This 90-minute webinar discusses strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance. Join Premier’s free Advisor Live® webinar series for a special Get Smart About Antibiotics Week presentation on Thursday, November 19 from 12-1:30 p.m. EST. The panel for this 90-minute webinar will discuss strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance. EXPERT PRESENTERS: - Gina Pugliese, RN, MS, vice president, Premier Safety Institute®, moderator - Arjun Srinivasan, MD, (CAPT, USPHS) medical director of the CDC’s Get Smart for Healthcare program, will highlight the national focus on antibiotic stewardship and reasons for the current urgency - Michael Postelnick, RPh, BCPS AQ- Infectious Diseases, clinical manager and senior infectious diseases pharmacist for Northwestern Memorial Hospital, will share lessons learned from implementing their antibiotic stewardship program - Craig Barrett, Pharm.D., BCPS, director safety solutions for Premier, Inc. will share strategies from Premier member hospitals striving for antimicrobial stewardship

1. Advisor Live®
Antimicrobial stewardship – Why now and how?
November 19, 2015
Download today’s slides at www.premierinc.com/events
@PremierHA
#AdvisorLive
#GetSmartWeek

2. 2 © 2015 PREMIER, INC.
Logistics

3. 3 © 2015 PREMIER, INC.
Faculty
MODERATOR
Gina Pugliese, RN, MS, FSHEA
Vice President
Premier Safety Institute®
CAPT Arjun Srinivasan, MD
Associate Director,
Healthcare associated infection
prevention programs, CDC
Michael Postelnick, RPh BCPS
AQ Infectious Diseases
Senior Infectious Diseases Pharmacist
Northwestern Memorial Hospital, Chicago
Craig Barrett PharmD,BCPS
Director, Safety Solutions, Premier Inc.
@PremierHA
#AdvisorLive
#GetSmartWeek

4. 4 © 2015 PREMIER, INC.
CAPT Arjun Srinivasan, MD,
Associate Director
Healthcare Associated Infection Prevention Programs
Division of Healthcare Quality Promotion, CDC
@PremierHA
#AdvisorLive
#GetSmartWeek

5. CAPT Arjun Srinivasan, MD
Associate Director for Healthcare Associated
Infection Prevention Programs
Division of Healthcare Quality Promotion
beu8@cdc.gov
Improving Antibiotic Stewardship in
Hospitals-
Why Now?

6. Why Antibiotic Stewardship?
• In hospitals, antibiotic stewardship programs
have been proven to:
– Improve antibiotic use
– Reduce antibiotic resistance
– Reduce complications of antibiotic use- especially
Clostridium difficile
– Improve patient outcomes
– Save money
•IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs
http://www.journals.uchicago.edu/doi/pdf/10.1086/510393

7. 77HAI Regional Training HAI Training Requirements is sponsored by SHEA and the CDC
Most Common Reasons for
Unnecessary Days of Therapy
192 187
94
0
50
100
150
200
250
Duration of Therapy
Longer than Necessary
Noninfectious or
Nonbacterial Syndrome
Treatmentof Colonization
or Contamination
DaysofTherapy
576 (30%) of 1941 days of antimicrobial
therapy deemed unnecessary
Hecker MT et al. Arch Intern Med. 2003;163:972-978.

9. Susceptibility Profile of KPC-Producing K.
pneumoniae
Antimicrobial Interpretation Antimicrobial Interpretation
Amikacin I Chloramphenicol R
Amox/clav R Ciprofloxacin R
Ampicillin R Ertapenem R
Aztreonam R Gentamicin R
Cefazolin R Imipenem R
Cefpodoxime R Meropenem R
Cefotaxime R Pipercillin/Tazo R
Cetotetan R Tobramycin R
Cefoxitin R Trimeth/Sulfa R
Ceftazidime R Polymyxin B MIC >4mg/ml
Ceftriaxone R Colistin MIC >4mg/ml
Cefepime R Tigecycline R

10. C. difficile
• Data from population-based surveillance in
2011.
• ~453,000 total annual C. difficile infections.
• ~15,000 attributable deaths
– 80% of deaths in patients >65 years old
– 66% of cases were healthcare associated.
– About $1 billion in excess healthcare costs and re-
admissions
• C difficile infections are now part of the
inpatient quality reporting program
• N Engl J Med 2015; 372:825-834

11. Antibiotic Stewardship to Combat
C. difficile
• 2014 meta-analysis on the impact of stewardship
on C. difficile included 16 studies.
• Stewardship programs were significantly
protective against C. difficile
–Pooled risk ratio 0.48; 95% CI: 0.38, 0.62
• Restrictive interventions were most effective.
• Protection especially strong in geriatric settings.
Feazel LM et al. J Antimicrob Chemother, March 2014

12. 1212
Impact of Reductions in Antibiotic Prescribing
on C. difficile in England
0
10000
20000
30000
40000
50000
60000
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
2004 2005 2006 2007 2008 2009 2010 2011
Cephalosporin doses Fluoroquinolone doses C. difficile in > 65 y.o.
70% reduction in C. difficile
infections over 7 years
Year
Defineddailydosesinhospitalinpatients
Numberofall(HA+CA)CDIcasesin>65yo
Ashiru-Oredope et al. J Antimicrob Chemother 2012; 67 Suppl 1: i51–i63
Wilcox MH et al. Clinical Infectious Diseases 2012;55(8):1056–63
http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1179745282388

13. P. aeruginosa susceptibilities before and after
implementation of antibiotic restrictions
(CID 1997;25:230)
0
20
40
60
80
100
Ticar/clav Imipenem Aztreonam Ceftaz Cipro
Percentsusceptible
Before After
P<0.01 for all increases

14. Clinical outcomes better with
antimicrobial stewardship program
0
10
20
30
40
50
60
70
80
90
100
Appropriate Cure Failure
AMP
UP
RR 2.8 (2.1-3.8) RR 1.7 (1.3-2.1) RR 0.2 (0.1-0.4)
Percent
AMP = Antibiotic Management Program
UP = Usual PracticeFishman N. Am J Med. 2006;119:S53.

15. 15 © 2015 PREMIER, INC.
Michael Postelnick, RPh BCPS AQ Infectious Diseases
Senior Infectious Diseases Pharmacist
Northwestern Memorial Hospital
Chicago, IL
@PremierHA
#AdvisorLive
#GetSmartWeek

16. Michael Postelnick, RPh BCPS AQ Infectious
Diseases
Senior Infectious Diseases Pharmacist
Northwestern Memorial Hospital
Chicago, IL
Measuring the Impact of
Antimicrobial Stewardship
Interventions on
Antimicrobial Resistance

17. Source: Penicillin finder assays its future. New York
Times. 26 June 1945: 21
Call to Antimicrobial Stewardship
“….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 the man who finally succumbs to
infection with the penicillin-resistant organism.”
- Sir Alexander Fleming, June 26, 1945

18. Davey P et al. Cochrane Database of Systematic Reviews
2013, Issue 4. Art. No.: CD003543
Do Antimicrobial Stewardship Interventions Effect
Resistance?

19. Presentation Overview
•Measuring Antimicrobial Use
•Measuring Antimicrobial Resistance
•Overview of Antimicrobial Stewardship at Northwestern
Memorial Hospital
•Representative Stewardship Initiatives
•Current Stewardship Focus at NMH
•Future Directions

20. Measuring
Antimicrobial Use
It is widely believed that you cannot manage what
you cannot measure. It is also true that you cannot
measure what you cannot define 1
1. Ibrahim OM and Polk RE. Infect Dis Clin N Am 28; 2014: 195-214

21. Measuring Antimicrobial Use
Measure Calculation Advantages Disadvantages Use?
DOT/1000 PD DOT/(PD/1000) More accurate than
DDD
Requires pt. level
data
Becoming standard
metric
DOT/1000
admissions
DOT/(admissions/1
000)
Not a function of
LOS
Requires risk
adjustment (RA)
Secondary measure
DDD/1000 PD http://www.whocc.
no/ddd/definition_
and_general_consi
dera/
Easily calculated,
does not require pt
level data
Less accurate and
consistent
Comparison across
countries
LOT/discharge Total LOT/discharge Provides average
duration of tx
Not normalized for
LOS, needs RA
Identify excessive tx
durations
DOT/LOT ratio DOT/LOT Measures agg-
regate combo tx
Pt level data
needed
Identify un-
necessary combo
Proportion
receiving abx
Treated
pts/admissions
Needs risk
adjustment
Identify
unnecessary tx

22. Interpreting Antimicrobial Use Data
•Benchmarking
•Use data must be risk adjusted
•Internal – ICU vs general care floor
•External – Academic medical center vs small rural hospital
•Identify Outliers
•Perform DUE to determine intervention strategies (if needed)
• Unnecessary therapy
• Prolonged durations
• Unusual resistance patterns

23. Benchmarking by Unit
Fridkin S et al. Clin Infect Dis 1999; 29:245-252

24. Risk-adjusted Benchmarking
Polk RE et al. Clin Infect Dis 2011; 53:1100-1110

25. Measuring
Antimicrobial
Resistance

26. The Hospital Antibiogram
•Most widely available measure of resistant organisms
•Measures proportion of susceptible organisms over time
•Designed for:
•Assisting empiric antimicrobial selection
•Guidance on formulary choices
•CLSI sets guidance for construction
Schulz LT et al. Pharmacotherapy 2012;32(8):668–676

27. Antibiograms to Assess Stewardship Interventions
Schulz LT et al. Pharmacotherapy 2012;32(8):668–676

28. What Factors Effect the Ability to Demonstrate
Interventional Impact on Resistance?
•Magnitude of Change
•Time-series analysis to forecast resistance changes related to
antibiotic use
•Ceftazidime/gram negative bacilli and imipenem/Pseudomonas
examined
•Complex mathematical model designed for analysis
• Lag-time accounted for
•Impact of changes in antimicrobial use significant but small
• 6% of variation in Pseudomonas susceptibility
predicted by imipenem use variation
Lopez-Lozano JM et al. International Journal of Antimicrobial Agents 14 (2000) 21–31

29. What Factors Effect the Ability to Demonstrate
Interventional Impact on Resistance?
•Dynamics of Resistance are Complex
•Bacterial resistance mechanisms effect multiple antibiotics
•Stewardship interventions local-resistance is global
•Unintended consequences (“squeezing the balloon”)
•Multiple simultaneous interventions
• Stewardship
• Infection Control
•Regression to the mean

30. Antimicrobial
Stewardship at
Northwestern
Memorial Hospital

31. • 894-bed Academic Medical Center
• Primary teaching affiliate of
Northwestern University Feinberg
School of Medicine
• Ranked as the No. 10 hospital in the
nation by U.S. News & World Report
for 2014-15 with 13 specialties
nationally ranked. No. 1 in Illinois and
the Chicago metro area.
• Fiscal Year 2014
• 47,139 Inpatient Admissions
• 598,553 Outpatient visits
• 12,497 Live Births
• 83,245 Emergency Department
Visits
• 12,794 Inpatient Surgeries
• 21,452 Outpatient Surgeries
Northwestern Memorial Hospital
Feinberg and Galter Pavilions Prentice Women’s Hospital

32. Evolution of Antimicrobial Stewardship
NMH 1987-2015
• 1987-1990: Implement Antimicrobial Formulary and
Pharmacokinetic Dosing Service
• 1990-1993: Implement Empiric Antimicrobial
Guidelines
• 1993-2002: Prospective audit and feedback
• 2002-2003: Initiate “Formal” Stewardship Program
• 2003: Implement Clinical Decision Support
• 2013: CDC-AUR participation

33. Current Stewardship Structure at NMH
• Stewardship physician (0.5 FTE)
 Daily TAM review and intervention
 Design and support educational initiatives
 Provide MD support for all stewardship activities
• Stewardship pharmacists (5 co-funded faculty, approximately 1.4 FTE)
 Daily restricted antimicrobial review
 72 hour review
 MALDI-TOF intervention
 Support clinical pharmacist stewardship activities
• Unit-based Clinical Pharmacist
 Antimicrobial dosing
 IV to PO recommendations
 Guideline-based recommendations
 72 hour review
 Antimicrobial de-escalation

34. What Have We Accomplished
•Continued control of antimicrobial costs
•2014 cost savings = $120,000
•Empiric Antimicrobial Use Guidelines and Incorporation
into Order Sets
•Optimized Dosing of Antimicrobials
•Comprehensive dosing protocols
•Prolonged infusion protocols for beta-lactams
•Leveraging Clinical Decision Support for Bug-drug
Mismatches and Restricted Antimicrobials
•Expansion of Training Programs for Infectious Diseases
Pharmacists

35. Where Have We Struggled
•Measurement of Impact on Utilization and Resistance
•Systematic metrics
•Benchmarking
•Antimicrobial Stewardship Outcomes Research

36. Representative
Stewardship
Interventions

37. Order Sets

38. Antimicrobial Indications

39. TAM Alerts
• Identify patients with susceptibility results without active
antimicrobial therapy
• Evaluated daily by stewardship physician
• Small minority require clinical intervention
• An average of 4 “critical interventions” identified monthly

40. TAM Alert Screenshot

41. TAM Documentation

42. TAM Alerts by Disposition
142
251
165
154
122
32
56 56
28
19
9 11
21 13 8
0
50
100
150
200
250
300
MAR-MAY 09 JUN-AUG 09 SEPT-NOV 09 DEC 09-FEB 10 MAR-MAY 10
Total
No Intervention
Overtreatment
Undertreatment
CriticalAlerts

43. Examples of Critical Alert Interventions
• Patient with methicillin-resistant S. aureus (MRSA) from
bursa fluid
 On clindamycin (isolate R)
 ASP notified hospitalist
 Patient was discharged with seven days of PO linezolid
• Patient with growth of P. aeruginosa from cerebrospinal
fluid in a patient with lumbar drain
 History of spine surgery with pseudomeningocele formation + CSF
leak
 ASP notified neurosurgery
 Infectious disease consulted, ceftazidime initiated

44. Restricted Antimicrobial Alerts
•Reviewed daily by stewardship pharmacist
•Evaluated against P&T approved criteria
•Interventions coordinated with unit-based clinical
pharmacist

45. Example Restriction Criteria
Linezolid
• Use should be restricted to patientswith one of the following:
 Documented or strongly suspected VRE infections that are also
ampicillin resistant, or VRE infectionsthat are ampicillin-susceptible
in patientswith penicillin allergy
 Documented or suspected hospitalacquired pneumonia, ventilator
associatedpneumonia, or healthcare associated pneumonia with
gram positive cocci obtained from a lower respiratory tractsample.
Subsequent documentationof MRSA from culture is required for
linezolid continuationbeyond 72 hours.
 Culture-documented methicillin-resistantstaphylococcal pneumonia
 MRSA infections in patients who exhibit a true allergic reaction to
vancomycin
 Critically ill patients for whom respiratory sample gram stain results
are unavailableor deemedunreliableand MRSA is strongly
suspected. Subsequentdocumentation of MRSA from cultureis
requiredfor linezolid continuationbeyond 72 hours.

46. Restricted Alert Screenshot

47. Restricted Drug Alert Documentation

48. Restricted Antimicrobial Disposition
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q1-08 Q2-08 Q3-08 Q4-08 Q1-09 Q2-09 Q3-09 Q4-09 Q1-10 Q2-10 Q3-10 Q4-10
%ordersoutsidecriteria
Restricted Antimicrobial Report
% Orders remaining
outside of criteria
% Orders changed
by AST
% Orders approved
by ID service
Target = 90%

49. Custom Alert Capability
•User generated
•Flexible
•Focused
•Simple for end user to design

50. De-escalation Alert Screenshot

51. De-escalation Documentation

52. Pip-tazo De-escalation Results
0
11
23
44
61
86
83
80
59
91
88 89
83
86 86
64 %
0
10
20
30
40
50
60
70
80
90
100
Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10
%AppropriatelyDe-escalated
% appropriately deescalated
Goal
Patel J et al. Am J Health-Syst Pharm 2012;69: 1543-44.

54. Ciprofloxacin MIC Alert

55. System Generated Antibiograms
•Simple, rapid generation
•Allows for unit and site specific evaluations
•Enhances ability to customize local guidelines
•Increases probability of active initial empiric therapy
•Can help minimize overly broad empiric treatment

56. Hospital-wide Antibiogram

57. Unit-specific Antibiogram
MICU 2014 Gram negative rods

58. Site-specific Antibiogram
BAL 2014 Gram negative rods

59. Pharmacist Interventions by Category
0
5
10
15
20
25
30
Dosing
CPOEError
Unnecessary
tx
ADE-nonMed
Rec
ADE-MedRec
Anticoagulation
Antimicrobial
Stewardship
Other
#ofinterventions/day
Jan '08
Feb '08
Mar '08
Apr '08
NMH Pharmacist Antimicrobial Stewardship
Interventions

60. Current
Stewardship Focus

61. Clostridium difficile Reduction Initiative
•Hospital C. diff rates are a publicly reported metric
•Partnership with Infection Prevention
•Initiative components:
 Education to ensure appropriate testing
 Continued strong infection prevention efforts
 10% reduction in overall antibiotic use
 Patient and family outreach

62. 10% Reduction Interventions and Metric
• Interventions
 72 hour structured antibiotic timeout
• EMR-triggered review of antibiotics at 72 hours
 Mandated end to prolonged post-operative surgical drain
prophylaxis
 End treatment of asymptomatic bacteriuria
 Rapid Diagnostics
• Stewardship-driven implementation of MALDI-TOF on blood and respiratory
samples
• Metric
 CDC AU DOT data for identified antibiotics

63. Future Directions

64. Leveraging the EMR
• Switching from Cerner to Epic offers opportunities
 Better use of clinical pathways and order sets
 Better use of Point of Ordering Clinical Decision Support
• Structured Antibiotic Timeout
 New EMR System provides opportunities to change
practice habits
• Switching from Cerner to Epic offers risks
 Adequate resources
 Time and energy devoted to switch can sap momentum
from initiatives

65. Benchmarking
• CDC AUR program provides opportunities for risk adjusted
benchmarking
 Potential to identify areas to focus improvements
 AUR may better define association of use and
development of resistance
• Improved TheraDoc Reporting Tools
 May provide for closer monitoring and local
benchmarking
 May provide the ability to focus interventions

66. Conclusions
• Identifying and reporting relevant metrics to demonstrate
the impact of a stewardship program are often challenging
• The EMR and Clinical Decision Support Software such as
TheraDoc can be leveraged to facilitate meaningful
stewardship interventions
• Progress is being made in developing useful and potentially
meaningful stewardship benchmarking methods
• The expanded threats posed by antimicrobial resistance has
made antimicrobial stewardship more recognized and
important than ever

67. 67 © 2015 PREMIER, INC.
CAPT Arjun Srinivasan, MD,
Associate Director
Healthcare Associated Infection Prevention Programs
Division of Healthcare Quality Promotion, CDC
@PremierHA
#AdvisorLive
#GetSmartWeek

68. CAPT Arjun Srinivasan, MD
The National Perspective on Antibiotic
Stewardship

69. Implementing Antibiotic Stewardship
 Hospitals don’t all look the same, and neither
do stewardship programs.
 There must be flexibility in how programs are
implemented.
 But, there are certain key elements that have
been strongly associated with success.

70. Core Elements for Antibiotic
Stewardship Programs
 Leadership commitment from administration
 Single leader responsible for outcomes
 Single pharmacy leader
 Antibiotic use tracking
 Regular reporting on antibiotic use and
resistance
 Educating providers on use and resistance
 Specific improvement interventions
http://www.cdc.gov/getsmart/healthcare/implementation/core-
elements.html

71. Where We Are Now: NHSN Annual Facility
Survey of ~4000 US Hospitals
 In 2014, 39.2% of US hospitals reported having
a stewardship program that meets all 7 CDC
core elements for hospital stewardship programs.
 Factors associated with meeting all Core
Elements
 Larger bed size
 Teaching status
 Leadership support (written > salary)
Preliminary findings from NHSN 2015 Annual Facility Survey - Not for distribution

72. Key Next Steps on Implementing
Stewardship Programs
• CDC is working with many organizations
through the National Quality Partnership to
develop a “playbook” to provide more specific
suggestions on implementing stewardship
programs.
• Working to connect with smaller hospitals that
have implemented all of the core elements to
get key lessons learned.

73. National Healthcare Safety
Network Antibiotic Use Option
 Captures electronic data on antibiotics
administered, along with
admission/discharge/transfer data.
 Calculates rates of administration for use:
 By facilities to monitor interventions on single
units or facility wide
 To collect aggregate information on antibiotic use
at a regional and national level
 Eventually, to create antibiotic use benchmarks.

74. Standardized Antibiotic Administration
Ratio (SAAR)
 CDC’s 1st attempt at developing a
benchmarking measure for antibiotic use.
 Similar in principle to the Standardized
Infection Ration (SIR).
 SAAR expresses observed antibiotic use
compared to predicted use.
 CDC worked with many partners to develop
the SAAR measure to try and make it most
useful for stewardship.

75. Standardized Antibiotic Administration
Ratio (SAAR)
 Experts in stewardship suggested that a variety
of different SAARs would be useful.
 SAARs for a variety of different patient
populations.
 SAARs for a variety of different groups of
antibiotics.

76. An Update on the Antibiotic Use
Option of NHSN
 The Standardized Antibiotic Administration
Ratio was approved for endorsement by the
Patient Safety Committee of the National
Quality Forum in June.
 Requested approval was for public health
surveillance and quality improvement only.
 A final vote is expected later 2015 or early
2016.

77. Key Points About the SAAR
 The SAAR is risk adjusted based only on
facility characteristics (e.g. presence of ICUs,
hospital size).
 The SAAR only helps directs stewardship
efforts to locations and antibiotics where use
appears to deviate from expected.
 High use might be perfectly justified, low use
might be harming patients.

78. Measuring Appropriate Use
We all agree that the ultimate goal of
stewardship is to improve appropriate use of
antibiotics.
It will be hard to measure progress towards
that goal if we don’t have measures of
appropriate use.
CDC is collaborating with partners to try and
help with ways to assess this.

79. Assessing Appropriate Use
CDC collaborated with partners to create
assessment tools for appropriate use that
hospitals can use for quality improvement.
Available on Get Smart for Healthcare website.
The 2015-15 national antibiotic use point
prevalence survey will include an assessment
of appropriate use for 2 agents (vancomycin
and quinolones) and 2 conditions (community
acquired pneumonia and urinary tract
infections)

80. Antibiotic Use in US Hospitals-
Key Areas for Attention
• In a 2011 survey in ~180 hospitals, CDC and
state collaborators reviewed charts of patients
who got antibiotics to determine the reason for
use, the top three were:
– Lower respiratory tract infections: 34.6%
– Urinary tract infections: 22.3%
– Skin and soft tissue infections: 15.4%
• These 3 infections accounted for more than
half of all in-patient antibiotic use.
JAMA. 2014;312(14):1438-1446

81. Stewardship in CAP
• Prospective intervention for patients being
treated for CAP.
• Treatment duration reduced from 10 d to 7 d
(p<0.001) with 148 fewer antibiotic days.
• Antibiotics more frequently narrowed based on
culture results (67% v. 19%).
• Fewer patients got duplicate therapy (10% vs
45%).
CID 2012;54:1581-7

82. “Kicking CAUTI”
• Quality improvement effort in two VA
hospitals in Texas.
• Developed a simple algorithm to improve
sending of urine cultures.
– Defined specific criteria when urine cultures were
indicated.
• Monitored impact on urine cultures and
treatment of UTI in intervention and control
hospitals.
JAMA Intern Med. 2015 Jul;175(7):1120-7.

83. “Kicking CAUTI”
• Rate of urine culture ordering in interventions
hospitals decreased during the intervention
period:
– From 41.2 to 23.3 per 1000 bed-days; (incidence
rate ratio [IRR], 0.57; 95% CI, 0.53-0.61)
– To 12.0 per 1000 bed-days; (IRR, 0.29; 95% CI,
0.26-0.32) during the maintenance period
– P < .001 for both.
• No change in control hospitals

84. Skin and Soft Tissue Infections
• Have become common reasons for admission
for antibiotics.
• Are overwhelmingly caused by gram positive
pathogens.
• Despite this, patients are often treated with
agents active against gram negatives and
anaerobes.

85. Improving Treatment of Skin and
Soft Tissue Infections (SSTI)
• Facility implemented a SSTI diagnosis and
treatment guideline.
• Intervention resulted in:
– 3 day reduction in antibiotic treatment (13 v 10d)
– Less use of agents with gram negative and
anaerobic activity
– Better use of diagnostic studies and consults
Jenkins TC Arch Intern Med 2011;171(12):1072-
1079.

86. Regulatory Requirements?
• Presidential advisors have called for CMS to
make antibiotic stewardship a requirement in
acute and long term care facilities through the
Conditions of Participation.
• CMS has already proposed such a requirement
in long term care.
• They have indicated that they are considering
this for acute care as well.

87. Accreditation Standards
• The Joint Commission has developed a draft
standard on antimicrobial stewardship that has
been reviewed by several stakeholders and was
recently approved by the Standards and Survey
Procedures Committee.
– It will now go for broader review before being
finalized.
• The standard aligns with and draws from the
CDC core elements.

88. Conclusion
• This is a critical time for our efforts to
implement antibiotic stewardship programs to
improve antibiotic use.
• We need to continue to build on this
momentum.
• Please tell me what we can do (or do more of)
to support your important work.

89. 89 © 2015 PREMIER, INC.
Craig Barrett PharmD, BCPS
Director, Safety Solutions, Premier Inc.
Former roles: Pharmacy clinical specialist for surgery and director of
pharmacy residency program at Carolinas HealthCare in Charlotte
@PremierHA
#AdvisorLive
#GetSmartWeek

90. 90 © 2015 PREMIER, INC.
Impacting the National Action Plan for CARB
PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.
Goal 1: ASP and biosurveillance
Slow the Emergence of Resistant Bacteria and Prevent the
Spread of Resistant Infections
Reducing inappropriate antibiotic use by 20 percent in inpatient
settings and 50% in outpatient settings
Goal 2: Increase AU and AR reporting
Strengthen National One-Health Surveillance Efforts to Combat
Resistance
Goal 3: Development of diagnostic tests
Advance Development and Use of Rapid and Innovative
Diagnostic Tests for Identification and Characterization of
Resistant Bacteria
Goal 4: Pharmaceutical development
Accelerate Basic and Applied Research and Development for
New Antibiotics, Other Therapeutics, and Vaccines
Goal 5: International engagement
Improve International Collaboration and Capacities for
Antibiotic-resistance Prevention, Surveillance, Control, and
Antibiotic Research and Development

91. 91 © 2015 PREMIER, INC.
Economic impact of redundant antimicrobial therapy in US hospitals.
Schultz L, Lower TJ, Srinivasan A, Nielson D, Pugliese G. Infect Control Hosp Epidemiol 2014;35(10):1229-1235
Premier, in collaboration with the CDC,
conducted a study of potentially
redundant antimicrobials.
Objective: This study explored the
incidence and economic impact of
potentially redundant antimicrobial
therapy.
Methods:
• Design: Retrospective analysis
• Study Population: All inpatient
discharges in 505 non-federal facilities
in Premier’s hospital database
• Study Period: January 1, 2008 to
December 31, 2011
• Evaluation: Potentially redundant
antimicrobial therapy defined as
overlapping antibiotic spectra for 2 or
more consecutive days. The study
evaluated 23 IV antimicrobial
combinations.

92. 92 © 2015 PREMIER, INC.
78% (394) hospitals had at least 1 of the 23
unnecessary drug combinations prescribed for 2 or
more days across 32,507 cases.
70% of cases represented 3 specific drug
combinations for anaerobic infections. Metronidazole
and piperacillin-tazobactam made up 53% of cases.
Nearly 150,000 days of potentially inappropriate
antibiotic therapy, resulting in nearly $13 million in
potentially avoidable healthcare costs.
If these cases were representative of all U.S.
hospitals over that same period of time, more than
$163 million could have been saved.
Economic impact of redundant antimicrobial therapy in US hospitals.
Schultz L, Lower TJ, Srinivasan A, Nielson D, Pugliese G. Infect Control Hosp Epidemiol 2014;35(10):1229-1235.
78%
70%
150,000
$163M

93. 93 © 2015 PREMIER, INC.
Economic impact of redundant antimicrobial therapy in US hospitals.
Schultz L, Lower TJ, Srinivasan A, Nielson D, Pugliese G. Infect Control Hosp Epidemiol 2014;35(10):1229-1235.
53% of all
patients received
redundant metronidazole
and piperacillin-
tazobactam therapy
5% of all patients
received redundant IV
linezolid and vancomycin
therapy
5%of all patients
with dual therapies
received dual beta-
lactam combinations
3 to 6 days was
the mean dose days with
the redundant
combinations

94. 94 © 2015 PREMIER, INC.
Antimicrobial stewardship is an effective strategy in
reducing overutilization and redundant therapy,
antimicrobial resistance, patient harm, and wasteful
spending.
Based on the study findings of metronidazole used with
piperacillin-tazobactam as the most common
inappropriate or redundant combination, this single
combination should be considered a possible initial target
for antimicrobial stewardship programs.
One successful approach that has been recommended is
for healthcare organizations to develop a list of “never”
combinations of antibiotics or redundant combinations
and provide alerts to providers when these combinations
are ordered.
Applying Lessons Learned

95. 95 © 2015 PREMIER, INC.
Launch of QUEST mini collaborative of 50 healthcare
organizations as part of White House commitment
September 2015 to June 2016.
Goals:
• Implement CDC Core Elements for hospital antibiotic stewardship
programs
• Reduce potentially inappropriate use of redundant combinations
of intravenous anti-anaerobic antibiotics
Results and learnings will be shared widely
More info at premierinc.com/antibiotics
Premier Collaborative on Antimicrobial Stewardship

96. 96 © 2015 PREMIER, INC.
Premier Research Institute
• Publication with the CDC in September 2014
• 78% of hospital patients treated received unnecessary or
duplicative IV antibiotics
• 70% of the inappropriate use was related to three specific
combinations of IV antibiotics used to treat anaerobic infections
Premier QUEST and PFP Hospitals
• QUEST sprint webinar series on AMS w/CDC
• Participate in performance improvement initiatives to drive AMS
techniques into patient safety practices
PremierConnect Quality
• Developed redundant/duplicative antibiotic usage reports
• Shared reports with member hospitals in October 2014
Premier Activities to Improve Antimicrobial Stewardship

97. 97 © 2015 PREMIER, INC.
PremierConnect Safety
• 1000 facilities use Premier’s CDSS to support ASP initiatives
• 27 facilities (~25% of all facilities) have submitted data to NHSN
Antimicrobial Use (AU) module
Premier Advocacy
• Participant in White House Forum on Antibiotic Stewardship
• Participant in Stakeholder Forum on Antimicrobial Resistance (S-
FAR)
• CDC White House Partner for “Get Smart Week 2015”
• Participant in National Quality Partners Antibiotic Stewardship
Action Team
• Participant in NQF initiative to develop a practical playbook to
advance effective antibiotic stewardship
Premier Activities to Improve Antimicrobial Stewardship

98. 98 © 2015 PREMIER, INC.
Premier’s Impact on the National Action Plan for CARB
PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.
Goal 1: ASP and biosurveillance
• Premier Research Institute
• PremierConnect Quality
• Premier QUEST and PFP Hospitals
• PremierConnect Safety
• Premier Advocacy
Goal 2: Increase AU and AR reporting
• PremierConnect Safety

99. 99 © 2015 PREMIER, INC.
Premier resources on antimicrobial stewardship on
Premier Safety Institute® website
Tools, resources, solutions,
blogs on measurement, and
e-surveillance for antimicrobial
stewardship from Premier at
premierinc.com/antibiotics

100. Thank you
Craig_Barrett@premierinc.com

101. 101 © 2015 PREMIER, INC.
Your questions
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Faculty
MODERATOR
Gina Pugliese, RN, MS, FSHEA
Vice President
Premier Safety Institute®
CAPT Arjun Srinivasan, MD
Associate Director,
Healthcare associated infection
prevention programs, CDC
Michael Postelnick, RPh BCPS
AQ Infectious Diseases
Senior Infectious Diseases Pharmacist
Northwestern Memorial Hospital, Chicago
Craig Barrett PharmD,BCPS
Director, Safety Solutions, Premier Inc.
@PremierHA
#AdvisorLive
#GetSmartWeek

103. 103 © 2015 PREMIER, INC.
Visit the Premier Safety Institute for tools,
resources, and e-surveillance solutions
www.premierinc.com/antibiotics
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