Antimicrobial Stewardship - the State Health Department Perspective - Dr. Marion A. Kainer, Director, Healthcare Associated Infections and Antimicrobial Resistance Program, Tennessee Department of Health, from the 2015 NIAA Antibiotic Symposium - Stewardship: From Metrics to Management, November 3-5, 2015, Atlanta, Georgia, USA. More presentations at http://swinecast.com/2015-niaa-symposium-antibiotics-stewardship-from-metrics-to-management

1. Antimicrobial Stewardship –
the State Health Department Perspective
Marion A. Kainer MD, MPH, FRACP, FSHEA
Healthcare Associated Infections and Antimicrobial Resistance Program
NIAA Antibiotic Stewardship: From Metrics to Management | Nov. 4, 2015

2. Acknowledgements
• CDC
 Funding support: ELC, EIP, CSTE HAI fellow
 National Healthcare Surveillance Network [NHSN]
infrastructure
 Technical support
• Reporting partners: Laboratories, healthcare facilities, infection
preventionists, pharmacists, clinicians
• Multidisciplinary Advisory Group on HAI & AMR
• Tennessee Department of Health [TDH]
 Surveillance systems and informatics
 Healthcare associated infections & antimicrobial resistance
No conflicts of interest

3. Multidisciplinary Advisory Group on HAI & AR

4. Every Infection/HAI Prevented, Represents:
http://www.tn.gov/health/topic/hai
 One less episode of antibiotic use
and thus one less opportunity for the
development of resistance
 One less exposure to a potentially
resistant infection
CLABSI in Adult/Ped ICU, TN

5. Standardized Infection Ratio (SIR):
Risk Adjusted Summary Measure
• SIR > 1.0: # infections are HIGHER than predicted
– SIR= 1.5: # infections = 50% HIGHER than predicted
• SIR < 1.0: # infections are LOWER than predicted
– SIR= 0.4: # infections = 60% LOWER than predicted
Observed (O) HAIs
Predicted (P) HAIs
To calculate O, sum the # of HAIs among a group
To calculate P, requires the use of the appropriate
aggregate data (risk-adjusted rates) (e.g., national NHSN
data for 2006-2008)
SIR=

6. CLABSI* – Adult/Pediatric ICUs, TN 1/2008- 12/2014
Start CLABSI
Collaborative:
CUSP
HHS Goal
* Central Line Associated Blood Stream Infections [CLABSI]

7. CLABSI – Adult/Pediatric ICUs, TN 1/2008- 12/2014
Start CLABSI
Collaborative:
CUSP
First report sent to
hospitals with
hospital specific data

8. Hospital A: CLABSIs in Adult & Pediatric ICU

9. Targeting facilities: TAP Strategy using the CAD
(or Number Needed to Prevent)
CAD = Cumulative Attributable Difference
= ObsFACILITY - (ExpFACILITY*HHS Goal SIR)
2013 HHS
Goals
SIR=0.75 (SSI, CAUTI, MRSA)
SIR=0.50 (CLABSI)
SIR=0.70 (CDI)
See also: Soe, MM et al. A Mathematical Model to Prioritize Healthcare Facilities for High Prevention
Impact on Healthcare-Associated Infections. CSTE Annual Conference 2013.
https://cste.confex.com/cste/2013/webprogram/Paper2070.html
Soe M, Gould CV, Pollock D, Edwards J. Targeted assessment for prevention of healthcare-associated
infections: a new prioritization metric. Infect Control Hosp Epidemiol 2015 (in press).
http://www.cdc.gov/hai/prevent/tap.html

11. http://tn.gov/health/article/hai-prevention-calculator
TN HAI Prevention Calculator

12. CLABSI – Neonatal ICUs, TN 7/2008- 12/2014

13. Emerging Infections Program (EIP)

14. 183 hospitals in 10 States (EIP) [25 hospitals in TN]
11,282 patients; HAI prevalence: 4%
Most common HAI pathogen: Clostridium difficile
Extrapolation: estimate 721,854 HAIs in the US in 2011

15. Overall Prevalence: 49.9%
TN: highest: 56.3% [lowest state: 43.9%]

16. • ICUs
• Medical
• Surgical
• Med/Surg
• Hem/Onc
AU Prevalence in Different Hospital Locations
Overall: 49.9%

17. Lower Resp tract
UTI
Skin, soft tissue
GI
Empiric
BSI
Infection Sites for Which Patients Received
Antimicrobial Treatment
34.6%
22.3%
16.1%
12.6%
8.5%
9.4%

18. 5 Most Common Antibiotics:
Community Onset (CO) vs Healthcare Facility Onset (HO)
CO HO

19. 63.4%
52.4% 54.6%
Small Medium Large
Slide shown at TN MDAG, March 27, 2012; TN provisional data
Proportion of Patients on Antibiotics,
by Facility Size, TN, 2011

20. 88.8%
83.6%
67.9%
10.9%
16.1%
31.7%
Small Medium Large
IV/IM Oral Enteral
Slide shown at TN MDAG, March 27, 2012; TN provisional data
Route of Administration by Facility Size, TN, 2011

21. Rationale for Antimicrobial Administration
at Patient Level, TN, 2011
46.0%
9.6%
1.6% 0.3%
2.4%
Treatment of
Active Infection
Surgical
prophylaxis
Medical
prophylaxis
Non infection None
documented
Slide shown at TN MDAG, March 27, 2012; TN provisional data

22. Most Common Antimicrobial Agents Given for
Active Infection, TN, 2011
0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00
Vancomycin
Ceftriazone
Levoflaxin
Pip/tazo
Azithromycin
Metronidazole
Ciproflaxin
Fluconazole
Clindamycin
Linezolid
Moxifloxazine
Doripenem
Meropemen
Proportions of Antimicrobials Given
Slide shown at TN MDAG, March 27, 2012; TN provisional data

23. Assessment of Appropriate Antimicrobial Use Among
Patients in Acute Care Hospitals in Tennessee (EIP Pilot)
High proportion
• Inadequate
microbiology
testing
• Inappropriately
tailored
antimicrobial
therapy

24. Antimicrobial
Stewardship Annual
Hospital Survey 2014

25. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
Core Elements of Hospital Antimicrobial
Stewardship Programs

26. 7 Core Elements of Antimicrobial Stewardship
• Leadership commitment: Dedicate necessary human, financial, and IT
resources
• Accountability: Appoint a single leader responsible for program
outcomes.
• Drug expertise: Appoint a single pharmacist leader to support
improved prescribing
• Act: Take at least one prescribing improvement action, such as
requiring reassessment after 48 hours to check drug choice, dose, and
duration
• Track: Monitor prescribing and antibiotic resistance patterns
• Report: Regularly report to staff prescribing and resistance patterns,
and steps to improve
• Educate: Offer education about antibiotic resistance and improving
prescribing practices

27. Core Elements: TN vs US (national), 2014
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Accountability Action Drug-expertise Education Leadership Reporting Tracking
The seven elements of antibiotic stewardship in TN compared to the US.
Nationwide
(N=4,091)
Tennessee
(N=112)

28. Aggregate Core Elements: TN vs US, 2014
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
4 or less 5 or more
Aggregated number of core elements
Nationwide (N=4,091)
Tennessee (N=112)42%
70%
30%
58%

29. Tennessee Healthcare Coalitions/EMS Regions
and Number of Acute Care Hospitals, 2014
EMS 1
Northeast/Sullivan
N=11
EMS 2
Knox/East
N=20
EMS 4
Upper
Cumberland
N=10
EMS 3
Southeast/Hamilton
N=13
EMS 5
Highland Rim
N=20
EMS 6
South Central
N=9
EMS 7
Region 7
N=14
EMS 8
Mid South
N=15
8 EMS regions, numbered from East to West
9 to 20 hospitals per EMS Region
TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1
112 15 14 9 20 10 13 20 11

30. >5 Core Elements of Stewardship by EMS Region, 2014
TN EMS-8EMS-7EMS-6EMS-5EMS-4EMS-3EMS-2EMS-1
58% 47% 50% 44% 60% 50% 61% 100% 18%

31. Leadership: Salaried Support TN, 2014
23%
(N=26)
77%
(N=86)
Facilities with salaried support for
antibiotic stewardship activities (N=112).
Yes
No
Q26. Does your facility provide any salary support for dedicated
time for antibiotic stewardship activities?

32. Leadership: Written Support TN, 2014
45%
(N=50)55%
(N=62)
Facilities with a written statement
designed to improve antibiotic use
(N=112).
Yes
No
Q23. Does your facility have a written statement of support from leadership
that supports efforts to improve antibiotic use (antibiotic stewardship)?”

33. Action as a Component of Antimicrobial
Stewardship , Hospitals, TN, 2014
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Policies present Treatment
recommendations
Review of
treatments
Antibiotic
approval by a
physician
Antibiotic review
by a physician
The five components of action towards antimicrobial stewardship.
Document
Indication “Time out”

34. >3 Core Elements of Action by EMS Region, 2014
TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1
50% 40% 64% 33% 55% 50% 31% 65% 45%

35. Action-Policies: Indication Documented, 2014
27. Does your facility have a policy that requires prescribers to document an
indication for all antibiotics in the medical record or during order entry?
TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1
21% 53% 36% 11% 5% 10% 100% 30% 18%

36. Action-Treatment Review (“Time-Out”), 2014
29. Is there a formal procedure for all clinicians to review the appropriateness of all
antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)?
TN EMS-8 EMS-7 EMS-6 EMS-5 EMS-4 EMS-3 EMS-2 EMS-1
22% 13% 29% 33% 25% 10% 23% 30% 9%

37. Antimicrobial Stewardship Recommendations,
THA Board Adopted (October 2015)
1. Hospital demonstration of commitment to
antibiotic stewardship via a written statement
of support and consideration of dedicated
pharmacy, clinician and IT staff time for
antibiotic stewardship activities.
2. All hospitals commit to reporting to the
National Healthcare Safety Network
antimicrobial use and resistance modules
within specified timeframes.
3. All hospitals commit to a policy requiring
documentation of indications for antibiotic
therapy.

38. Antimicrobial Stewardship Recommendations,
THA Board Adopted (October 2015)
4. All hospitals commit to implementing a policy
requiring an “antibiotic review” at 48-72 hours
to allow for appropriate review of clinical
indication of need, response and any
therapeutic revisions that might be appropriate.
5. Participation by hospitals in an antibiotic
stewardship collaborative to encourage best
practice / lessons learned sharing, and
development of appropriate educational
programing, as well as any other steps or
activities that would assist with antibiotic
stewardship.

39. National Healthcare Safety Network (NHSN)
 NHSN is a surveillance system that serves multiple
users and uses
 NHSN is used by
>17,000 healthcare facilities to track HAIs,
antimicrobial use and resistance, and adherence to
prevention guidelines; guide prevention efforts;
submit data for public reporting and quality
measurement purposes
Health departments for surveillance, prevention, and
public reporting
CMS for quality measurement and reporting,
reimbursement, and prevention
HHS to measure national progress

40. NHSN Antimicrobial Use & Resistance Module
• Only electronic data submission using CDA
(clinical document architecture).
• NO MANUAL data entry
• Antimicrobial Use [AU]
– eMAR (electronic medication administration record)
or
– BCMA (bar code medication administration system
– ADT (admission, discharge, transfer) or registry data
• Antimicrobial Resistance [AR]
– LIMS (laboratory information system)
– ADT (admission, discharge, transfer) or registry data

41. Reporting Data to NHSN AUR Module
• Stakeholder Meeting March, 2015:
– THA (Tennessee Hospital Association)
– CMO Society (Chief Medical Officer)
– TN Pharmacy Coalition
– TDH (Tennessee Dept of Health)
• Objective: Prepare hospitals and health systems for the
expected state and federal reporting requirements on
antibiotic use and resistance (AUR) to NHSN.
– Data submission to NSHN is electronic only and involves
multiple sources of data (ADT, LIMS, eMAR/BCMA).
– Requires lead time
• time and resources

42. Facilitating Reporting to NHSN AUR Module
• Sharing lessons learned from two TN hospitals reporting
data to the NHSN AU module
– Holston Valley Medical Center (major teaching hospital)
– Maury Regional Medical Center (medium size)
• Inventory of electronic systems in use at TN healthcare
facilities:
– ADT
– BCMA
– eMAR
– LIS
– 3rd party software

43. Interim Measurement Solution Until More Facilities
Report to NHSN: Serial Point Prevalence Surveys

45. Facility AV: Reduction in Antimicrobial Use

46. Example Report: Facility vs Collaborative
All Antibiotics and Quinolone use

47. Distribution of Patients on Quinolones TN, 2014-15
4% 12% 20% 28% 36%

48. Pharmacist Training
Antimicrobial Stewardship Training Programs
http://mad-id.org/
Basic Program
http://mad-id.org/antimicrobial-
stewardship-programs/antimicrobial-
stewardship-programs-basic-program/
Advanced Program
http://mad-id.org/antimicrobial-
stewardship-programs/advanced-
program/
Antimicrobial Stewardship: A Certificate Program for Pharmacists
http://www.sidp.org/page-1442823

49. Outpatient Antibiotic Use Rates (2010)
Center for Disease Dynamics, Economics & Policy <http://www.cddep.org/node/4933>
Hicks et al. U.S. Outpatient Antibiotic Prescribing, 2010. N Engl J Med 2013; 368:1461-1462
 Number of dispensed outpatient antibiotic
prescriptions per 1,000 inhabitants
Tennessee
=1,159 per 1,000
inhabitants
Alaska
=511 per 1,000
inhabitants
California
=555 per 1,000
inhabitants
U.S. Average
=801 per 1,000
inhabitants

50. Governor Proclamation:
Get Smart About Antibiotics Week
Governor Haslam has
declared November
16-22, 2015 as
Get Smart About
Antibiotics Week
in Tennessee
http://tn.gov/health/topic/
appropriate-antibiotic-use

51. http://www.tnpca.org/?Connections1015

52. CSTE PS 14-ID-01
Recommendations for Strengthening Antimicrobial Stewardship in the
US, including Role of State and Local Health Departments
1. CSTE recommends all state health departments evaluate and incorporate
stewardship activities across healthcare settings into their HAI programs.
The degree to which health departments can include these programs
depends upon the resources, including training and access to subject
matter. Examples of activities that can be conducted with current and with
expanded funding levels are presented in Appendix 1.
2. CSTE recommends that CDC identifies a standardized metric for measuring
inpatient antimicrobial use to facilitate risk-adjusted benchmarking and
evaluation of national trends of antimicrobial usage over time using data
reported to the National Healthcare Safety Network’s Antimicrobial Use and
Resistance (AUR) Module and train health departments on the use of these
metrics. These data can then be used by state and local health departments
in their antimicrobial stewardship efforts.
3. CSTE recommends that CDC evaluates existing measures for monitoring
outpatient antibiotic prescribing practices and determine whether
expansion of existing measures or development of new measures are
needed.
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2014PS/14_ID_01upd.pdf

53. Appendix 1: Sample Antimicrobial Stewardship
(AS) Activities
1. Convene a State Workgroup on AS
2. Assess AS Activities and Needs
– Surveys and Assessment Tools
– Focus Groups
3. Support Interest and Efforts to Collect and Evaluate
Antimicrobial Use Data: Encourage NHSN AUR module
– Interim options (acknowledging delays in all HCFs
submitting data to NHSN AUR module):
• Point prevalence surveys
• Days of Therapy (DOT ) per 1,000 days present
• Behavioral Risk Factor Surveillance System
4. Educate and Provide Tools for AS
5. Support, Coordinate and/or Participate in State and
Local Prevention Collaboratives on AS

54. Appendix 1: Sample Antimicrobial Stewardship
(AS) Activities
1. Convene a State Workgroup on AS
2. Assess AS Activities and Needs
– Surveys and Assessment Tools
– Focus Groups
3. Support Interest and Efforts to Collect and Evaluate
Antimicrobial Use Data: Encourage NHSN AUR module
– Interim options (acknowledging delays in all HCFs
submitting data to NHSN AUR module):
• Point prevalence surveys
• Days of Therapy (DOT ) per 1,000 days present
• Behavioral Risk Factor Surveillance System
4. Educate and Provide Tools for AS
5. Support, Coordinate and/or Participate in State and
Local Prevention Collaboratives on AS

55. Position Statement 15-ID-02

56. CDC & State Health Departments Consider for Implementation
Any Number of Strategies Below as Resource Allow (Appendix)

57. Thank You!
Contact:
(615) 741-7247 (24/7, 365)
Hai.health@tn.gov
http://tn.gov/health/topic/hai