Appropriate Antibiotic Prescribing. Frank Romanelli, Pharm.D., MPH, AAHIVP Professor & Associate Dean Paul F. Parker Endowed Professor of Pharmacy

Transcription

1 Appropriate Antibiotic Prescribing Frank Romanelli, Pharm.D., MPH, AAHIVP Professor & Associate Dean Paul F. Parker Endowed Professor of Pharmacy

2 Objectives Discuss CDCs Core Elements of abx stewardship. Identify high priority conditions to target for improvements in abx prescribing. Discuss common barriers to appropriate abx prescribing. Identify effective abx stewardship interventions to improve outpatient abx prescribing.

3 Background Abx resistance now considered a public health issue Resistance = inc health care cost and inc morbidity and mortality Critical modifiable risk factor: inappropriate abx prescribing Estimated that 50% of all abx RX d are inappropriate

4 Background Estimated that 30% of all outpatient abx RX d are unnecessary Approx 60% of all abx are RX d outpatient Approx 70 80% of all pts who present to ED with URI receive abx 2013: ~269,000,000 abx RX were dispensed in the US

5 What % of outpatient visits result in an ABX RX? Adult? Pediatric?

6 What % of outpatient visits result in an ABX RX? Adult? 10% Pediatric? 20%

7 Background ABX A/Es result in ~143,000 ER visits annually One third of all new C. Diff infections result of outpatient abx RX

8 Fleming Durta, et al. JAMA 2016;315(7): Ambulatory Care Visits from Of 180,032 visits 12.6% resulted in an abx RX [95% CI %] Sinusitis was the most common dx resulting in an abx RX per 1K (56 scripts [95% CI 48 64] Sinusitis was followed by OM and pharyngitis

9 Fleming Durta, et al. JAMA 2016;315(7): Of all RXs for acute URIs (221 per 1K) only 111 were considered appropriate For all conditions 506 abx RXs were written per 1K with 353 being deemed appropriate over diagnosis of certain conditions is obvious Highest rate of abx RXing in the NE and lowest in the West **Note: appropriate abx selection was not addressed

10 2016 CDC Core Elements of Outpatient Antibiotic Stewardship Framework for abx stewardship for outpatient practices Previous Core documents have focused on hospital practice and nursing homes. Aim to align abx prescribing with evidencebased recommendations. Sanchez GV, Fleming Dutra KE, Roberts RM, et al. MMWR Recomm Rep 2016 ;65(No. RR 6):1 12.

11 Four Cores Commitment Action for Policy and Practice Tracking and Reporting Education and Expertise

12 ANTIBIOTIC STEWARDSHIP is HOT Effort to measure abx prescribing Effort to prescribe abx only when needed Effort to minimize misdiagnosis or delayed diagnosis leading to underuse of abx Effort to ensure that the right abx, abx dose, and abx duration are selected

13 Stewardship in Action Identify one or more high priority conditions for intervention. sore throat Identify barriers that lead to deviation from best practices. need to see patients quickly Establish standards for abx prescribing. strictly adhere to national guidelines

14 Clinician Checklist Can you demonstrate dedication and accountability for optimized and safe abx RXing? Have you implemented at least one practice to improve abx prescribing? Do you monitor at least one aspect of abx prescribing? Do you educate pts regarding abx and do you seek out CE related to abx Rxing?

15 Prescribing Flags If its not needed it won t hurt anyways. The patient demanded a script. I do not feel like I have done anything for pts unless I give them a RX. Pts do not feel like I have done anything for them unless I give them a script.

16 Common Outpatient Scenarios

17 Condition Common Cause ABX? Strep Pharyngitis Bacteria (Streptococcus pyogenes) YES (PCN) Pertussis Bacteria YES (Macrolide) cmrsa Bacteria YES (Bactrim DS ) Sinus Infection Bacteria or Virus Clinical Call Otitis Media Bacteria or Virus Clinical Call Bronchitis Bactria or Virus No Rhinorrhea Virus No sore throat Virus No Influenza Virus No

18 American College of Physicians 2016 Guidelines for Appropriate Antibiotic Use Upper Respiratory Tract Infections 1. Clinicians should not perform testing or initiate therapy in pts with bronchitis unless pneumonia is suspected. 90% of all cases of cough are viral. Bacterial causes to consider mycoplasma, chlamydophila, pertussis. Tachycardia? Tachypnea? Fever? CXR? a chest cold

19 American College of Physicians 2016 Guidelines for Appropriate Antibiotic Use Upper Respiratory Tract Infections 2. Clinicians should test pts with sxs suggestive of GAS pharyngitis by rapid antigen detection or throat culture. Confirmed cases should be treated. Almost always benign and self limiting. Almost always viral. Persistent fever? Rigors? Night Sweats? Rash?

20 American College of Physicians 2016 Guidelines for Appropriate Antibiotic Use Upper Respiratory Tract Infections 3. Clinicians should reserve abx therapy for acute rhinosinusitis for pts with persistent sxs of at least 10 days, onset of severe sxs or high fever (>39ºC) with purulent nasal discharge or facial pain lasting three consecutive days, or onset of worsening sxs following a typical viral illness of at least 5 days that was improving but now worsens. Self limiting wth most cases resolving in one week. 80% of visits result in an abx RX (usually a macrolide). Almost always viral but can be assoc with a secondary bacterial infection. Sx persist fo 10 days? Sx worsen after improvement?

21 American College of Physicians 2016 Guidelines for Appropriate Antibiotic Use Upper Respiratory Tract Infections 4. Clinicians should not prescribe abx for the common cold. Most common acute illness in US. 30% of visits result in abx RX. Sx may last up days. Symptomatic tx only.

22 VACCINATE! Influenza (trivalent/quadravalent) TDaP/Td Varicella Zoster Pneumococcus (PCV13 first then PSV23)

23 Educate Viral vs Bacterial Patient information (written) vs an RX Symptomatic support (antihistamines, antipyretics, NSAIDs, antitussives, decongestants, diphenhydramine, etc.) Empathize

24 Direct to Consumer Advertising (DTC)

25

26