Page 34 - Christiana Care Focus October 2018

Pharmacy Services |
The Christiana Care Antimicrobial Stewardship Program: Year in Review
Nicole S. Harrington, Pharm D, BCPS, AQ-Infectious Diseases; Jillian Dougherty, Pharm.D, BCPS; Julianne Gardner, Pharm.D; David M. Cohen, M.D.
The Christiana Care Antimicrobial Stewardship Program (ASP) highlights some of the great work completed in FY ‘18. Combatting antimicrobial resistance and complications such as C. difficile infection, and promoting appropriate, judicious antimicrobial use has really become a shared responsibility among both caregivers and patients. The Christiana Care ASP would like to express a sincere thank you to those who have made antimicrobial stewardship a top priority.
PROJECT
FINDINGS/COMMENTS
Outpatient Antimicrobial Stewardship
Over the past year, eBrightHealth has tasked members of the statewide strategic alliance to promote the Choosing Wisely campaign recommendations for upper respiratory tract infections (URIs) among outpatient practices. Specifically, avoiding antibiotic prescribing for viral URIs (sinusitis, pharyngitis, and bronchitis). At Christiana Care,
a baseline needs assessment was distributed to providers, nurses and medical assistants within our primary care practices. Barriers identified include limited time with patient, patient expectations, cost of over the counter remedies not covered by insurance, and lack of access to educational materials. Educational posters and brochures have since been shared with each practice. Additional efforts are underway including updating the patient portal to increase access to educational material. Lastly, the Christiana Care Medical Aid Units (MAUs) have implemented guidelines
for antibiotic use, with subsequent audit and feedback to providers. Over a 16-month time period, total antibiotic use declined from 67 antibiotic prescriptions per 100 visits to 44 antibiotic prescriptions per 100 visits (RR 0.55, 95% CI 0.37-0.80). Azithromycin use declined from 14 prescriptions per 100 visits to 4 prescriptions per 100 visits (RR 0.32, 95% CI 0.10-0.88).
Beta-lactam (penicillin) allergy assessment for pre-op surgical prophylaxis
In August 2017, the Perioperative Evaluation and Preparation (PEP) nurses began evaluating presurgical patients with a beta-lactam allergy according to a standardized algorithm. Patients deemed low risk for cephalosporin reaction can safely receive cefazolin (the preferred surgical prophylaxis agent for most procedures). As of February 2018, the PEP nurses evaluated 1,476 patients in which 30% were evaluated as low risk. Of those, 41% received a cephalosporin as prophylaxis. Compared to a pre-intervention phase where only 12.5% of low risk patients received a cephalosporin. Additional work is needed to further increase cephalosporin use in low risk beta-lactam allergic patients.
Impact of doxycycline in place of azithromycin for community acquired pneumonia (CAP) on Clostridium difficile infection
In 2015, the Christiana Care Emergency Department launched a clinical decision support tool to encourage the use of doxycycline with ceftriaxone in non-ICU patients with CAP in an effort to decrease the risk of CDI. Among nearly 1,000 patients admitted to Christiana Care with CAP, the relative risk of CDI was 0.15 (95% CI 0.03-0.75; p = 0.02) when comparing doxycycline to azithromycin in combination with ceftriaxone further validating previous literature suggesting doxycycline may be C. difficile protectant.
Impact of a ventriculostomy bundle and limited duration neurosurgical drain prophylaxis on drain-related infections, antibiotic resistance, and CDI
In 2016, a Christiana Care ventriculostomy bundle was implemented followed by a power plan change to support only one preoperative antibiotic dose to be in accordance with national guidelines. As a result, we have observed a significant decrease in antibiotic use (limited duration of therapy 14.3 % vs 96.3% post intervention; p < 0.001) with no statistically significant changes in the incidence of drain-related infections (5.5% vs 5.6% post intervention).
Antibiotic Indication Pilot
In accordance with the Joint Commission ASP standards, an antibiotic indication requirement for select antibiotic orders was launched in December 2017. Accuracy (indication matched chart review indication) amongst 182 orders was as follows: Cefepime: 94%; Ceftriaxone: 88%; Ciprofloxacin: 78%; Levofloxacin: 89%. Opportunity exists with dose optimization as well as the category of “other” as an antibiotic indication. This will be further explored with ongoing monitoring of this intervention.
Antimicrobial Stewardship Website
Our ASP website had a facelift this year! Check out the new site by searching ASP or under the Infection Prevention tab of the green banner on the portal. You can access guidelines, past ASP quarterly lectures, the antibiogram, additional resources as well as submit questions!
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for their ongoing support of the Christiana Care Antimicrobial Stewardship Program.
ASP leadership would like to express a special thank you to the eBrightHealth ACO and the Christiana Care Value Institute
Therapeutic Notes