he stated in
the New York Times, "that the microbes are educated to resist penicillin and a host of
penicillin-fast organisms is bred out.
In such cases the thoughtless person playing with penicillin is morally responsible for
the death of a man who finally succumbs to infections with the penicillin-resistant organism.
I hope this evil can be averted."
So, basically we've gone from infectious disease killing people, to people being saved by penicillin
and antibiotics now back full circle to these multi-drug-resistant organisms killing people
once again.
If we fast forward to 2000 [inaudible 00:02:17] by saying, "The healthcare system needs to
improve how it detects patients with drug-resistant infections, controls the spread of such infections,
prevents them from happening in the first place, and incentivizes drug-makers to develop
new antimicrobials."
So, some background statistics I'd like to review, include that two million Americans
develop resistant infections every year.
This leads to 23 thousand Americans dying from drug-resistant infections annually.
Antimicrobial agents continue to be the largest portion of pharmacy expenditures with up to
fifty percent of antimicrobial use being deemed inappropriate.
This inappropriate use can lead to resistance and other adverse events and appropriate use
may actually improve patient outcomes and reduce healthcare costs.
Not only are the number of infections and diseases and deaths rising, we also see our
sequelae from overuse of antimicrobials rising.
For instance, C. Diff. infections have increased to 250 thousand illnesses annually with approximately
14 thousand deaths due to C. Diff.
There are many other untoward [effects 00:03:33] that we need to consider.
These include the increase of antibiotic resistance associated with overuse of antibiotics, increased
healthcare costs with up to 30 billion dollars spent annually, increased risk of adverse
drug events with things such as hypersensitivity, diarrhea, and as we spoke just a moment ago
about Clostridium Difficile.
This is the class of medications that when you use it in one patient the effects can
reach those around them.
Antimicrobial resistance we see an increase in overuse and misuse of antimicrobials and
this forces the bacteria to either adapt or die leading to selective pressure.
Bacteria that can adapt and survive antimicrobial therapy then carry genes for resistance and
these genes are transmitted to future generations of bacteria.
When we further look into resistance we see that bacteria may also colonize and infect
organisms, especially if they're becoming more and more exposed to antibiotics.
Resistant organisms can be transmitted between patients and there are some examples here
of some of our more common resistant organisms including Methicillin-resistant Staph Aureus
and Carbapenem-Resistant Organisms.
The highest risk patient groups that acquire resistant pathogens include those that are
immuno compromised, our hospitalized patients and those that have invasive devices placed
such as central venous catheters or Foley catheters.
Further indirect impact to the patient includes increased office visits, lost time from work,
severity of illness, increased length of stay if they're hospitalized and patients having
adverse events from multiple antibiotics.
This can even lead to death.
So why do we need to worry about antimicrobial stewardship?
We really need to improve our antimicrobial prescribing.
We also need to minimize misdiagnosis and delayed diagnosis and the under-use of antimicrobials
when needed.
We also need to ensure that we're using the right drug, dose and duration of therapy and
we can track these things overtime to make sure that we are prescribing in an appropriate
manner.
We can also use this tracking to help us show a slowing and prevention of development of
resistance.
The Center for Disease Control has developed some guidelines for a core group of team members
that can be part of your Antimicrobial Stewardship program.
Here is a list that is inclusive but not limited to infectious disease providers, clinical
pharmacist with infectious disease training, clinical microbiologists, information system
specialists, infection control professionals and hospital epidemiologists.
And of course you definitely require the support and collaboration of hospital administration,
your medical staff and any local providers and pharmacists involved in the care of the
patient.
Some benefits of antimicrobial stewardship include the improved clinical outcome, providing
more cost effective care to our patients by decreasing the use of costly antimicrobials
and also decreasing the length of stay, especially when they're hospitalized, reducing readmissions
to the hospital setting, and preventing hospital and healthcare associated infections.
We also can decrease adverse event rates using antimicrobial stewardship.
Some further benefits include curtailing antimicrobial resistance such as our multi-drug resistant
organisms that we mentioned earlier.
Also reducing overall healthcare expenditures and both of these regulatory bodies here require
that we do this and we need to make sure that we're meeting those requirements from the
Joint Commission and the Centers for Medicare and Medicaid Services.
Some strategies to use are core strategies, which include perspective audit with interventions
and feedback.
This is basically your perspective review of a patient on a daily basis to make sure
they're receiving the most appropriate therapy.
You also can use formula restriction and pre-authorization.
This would restrict those agents that you would only wanna use in a setting of resistance
or intolerance for the patient.
And then, supplemental strategies include education, guideline and pathways to help
direct therapies, streamlining and de-escalation of therapy, dose optimization, IV to PO conversion
and computer assisted decision support for different infection types.
Antibiotic use definitely can lead to resistance as we've mentioned earlier.
So we definitely want to look at patients with a history of antimicrobial use and monitor
their risk for resistance.
We also wanna look at antibiograms and determine if regions have a prevalence of antimicrobial
resistance.
We can definitely change our prescribing patterns to help to curtail resistance or to also lead
to resistance so we need to be monitoring that with some of our metrics.
And then we want to look at dose-response relationships and making sure that we're optimizing
the dose for the antimicrobial and for the patient.
What can we do as pharmacists to help improve this scenario?
There are several things that we have listed here.
We definitely can review culture data and de-escalate therapy when appropriate.
We can help optimize our dosing strategies both based on the drug and also the pharmacodynamic
effect of the antimicrobial in the patient's body.
We can also do medication use evaluations and look for trends in prescribing that may
be leading to resistance.
We can look for drug allergy information and we can also promote our antibiograms and make
sure they're readily available when prescribing is occurring.
And definitely helping the patient to know what the adverse drug events are and to help
with monitoring of those.
So for example [inaudible 00:10:07] antibiotic allergy history most people who believe that
they are allergic to an antibiotic can take that antibiotic without a problem and they
may not even have a true allergy.
So a good patient antibiotic history can help sort out whether or not these patients can
actually receive that antibiotic in question.
So here we have a list of questions that you can ask your patients.
This would include does the parent remember having an allergy or was it just told to them
by a parent or grandparent?
How many years ago was the reaction?
Was the reaction with the first dose?
How was it treated?
What occurred when the action happened?
And did the patient take other medications at the same time that could have led to that
reaction?
If the patient is unsure of these questions, you may be able to try that in a microbial
and actually use it to treat an infection for the patient.
The strategies to improve antimicrobial use include making sure that the patients are
adherent to their therapy.
Also making sure that the providers are adherent to practice guidelines.
We have a lot of clinical pathways that we can use that are based on guidelines and evidence
that help us streamline our therapy for our patients once a culture is returned.
Using appropriate dose and duration only when the antimicrobial is necessary and looking
for things like adverse events, symptom management and helping with antimicrobial resistance
when we're talking with providers.
An example of prevention strategies that we can use as pharmacists is in the management
of upper respiratory tract infections.
These infections occur primarily in the outpatient setting but we do see them in both the inpatient
and outpatient environments and they're associated with about 15 million infections per year
and they account for about 68 percent of all outpatient antibiotics.
However, the majority are caused by viruses which would not need any antibiotic therapy.
In fact, for Pharyngitis, only about 15 to 30 percent are actually caused by bacteria
and sinusitis about 80 percent has a viral cause and for otitis media 80 percent can
resolve spontaneously without any treatment.
So most cases can be treated by a watch and wait approach with symptomatic management.
So let's look specifically at some of these upper respiratory tract infections, the first
of which is Acute Otitis Media or the common ear infection.
As we see with treatment guidelines, the lowest risk children, those that are greater than
2 years of age, have had no recent antibiotics and have no history of any ear infections
, can actually be observed for 24 to 72 hours before antibiotic therapy is started if it's
needed at all.
Whereas those with highest risk you would want to go ahead and treat them with antimicrobial
therapy.
So what does that watch and wait look like?
If we look at the number needed to treat to prevent one case of ear pain, it takes about
20 children to be treated with antimicrobial therapy just to prevent one case of the ear
pain.
And 33 children needed to be treated to prevent one perforation.
Whereas, 1 in every 14 children will develop diarrhea, rash or vomiting from antimicrobial
therapy.
So as you can see, it's much more risky to treat them with antimicrobial therapy if they
don't need it due to the adverse events associated with that therapy.
So a wait of 1-3 days before initiating antimicrobial therapy may be warranted in Acute Otitis Media.
If we look at another upper respiratory tract infection, Pharyngitis has treatment guidelines
that recommend that most of the time in children less than 3 years of age this is going to
be a viral infection so it's rarely gonna need antimicrobial therapy.
And then you can use other strategies to determine the risk associated with an actual bacteria
pathogen, Group A Strep in the diagnosis of Pharyngitis.
So the peak incidence of this group A strep is between 5 and 15 years of age.
You definitely want to look at other non-infectious causes such as allergies, malignancy, chemotherapy
or chemical exposure, and direct trauma to the area such as drinking something hot, that
could be causing the throat pain before you automatically jump to an antimicrobial therapy.
There are some criteria for the rapid strep test.
First of all, you definitely want to determine who to treat versus who are at the latest
risk of having a strep bacterial infection.
So you definitely would use that primary age group of 4 to 15 and some of the Centor Criteria
can be used to determine whether or not they need antimicrobial therapy are a fever greater
than 101, a tonsillar exudate or pus at the back of the throat, absence of a cough or
cervical lymph node involvement.
If they have 2 or more of these, you probably do wanna go ahead and test them for strep
and rule out other causes if necessary.
And then finally, the 3rd upper respiratory tract infection that we wanted to discuss
is Sinusitis.
Treatment should only be offered to patients who have an onset of symptoms that are lasting
for greater than 10 days without improvement, have an onset of severe symptoms or have a
very high fever with a very purulent nasal discharge or facial pain or have worsening
of symptoms.
And sometimes this is deemed the "double sickening," where they actually had a viral infection
primarily, that lasted 5 to 6 days and that trapped bacteria causing a bacterial infection
which lead to the need for antimicrobial therapy.
So definitely using those criteria to determine whether or not a patient needs therapy.
Some other prevention strategies are using vaccines for vaccine preventable infections.
Some of these are listed here below.
The most common obviously are influenza and pneumococcal infection but we also definitely
want to vaccinate our children for some of these others and then there's also travel
vaccines that we can use to prevent things such as malaria, when we travel to other countries.
Another promise of the pharmacist is to provide patient counseling.
We definitely want to encourage the patient to finish their full course of antimicrobials.
Also, tell them what to look out for when they're taking their antimicrobials, whether
it be the most common adverse effects like rash and diarrhea, or something less common
that they may run across when they're taking therapy.
Also emphasize adherence, making sure that if they're taking something several times
a day that they take every dose.
Looking at other ways to manage their symptoms, helping with them antipyretics and analgesics.
Also, providing them with tools to measure whatever symptom management agent they're
using, especially in children.
It's really important to provide them with an exact measuring device versus a tablespoon.
Also, talking about alarm symptoms.
So if you're using that watch or wait approach, where you're actually watching a child for
48 to 72 hours, you want to give them parameters by which to seek help if they start to have
worsening of symptoms.
Some other responsibilities of the pharmacist include discharge planning if they're in the
hospital.
Also providing education to other healthcare providers.
Performing formulary reviews of new or reformulated antimicrobials.
It's really important to get ahead of the prescribing pattern before it starts, so when
you have a new agent to review it and make sure that you have criteria developed for
use of that agent.
Precepting and mentoring pharmacy students and helping them understand the principles
of antimicrobial stewardship.
Providing presentations at local, state, national levels and then conducting research to help
to control antimicrobial use, maybe restrict use and also aide in reporting good antimicrobial
stewardship practices.
And then one further role, looking at colonization vs. infection, infection suggests that the
invasive microorganism, like a bacteria or a fungi, is actually penetrating the tissues
of the body and so that results in signs and symptoms such as fever, pus, high white blood
cell count, pain or organ dysfunction.
Whereas colonization is just the microorganism, whether it be a bacteria or a fungi, that
actually resides in the body without invading the tissue.
So it doesn't cause those signs and symptoms that we just talked about.
So there's a lot of different microorganisms that can colonize the skin, the wounds, airways,
GI tract, urinary or the mouth and the nose.
So it's really important as pharmacists for us to be able to distinguish between infection
and colonization so that we can help make good treatment choices and determine when
antibiotics are needed.
An example of this is asymptomatic bacteria.
A bacterial urinary tract colonization should not be treated with antibiotics.
That means that unless a patient has symptoms of a UTI, bacteria in the urine should not
be treated.
And so we definitely don't wanna treat a UTI based on urine smell or appearance.
And we're in a great position to reinforce these principles with patients and families.
More strategies that we've discussed earlier but just wanted to highlight again, we definitely
want to make sure that we don't take any antimicrobials for viral infections.
That we're obtaining culture before we're starting antibiotics and that we don't treat
those colonizations that we just talked about.
We wanna discontinue therapy if it's a non-infectious diagnosis.
So a good example here in the hospital is looking at pneumonia versus heart failure.
If you have an unclear chest x-ray and then a CT is performed and it definitely shows
a fusion versus a bacterial source or a pneumonia source, then you definitely can streamline
and discontinue antibiotic therapy.
And then limiting the duration of therapy to the appropriate length based on evidence
with common infection types.
And this is something that we're definitely trying to do with both the outpatient and
inpatient settings.
Finally, just to review the Clostridium Difficile infection risk factors, we definitely want
to decrease the use of antibiotics that are frequently associated with this infection
type and some of the more common ones are things like broad spectrum penicillin, an
example being Eosin, or a broad spectrum cephalosporins such as ceftriaxone.
These agents definitely frequently lead to CDI and so we want to make sure that we're
limiting the use and only using them when absolutely necessary.
And although all antibiotics can cause C. Diff, these are the ones that we want to focus
on especially.
And so in conclusion, by making antimicrobial stewardship part of your daily practice, you
can improve patient safety and care, reduce the unnecessary use of valuable resources
and reduce bacterial resistance.
Thank you.
Thank you Dr. Collins.
I'd like everyone to please take time to look at these resources on this page.
You can use these in your practice.
Now that you've completed the review of the resources and you've listened to this recorded
education, you're ready to complete the post test.
Click on the green icon to the right, the one with the pencil and complete your test.
Once you've passed the posttest with a 70 percent or higher score, you will receive
a certificate for credit in the email within a week.
We appreciate that you have used this education and hope that it will help you in your practice.
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