Practical Approaches to Measuring and Reporting

Antibiotic use in Nursing HomesGhinwa Dumyati, MD

Professor of Medicine

Infectious Diseases Division

Center for Community Health and Prevention

University of Rochester Medical Center

June 5, 2019

Objectives

• Discuss the advantages and disadvantages of different antibiotic measures

• Describe sources of antibiotic data

• Review examples of data summaries and how to make the data actionable

“If you cannot Measure it,

you cannot Improve it”

Quote from Lord Kelvin

1. Lim et al. Clin Interven Aging. 2014 Jan 13;9:165-77.2. Nicolle et al. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45

https://www.cdc.gov/longtermcare/pdfs/Infographic-Antibiotic-Stewardship-Nursing-Homes.pdf

https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdfhttps://www.cdc.gov/longtermcare/pdfs/Nursing-Homes-Core-Elements-C-508.pdf

Antibiotic Measures

• Antibiotic starts

• Antibiotic days of therapy

• Point prevalence of antibiotics

• Proportion of antibiotics >7 days

Antibiotic StartsPro

Tracks prescribing for specific indications (e.g. UTI)

Tracks efforts to lower antibiotic prescription rates

Con

Does not measure total antibiotic burden or length of treatment

May overestimate antibiotic use if antibiotics are changed

Modified from Jump RLP et al. https://www.jamda.com/article/S1525-8610(17)30430-9/pdf

Antibiotic Days of Therapy

Pro

• Estimates total burden of antibiotic use

• Tracks efforts to lower antibiotic use rates

Con

• Does not measure length of treatment

• Skewed by long-term prophylactic antibiotics

Modified from Jump RLP et al. https://www.jamda.com/article/S1525-8610(17)30430-9/pdf

Antibiotic Starts vs. Antibiotic DOT

Name Antibiotic dose Start date End date Duration

WJ Ceftriaxone for pneumonia

1g X1 9/17/18 9/17/18 1 day

WJ Doxycycline for pneumonia

100 mg twice a day

9/17/18 9/21/18 5 days

Antibiotic starts: 2 antibiotic starts Days of therapy (DOT)= 6 (5+1) Duration of total therapy for pneumonia (length of treatment): 5 days

Antibiotic Use Rates

Allows a comparison of data over time and across facilities:

e.g. monthly rate per 1000 resident days

Number of antibiotic starts or DOT per month X1000

(N of residents in facility/unit during the month) x (N of days in the month)

Point Prevalence of Antibiotic Use

Pro

• Can be collected for 1 day or a week or a month

• Easy to collect

• Can provide a snap shot on the indication of antibiotics and the most common agents

Con

• May not portray the magnitude of antibiotic use over time if done infrequently

• Cannot determine length of treatment

Repeated Weekly Point Prevalence of Antibiotic Use

Barney GR, et al. Infect Control Hosp Epidemiol. 2019 Feb;40(2):221-223

Sources for Antibiotic Data in Nursing Homes

• Purchasing data• Different from hospital as medications purchased in bulk• Can be difficult for dispensing from a central pharmacy location to many facilities

• Electronic medication administration records (MAR)*• Not available in many nursing homes

• Dispensing data• Does not insure the antibiotic was administered• Often the dispensing pharmacy is outside the facility

• Manual data collection• Daily• Weekly

*https://www.health.state.mn.us/diseases/antibioticresistance/hcp/ehrfs.pdf

Antibiotic Dispensing data

Requesting Dispensing Data

Useful variables to ask for:• Unique number for each patient or patient’s name• Drug name and dose• Complete “Sig” (contains indication, route)• Start and end dates• Days of therapy or days dispensed• Nursing home unit

• Other data:• Date of admission• Prescriber’s name

Cleaning Antibiotic Dispensing Data• May have to enter data manually into Excel

• Usually requires significant cleaning of the data• Standardize drug name

• Assign drug type (antibiotic, antiviral)

• Remove topical agents

• Standardize indications (e.g. UTI, pneumonia, bronchitis)

• Combine transactions for the same patient/drug/indication

• Calculate days of therapy if not provided

This is not easy….

Collaborate with your consultant or dispensing pharmacist or hospital antibiotic stewardship experts

Manual Data Collection

Rochester Patient Safety Collaborative Antibiotic Tracking Tool

http://www.rochesterpatientsafety.com/index.cfm?Page=For%20Nursing%20Homes

Antibiotic Tracking Tool• Measures antibiotic starts and DOT by indication

and agent

• Measures antibiotic use per unit

• Able to capture hospital and nursing home antibiotic starts

• Measures antibiotic use by provider

• Trending data entered manually

How To Make Your Antibiotic Use Data Actionable?

• What? is the most frequent antibiotic

• Why? Common reason for antibiotic

• Where? Is the unit with the highest use

• Who? is prescribing the antibiotic

• When? Time of the day or day of the week

What is the most frequent antibiotic?

Fluroquinolones33%

Cephalosporins22%

Penicillins20%

Clindamycin7%

TMP/SMZ7%

Others11%

Why? Most Common Indications

980

878

689

562

531

435

284

178

UTI

UTI prophylaxis

Pemphigoid

Skin and soft tissue

Pneumonia

C. difficile

Bone/joint

Head and ENT

0 200 400 600 800 1000 1200

102

62

48

19

13

13

12

12

UTI

Skin and Soft tissue

pneumonia

dental prophylaxis

Bronchitis

C. difficile

HEENT

UTI prophylaxis

0 20 40 60 80 100 120

8 most common antibiotic indications by days of therapy (DOT)

8 most common indications by number of residents

How Do We Treat UTI?

87

15

14

12

11

10

8

8

6

5

4

2

1

1

Ciprofloxacin

Levofloxacin

Nitrofurantoin

Cephalexin

SMZ-TMP

Amoxicillin

Ampicillin

Ceftriaxone

Amox/K Clav

Trimethoprim

Cefpodoxime

Doxycycline

Fluconazole

Linezolid

0 10 20 30 40 50 60 70 80 90 100

55% are quinolones!

Number of residents

Organism

# of

Isola

tes Am

pic

illi

n

Am

ox

icil

lin

/Cla

v

Am

pic

illi

n/s

ulb

act

am

Cef

azo

lin

Cef

tazi

dim

e

Cef

tria

xo

ne

Cef

epim

e

Cip

rofl

oxaci

n

Gen

tam

icin

Imip

enem

Lev

ofl

oxa

cin

Pip

era

cill

in/t

azo

ba

cta

m

To

bra

my

cin

Tri

met

ho

pri

m/s

ulf

a

Nit

rofu

ran

toin

Lin

ezo

lid

Da

pto

my

cin

Va

nco

my

cin

Do

xy

cycl

ine

Tet

racy

clin

e

Gram Negative

Organisms

Escherichia coli 87 62 90 72 92 94 94 94 62 89 100 50 99 90 80 97

Klebsiella

pneumonia *

19 0 10

0

100 100 100 100 100 100 100 100 100 100 10

0

100 47

Proteus mirabilis * 25 84 96 92 88 100 100 100 88 92 92 88 100 96 88 0

Gram Positive

Organisms

Enterococcus

faecalis *

12 100 75 75 100 100 100 100 42 42

Is Ciprofloxacin the Best Treatment Choice?

*Differences in the % susceptible for an organism represented by <30 isolates may not be statistically significant from year to year.

Clinical Situation

Diagnostic Processand Decision Makings

Decision to treat or active monitoring

Monitor Clinical situation and Lab results

Reassessment at 48-72 hours:Stop, or change antibiotic, decide on duration

Medical Record Review To Understand Where to Intervene

50% of treatment for UTI are after culture is back

By Whom?

0

2

4

6

8

10

12

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Nu

mb

er

WHY?

Tracking Antibiotic Process Measures

Is there a documented indication for each order?

Is there a standard use of tool for clinical evaluation

e.g. Use of SBAR tool

Did the infection fit criteria to start antibiotic (Loeb) or surveillance criteria (udated McGeer)?

Is the antibiotic choice according to the facility treatment guidelines?

37%

33%

25%

37%

33%

24%26%

19%

29%31%

15%

22%24%

19%

11% 12%9%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Q12014

Q22014

Q32014

Q42014

Q12015

Q22015

Q32015

Q42015

Q12016

Q22016

Q32016

Q42016

Q12017

Q22017

Q32017

Q42017

Q12018

Star

ts M

issi

ng

Ind

icat

ion

Proportion of Antibiotic Starts With No Indication

115 115

64

105

81

47 48

26

46

26

15 179

15 13

0

20

40

60

80

100

120

140

Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017

Nu

mb

er

Cultures Treated Met Criteria

Urine Cultures, UTI Treatment, and UTI Surveillance criteria

Antibiotic Name and Days of Therapy Revised McGeer Criteria: Signs and Symptoms

Data collection template created by Dallas Nelson, MD, Timothy Holahan, MD. Modified by NYSDOH Project Team for the CLASP Project

http://www.rochesterpatientsafety.com/index.cfm?Page=For%20Nursing%20Homes

Example of UTI Tracking Sheet

Urine Culture Results48-72 hrreassessment

Meets McGeer Criteria

0

1

2

3

4

5

6

7

8

9

Q12014

Q22014

Q32014

Q42014

Q12015

Q22015

Q32015

Q42015

Q12016

Q22016

Q32016

Q42016

Q12017

Q22017

Q32017

Q42017

Q12018

Rat

e (p

er 1

,00

0 R

esid

ent

Day

s)

7/2015: UTI Education Began

Q1 2016: UTI Treatment Guidelines and IP s Review of Cultures

Tracking Progress-UTI Starts

0

50

100

150

200

250

300

Q12014

Q22014

Q32014

Q42014

Q12015

Q22015

Q32015

Q42015

Q12016

Q22016

Q32016

Q42016

Q12017

Q22017

Q32017

Q42017

Q12018

DO

T

Other Agents

Amoxicillin

Levofloxacin

Cefpodoxime

Ceftriaxone

Keflex

Bactrim

Nitrofurantoin

Ciprofloxacin

Tracking Progress- UTI Antibiotic ChangeIntervention to reduce quinolone use for UTI

Tracking progress-Total DOT rate

0

10

20

30

40

50

60

70

80

Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018

DO

T R

ate

per

1,0

00

Res

iden

t D

ays

How Does My Data Compare to Other Nursing Homes?

JAMA Intern Med. 2015;175(8):1331-1339

Total Burden of Antibiotic Use-Less is BetterResidents in High Use nursing homes have a 24% greater risk of antibiotic related adverse effects:

C difficile, diarrhea or gastroenteritis, antibiotic-resistant organisms, allergic reactions to antibiotics, or general medication adverse events

Access to Comparative Antibiotic Data

• Get involved in collaborative projects

• Ask your consulting pharmacist that service many facilities if they can provide de-identified comparative data

• Enter data into NHSN (UTI)

Collaborative Rate of UTI Starts

0

0.5

1

1.5

2

2.5

3

3.5

4

4 3 1 10 2 8 9 1 11

Star

ts p

er 1

,00

0 r

esid

ent

day

s

2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 2017Q2 2017Q3 2017Q4 2018Q1

Line is 2017 collaborative average UTI start rate (1.32 per 1,000 resident days)

Antibiotic Stewardship is a Multidisciplinary Effort

ASP QI Team

IP/Medical Director

Director of Quality

Nurse educator

Microbiology Lab

Dispensing Pharmacy

Consultant Pharmacist

Director of Nursing

Nursing Home Administrator

Every member has a role

Antibiotic Measurement Tools• Rochester Patient Safety Collaborative:

http://www.rochesterpatientsafety.com/index.cfm?Page=For%20Nursing%20Homes

• Nebraska ASAP: https://asap.nebraskamed.com/long-term-care/tools-templates-long-term-care/

• Minnesota Infection and Antibiotic Use Tracking Tool Instructions: https://www.health.state.mn.us/diseases/antibioticresistance/hcp/asp/ltc/apxlinstructions.pdf

• AHRQ Nursing Home Antimicrobial Stewardship Guide: https://www.ahrq.gov/nhguide/toolkits/implement-monitor-sustain-program/toolkit2-monitor-sustain-program.html

• https://qioprogram.org/sites/default/files/editors/141/LTCF_Measuring_Antibiotic_Use_September_2016_DoddsAshley_E4review.pdf

Questions?