Review of AUR/SAAR Ed Septimus, MD, FACP, FIDSA, FSHEA

Therapeutics Research and Infectious Disease Epidemiology, Department of Population Medicine

Harvard Medical School & Harvard Pilgrim Health Care InstituteProfessor Internal Medicine, Texas A&M College of Medicine

Agenda

• Describe antimicrobial use and resistance (AUR) surveillance via NHSN,

focusing on the AU reporting option

• Summarize the Standardized Antimicrobial Administration Ratio (SAAR),

which is the quantitative centerpiece of NHSN’s new AU measure

• 2017 updates

Antimicrobial Use and Resistance (AUR) Module

The Basics

• Designed to support healthcare and public health efforts to:

(1) Monitor and improve antimicrobial prescribing

(2) Identify, understand, and respond to antimicrobial resistance patterns or

trends

• Provides a common set of technical specifications and a single surveillance

platform for hospitals to report AU and AR data

• All data must be submitted electronically to the AUR Module

• Data that are successfully transmitted are available immediately to NHSN

users for analysis and visualization

• Summary data provide AU and AR benchmarks that hospitals, healthcare

systems, and public health agencies can use for comparative purposes and as

a guide for further analysis and action

NHSN AU Reporting Option: Operational Overview

Participation:• General acute care hospitals, long-term acute care hospitals, inpatient

rehabilitation facilities, oncology hospitals, critical access hospitals

Data Sources:• Electronic Medication Administration Record (eMAR) or Bar Coding

Medication Administration (BCMA) systems for AU data

• Admission/Discharge/Transfer (ADT) systems for patient location data

Monthly Numerator Data:• Antimicrobial days – Days of therapy for a specified antimicrobial agent

administered in a patient care location

• Over 85 antimicrobials are in scope - Antibacterial, antifungal, and anti-influenza agents, stratified by route of administration (intravenous, intramuscular, digestive, and respiratory)

Monthly Denominator Data: • Days present – Number of patients in a specific location or facility, per

day, aggregated for a monthly total.

• Admissions – Number of patients admitted to the hospital

Background

▪ What is the SAAR?• The SAAR, or Standardized Antimicrobial Administration Ratio, is a metric that compares

observed antimicrobial days of therapy (DOT) to predicted DOT for specified groups of antimicrobials being used in specified patient care locations which is risk adjusted

SAAR = Observed Antimicrobial Use

Predicted Antimicrobial Use

Interpreting SAAR values

SAAR values are always greater than 0, and a value of 1.0

suggests equivalency between observed and predicted AU.

• A high SAAR (above 1.0) that achieves statistical significance (i.e., different from 1.0) may indicate excessive AU

• A SAAR that is not statistically different from 1.0 indicates AU is equivalent to the referent population’s AU

• A low SAAR (below 1.0) that achieves statistical significance (i.e., different from 1.0) may indicate antimicrobial under use

• The SAAR is useful in indicating where potential overuse or underuse of antimicrobials may be occurring, but a SAAR alone is not a definitive measure of appropriateness or judiciousness of AU, and any SAAR may warrant further investigation.

Background continued (2)

▪ How do 2017 baseline SAARs differ from 2014 baseline SAARs?• Adult and pediatric patient populations were modeled separately

• Patient care locations were added: NICU not included

• Adult general hematology-oncology wards

• Adult step-down units

• Revised antimicrobial categories

• New risk adjustment variables were assessed:

• Percentage of ICU beds (total # ICU beds/total # hospital beds)

• Average length of stay (total annual patient days/total annual admissions)

• Larger sample size:

• 2014 models: 77 acute care hospitals (350 adult and 33 pediatric locations)

• 2017 adult models: 449 acute care hospitals, 2156 locations

• 2017 pediatric models: 109 acute care hospitals, 170 locations

8

National NHSN Antimicrobial Use Reporting

Source: CDC DHQP / Office of Antibiotic Stewardship

Risk adjustments: 2017 baseline▪ Adult SAAR models

Factor BSHO BSCA GramPos NSBL Fungal CDI All

Location type

Facility type

Medical school affiliation

Total number of hospital beds

Total number of hospital ICU beds

Percentage of hospitals beds that are ICU beds

Average hospital length of stay

▪ Pediatric SAAR modelsFactor BSHO BSCA GramPos NSBL Azithro Fungal CDI All

Location type

Facility type

Location type with facility type

Medical school affiliation

Total number of hospital beds

Total number of hospital ICU beds

Percentage of hospitals beds that are ICU beds

Average hospital length of stay

Background continued (3)

▪ How do 2017 baseline SAARs differ from 2014 baseline SAARs?• Changes made to SAAR antimicrobial categories:

• Agents used for MDRO infections removed from hospital-onset agent group

• Anti-MRSA group renamed “Antibacterial agents predominantly used for resistant Gram-positive infections”

• Surgical site infection prophylaxis agent category removed

• Narrow spectrum beta-lactam group added

• Antifungal agent category added

• Antibacterial agents posing highest risk for CDI category added

• Azithromycin added (peds only)

2017 baseline SAAR antimicrobial categories

▪ Broad spectrum antibacterial agents predominantly used for hospital-onset infections

▪ Broad spectrum antibacterial agents predominantly used for community-acquired infections

▪ Antibacterial agents predominantly used for resistant gram-positive infections (e.g., MRSA)

▪ Narrow spectrum beta-lactam agents*

▪ Azithromycin (peds only)*

▪ Antifungal agents predominantly used for invasive candidiasis*

▪ Antibacterial agents posing the highest risk for CDI (Clostridium difficile infection)*^

▪ All antibacterial agents

*New categories

^Not mutually exclusive (includes antimicrobials found in other SAAR categories)

Adult Broad-spectrum antibacterial agents predominantly used for hospital-onset infections

AMIKACIN (IV only)

AZTREONAM (IV only)CEFEPIMECEFTAZIDIMEDORIPENEMGENTAMICIN (IV only)

IMIPENEM/CILASTATINMEROPENEMPIPERACILLIN/TAZOBACTAMTOBRAMYCIN (IV only)

Adult Broad-spectrum antibacterial agents predominantly used for community-acquired infections

CEFACLORCEFDINIRCEFIXIMECEFOTAXIMECEFPODOXIMECEFPROZILCEFTRIAXONECIPROFLOXACINCEFUROXIMEERTAPENEMGEMIFLOXACINLEVOFLOXACINMOXIFLOXACIN

Adult Antibacterial agents predominantly used for resistant Gram-positive infections (e.g., MRSA)

CEFTAROLINEDALBAVANCINDAPTOMYCINLINEZOLIDORITAVANCINQUINUPRISTIN/DALFOPRISTINTEDIZOLIDTELAVANCINVANCOMYCIN (IV only)

Adult Narrow spectrum beta-lactam agents AMOXICILLINAMOXICILLIN/CLAVULANATEAMPICILLINAMPICILLIN/SULBACTAMCEFADROXILCEFAZOLINCEFOTETAN

CEFOXITINCEPHALEXINDICLOXACILLINNAFCILLINOXACILLINPENICILLIN GENICILLIN V

Adult Antibacterial agents posing the highest risk for CDI

CEFDINIRCEFEPIMECEFIXIMECEFOTAXIMECEFPODOXIMECEFTAZIDIMECEFTRIAXONECIPROFLOXACINCLINDAMYCINGEMIFLOXACINLEVOFLOXACINMOXIFLOXACIN

Adult Antifungal agents predominantly used for invasive candidiasis

ANIDULAFUNGINCASPOFUNGINFLUCONAZOLEMICAFUNGIN

2017 baseline SAAR models:

▪ Adult SAARs available for:• Medical, medical-surgical, surgical ICUs

• Medical, medical-surgical, surgical wards

• Step-down units

• General hematology-oncology wards

▪ Pediatric SAARs available for:• Medical, medical-surgical ICUs

• Medical, medical-surgical, surgical wards

National Quality Forum Endorsement

▪ The SAAR was originally endorsed by the National Quality Forum in 2015-approved by Patient safety Committee for re-endorsement 2019

▪ New SAAR models will be included in the NHSN AU quality measure maintenance proposal which will soon be submitted to the National Quality Forum

Public health/disease surveillance

Quality improvement (internal to the specific organization)

Quality improvement (external benchmarking involving multiple organizations)

Public reporting

Payment program

Regulatory and accreditation programs

Professional certification or recognition program