Transcript history of antibiotics - Nevada Public Health Foundation

NEVADANS FOR
ANTIBIOTIC AWARENESS
2004 Partner Conference
April 9, 2004
Bill Berliner, MD
THE
ANTIBIOTIC
RESISTANCE
CRISIS
THE ANTIBIOTIC
RESISTANCE CRISIS
• HISTORY OF BACTERIA
• HISTORY OF ANTIBIOTICS
• RESISTANCE
• THE PROBLEM NOW
• NEVADANS FOR ANTIBIOTIC
AWARENESS
HISTORY OF BACTERIA
BACTERIA HAVE BEEN AROUND
LONGER THAN ANY LIVING THING ON
EARTH.
FOSSIL EVIDENCE DATES BACK 3.5
BILLION YEARS.
HISTORY OF BACTERIA
EARTH AS A DAY:
5:00 AM -
BACTERIA APPEAR
10:00 PM - DINOSAURS APPEAR
11:59 PM - HUMANS APPEAR
HISTORY OF ANTIBIOTICS
1928 – DR. FLEMING DISCOVERS
PENICILLIN FROM BREAD MOLD
1944 – U.S. MILITARY TAKES
PENICILLIN TO THE
BATTLEFIELD
1945 – BACTERIA WITH RESISTANCE
TO PENICILLIN ISOLATED
HISTORY OF ANTIBIOTICS
RESISTANCE
1960’s: METHICILLIN INTRODUCED
1991:
29% OF STAPH AUREUS
RESISTANT
2001:
62% OF STAPH AUREUS
RESISTANT
THE PROBLEM
PSEUDOMAS AEROGINOSA
% RESISTANCE
26
28
23
13
1991
14
1999
16
18.5
2000
CEFTAZIDIME
2001
16
1991 1999
2000
2001
IMIPENEM
THE PROBLEM
% RESISTANCE
STREPTOCOCCUS PNEUMONIA
42
32
29
22
2000
2001
PENICILLIN
2000
CEFOTAXIME
2001
THE PROBLEM
> 50% OF HOSPITAL ACQUIRED
BLOODSTREAM INFECTIONS ARE
CAUSED BY METHICILLIN-RESISTANT
STAPH AUREUS (MRSA)
> 70% OF NURSING HOME STAPH
INFECTIONS ARE CAUSED BY MRSA
THE PROBLEM
“THERE ARE
PATIENTS TODAY IN
HOSPITALS FOR
WHOM THERE ARE
NO EFFECTIVE
THERAPIES.”
Gary Doern
Director of Clinical Microbiology
University of Iowa
NEVADANS FOR
ANTIBIOTIC AWARENESS
WHO WE ARE
A STATEWIDE TASK FORCE THAT HAS
BEEN IN EXISTENCE SINCE FEBRUARY
2001
3 SUBCOMMITTEES
• PUBLIC AWARENESS
• PROVIDER EDUCATION
• INFECTION CONTROL & SURVEILLANCE
Pharmacist-directed
pneumococcal vaccine
protocol increases number
of patients receiving
immunization by 1200%
MountainView Hospital - Las Vegas, Nevada
Warren Wood, Pharm.D.
Program Revised in 1999
MountainView Hospital
• Criteria checked by admitting nurse
– Over 65
– Hx of COPD,CHF,CAP,Splenectomy, No
previous vaccine
• If criteria is met, chart is stamped with an optional
order for the physician to check off
• Once ordered, the patient was to receive the vaccine
after consent was signed
• Started June 1999
Pneumococcal Vaccine Results after 3 Years
# Patients Receiving During Hospitalization
25
20
15
Total doses
administered for all of
2002 = 91
10
5
0
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Federal Register Oct 2002
CMS modified guidelines, Standing Orders
• Removed requirement for specific physician
order
• Allowed Medical Staff Approved protocols, in
place of specific orders
• Approved for Nursing Homes, Clinics, and
Hospitals
Pneumococcal Vaccine Criteria
CDC/MMWR 1997
• All immunocompromised persons aged >2yr
• All persons over 5yr
• Persons age 2-64 with:
–Cardiovascular or pulmonary disease
–Diabetes mellitus
–Kidney disease
–Alcoholism, chronic liver disease
–Cerebrospinal fluid leaks
–Functional or anatomic asplenia
–Living in special environments or social settings
Pneumococcal Vaccine
Process Revision
• Proposed Protocol:
• Nurse assessment as before, list sent to pharmacy
• Move to a Pharmacist-Directed approach:
– Past success with IVtoPO conversion
– Change in Medicare Regulations
• Pharmacist will write order to administer Vaccine
next day
• Physician and/or Patient has over-ride ability
Pneumococcal Vaccine Process Flowchart
Patient is Admitted
Report of admits from
last 24h prints in
Pharmacy after
midnight. Data
includes: vaccine
status, age, diag,
reason for admission
Administration is recorded in
patient’s chart and nurse
gives patient vaccination
pocket card
Floor Nurse does
usual assessment
which includes
vaccine query
Pharmacist reviews data and
makes further inquiries if needed,
then writes order, and sends sheet
to floor to be placed on chart
Next Day at 2PM, Nurse
confirms with patient that
they want vaccine, then
administers dose
4th Qtr
2003
Mountain
View =
88%
Pneumococcal Vaccine Results
#Patients Receiving During Hospitalization
140
120
1200% Increase over 2002
100
80
60
40
20
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicare National Voluntary Hospital
Reporting Initiative
4th Qtr MountainView was at 88%
45
40
35
30
25
20
Top
2%
15
10
5
0
>90 80-90 70-80 60-70 50-60 40-50 30-40 20-30 10-20 <10
Urgent Care Antibiotic Use
Eugene Somphone MD
Urgent Care Department Chief
Southwest Medical Associates
Introduction
•
•
•
•
•
•
Reduction of antibiotic use
Initial assessment of antibiotic use
Provider and patient education
Incentives to reduce inappropriate use
Follow-up studies
Future reduction
Urgent Care History
• SMA Urgent Cares 100,000 visits a
year
• High volume of respiratory infections
• High rate of antibiotic prescriptions
Inappropriate Uses
• Over one-half of all antibiotics
written annually are for respiratory
infections
• More than 50 million unnecessary
prescriptions are written annually
• 17 million prescriptions for antibiotics
are written for the common cold
• Antibiotics are given to 75% of
patients with sore throat
Initial Study
• Random charts pulled for upper
respiratory complaints
• Symptoms of cough, sore throat,
runny nose, congestion, sinus pain
• Percentage of patients prescribed an
antibiotic
Results of Initial Study
•
•
•
•
•
Overall prescription rate 66.7%
Fulltime providers 53.5%
Per diem providers 78.8%
Range 14-100%
3 providers prescribed antibiotics
100% of the time!
Methods to Reduce
Inappropriate Use
• Patient education
– Handouts
– Posters
– Discussion
• Provider education
• Financial incentives to reduce
inappropriate use
Provider Education
• URIs are self-limiting
• Colored secretions are not predictors
of bacterial infection
• Bronchitis is viral in nature
• Differentiate sinus symptoms from
sinus infection
• Otitis media is oftentimes selflimiting
• Criteria for Strep throat
Financial Incentives
• SMA Bonus
• Antibiotic use as quality measure
• Goal set at less than 45%
Results
• After 3 months rate decreased to
34.2%
• After 6 months rate decreased to
30.5%
Patient Satisfaction
• Overall patient satisfaction rate
remains high
• Some disgruntled patients
• Less resistance from patients
Rocephin
• In 2001 Rancho Urgent Care used
$70,000
• Provider education and guidelines
• In 2002 all 3 SMA Urgent Cares used
$40,000
Choice of Antibiotics
• Generic vs. Branded
• Narrow-spectrum vs. Broad-spectrum
Provider A
• Branded antibiotics prescribed in a 6-month
period:
– Augmentin 2
– Cipro 1
– Floxin 1
– Levaquin 1
– Omnicef 1
– Tequin 29
– Z-pak 9
Provider A
• Generic antibiotics prescribed in a 6-month period:
– Amoxicillin 185
– Cefaclor 11
– Cephalexin 87
– Doxycycline 34
– Erythromycin 36
– Penicillin 14
– Tetracycline 3
Provider B
• Branded antibiotics prescribed in a 6-month
period:
– Augmentin 6
– Ceftin 2
– Cipro 7
– Levaquin 6
– Tequin 4
– Z-pak 5
Provider B
• Generic antibiotics prescribed in a 6-month period:
– Amoxicillin 75
– Cephalexin 57
– Doxycycline 19
– Erythromycin 20
– Penicillin 38
Future Reductions
• Rapid Strep Testing
• AOM: recent recommendations
Stop Antibiotic
Resistance In Washoe
County!
How Can Childcare Providers
Help?
Joyce Minter, RN, PHN
www.co.washoe.nv.us/health/cchs
About one-third of
Nevada’s children under
the age five are in some
form of licensed childcare
because their parents
1
work
Source: Washoe County Child Care Health
Consulting; Trust Fund for Public Health, RFA
2002-2003
Approximately 10,000
children under age six
attend 327 licensed
childcare homes and
1
centers in Washoe County
Source: Washoe County Child Care Health
Consulting; Trust Fund for Public Health, RFA
2002-2003
Childcare providers play a
key role in disseminating
information and health
education to children and
families
Antimicrobial Resistance (AR)
outreach was put into the Child
Care Health Consulting (CCHC)
grant, a Trust Fund for Public
Health (TFPH) grant, to do
education and evaluation of efforts
The CCHC is part of Health Child
Care Nevada, which is part of the
Health Care America campaign
Plan
• Send a survey to all (1250) child care
providers
• Educate staff at 3 centers and 9
homes
• Then do a follow-up survey on those
selected providers to see if they
learned anything
Childcare Consultants
Grant
• Printing and postage paid through
grant
• PHN time was “in kind” contribution
AR Objective of Grant
• Targeted child care providers will
achieve scores at least 10% higher
than the entire population of providers
in Washoe County on a survey
measuring knowledge of antibiotic
resistance after an educational session
is completed
Child Care Providers
• Obtained list of childcare providers
from Social Services-approx. 1250
questionnaires sent out
1---------232
5---------39
10--------34
20--------16
30--------5
Questionnaire
Development
• Made a list of 20 most important
messages we wanted to convey
• Put into questionnaire form and data
base created (special “Thanks” to Lei
Chen)
• Questionnaires coded with identifying
information so we could compare pretest with post test
Survey Packet
• Letter explaining program and instructions to
return questionnaire:
If a childcare center - to fax completed
questionnaires
If individual childcare provider envelope with return postage guaranteed
• Questionnaire
• Business card
• 2 NAA AR bookmarks for each provider as a
“Thank you”
Ideas for Incentives
•
•
•
•
•
•
Totes – NAA
Continuing education credit
Mugs
Water bottles
Purell hand sanitizer
Magnets-able to use some
immunization funding
• A drawing/raffle
Activities
• Mailed survey to all licensed child
care providers to assess baseline
knowledge of antibiotic resistance and
entered data for analysis
• Provided educational materials about
antibiotic resistance to targeted centers
• Provided survey to targeted centers
post intervention to measure change in
attitudes
Initial Questionnaire
Results
• 346 of 1250 returned = 28% response
rate
• Average score was 75.1, standard
deviation 13.8. Range of score was
25-100. Full score is 100.
Stop Antibiotic
Resistance In Washoe
County!
for more information
www.co.washoe.nv.us/health/cchs
A special thanks to Jane Harper, MS, at Minnesota
Department of Health for providing most of the
information in this presentation
Learning Objectives
• List two types of germs that cause
common childhood respiratory
illnesses
• State what antibiotics cannot do if
you are sick with a viral infection
• List comfort measures that can help
children with viral infections feel
better (hint: an antibiotic is not one
of them!)
Learning Objectives
• Name one myth and one fact about
antibiotic use
• List 3 steps childcare providers can
take to help keep antibiotics working
• Name one bacterial illness which can
be prevented by proper immunization
• State the most effective way to prevent
the spread of all infections in childcare
Take Home Messages
• Viruses cause most common
childhood respiratory illnesses
• Viral illnesses need time to heal antibiotics cannot help
Take Home Messages
• Taking antibiotics for viral illnesses
will not:
– cure the infection
– keep others from getting the
illness
– make you feel better
And may lead to antibiotic-resistant
bacteria
Take Home Messages
• Comfort measures ease symptoms of
viral illnesses (extra fluids, rest, a
vaporizer, a smoke-free environment)
• Sick children should stay home until
fever-free and able to participate in
routine activities without more care than
usual from childcare staff
• Always wash your hands - and help
children wash theirs!
• Keep immunizations up to date
Bottom Line
• Antibiotics are powerful medicines,
but they're not always the answer!
• Misusing antibiotics now means
they may not work when needed
later to fight a bacterial infection
• Help keep antibiotics working!
Education & Post-Test
• The three centers have completed
the education and post-testing
• The nine individual providers will
be completed by May
Post-Test Survey Results
• 57 post-tests completed
• Average score: 89.5, standard deviation 12.9.
Range of score is 42-100. Full score 100.
(pre-test average: 75.1)
• Paired comparison result: Fifteen participated
in pre and post test. The average score was
improved by 13 before and after the education
(statistically significant---P=0.005 by pairing
sample T-test).
• 56/57 (98%) participants indicated on their
post-tests that the presentation was very useful
THE RURAL EXPERIENCE
LYNN EVANS, LPN
ANTHEM BLUE CROSS & BLUE
SHIELD
MY ASSOCIATION
WITH THE NAA
• SUB-COMMITTEES
• PHYSICIAN OFFICE SITE REVIEWS
ROADBLOCKS ALONG
THE WAY
• TRAVELING LITE
• WEATHER
• WHO IS THE NAA?
WHAT I HAVE
ACCOMPLISHED
• GETTING THE INFORMATION OUT
• INCREASED AWARENESS
ELKO, WINNEMUCCA, CARLIN, FALLON,
YERRINGTON, WELLINGTON, DAYTON,
SILVER SPRINGS, GERLACH, CARSON CITY,
GARDNERVILLE, MINDEN, FERNLEY,
STATE LINE, LAKE TAHOE,
HAWTHORNE, LAUGHLIN, MESQUITE,
PAHRUMP
MY MOST
MEMORABLE RURAL
VISIT
• MOST “FAR OUT” PLACE
FUTURE PLANS
• THE “RURAL SWEEP”
• FROM TONOPAH TO RENO
Measuring the Appropriate
Use of Antibiotics
Mary Hothem, R.N.
Anthem Blue Cross Blue Shield
April 9, 2004
HEDIS--Who, What & How
• Administered by NCQA
• Used by most HMO’s across the country to
measure plan performance
• Standardized methodology and comprehensive
audit checks to ensure comparability
• In Nevada, Aetna, Health Plan of Nevada, IHC
Health Plans, and Pacificare, already publicly
report results
• HMO Nevada does not currently publicly
report results due to size, although does collect
the data
New to HEDIS 2004
• Appropriate Treatment of Children
With Upper Respiratory Infection
– Children age 3 months to 18 years
– Outpatient visit with diagnosis of URI
(460 or 465) ONLY (no secondary
diagnosis
– % with no prescription for antibiotic 30
days before visit date or 3 days after
visit date
New to HEDIS 2004
• Appropriate Testing for Children With
Pharyngitis
– Children age 2 to 18 years
– Outpatient visit with diagnosis of
pharyngitis (462, 463, 034.0), ONLY
– Received a prescription for antibiotic 3
days before visit date to 3 days after visit
date
– % that also had a group A streptococcus
test
Considerations for NAA
• This may be a way to measure the
effectiveness of FUTURE
interventions
• Would allow for benchmarking
current Nevada practice patterns with
other states / regions
• Would allow for benchmarking across
health plans and identify best
practices
Antimicrobial Resistance
Surveillance Project
Linda Verchick, MS
Clark County Health District – Office of
Epidemiology
Nevadans for Antibiotic Awareness Surveillance
Committee
Antimicrobial Resistance
Surveillance Project - 2000
through 2003
•
•
•
•
Initial Surveillance
Surveillance of six organisms
Data collected from three county facilities
– Major laboratory
– Two major hospitals
Data reported quarterly
Provided some community information
Antimicrobial Resistance
Surveillance Project - 2000
through 2003
Initial Surveillance Drawbacks
• Limited number of organisms and antibiotics
surveyed
• No elimination of duplicate reports
• Limited patient information
• Data entry time consuming
Antimicrobial Resistance
Surveillance Project - 2000
through 2003
Surveillance Organisms
•
•
•
•
•
•
Streptococcus pneumoniae
Staphylococcus aureus (coag +)
Pseudomonas aeruginosa
Acinetobacter calcoaceticus
Enterococcus faecium
Enterococcus faecalis
Streptococcus pneumoniae Percent Susceptibility to
Penicillin - Clark County, NV 2000-2003
Susceptibility (%)
100
80
60
40
20
0
2000
2001
2002
Year
2003
Susceptibility (%)
Streptococcus pneumoniae Percent Susceptibility to
Cefotaxime - Clark County, NV 2000-2003
100
80
60
40
20
0
2000
2001
2002
Year
2003
Antimicrobial Resistance
Surveillance Project - 2004
New Surveillance Advantages
• Data electronically received
• Elimination of duplicates
• Antibiotic susceptibility from all positive
bacterial cultures from all sources
• Antibiotic susceptibility reported in
minimum inhibitory concentrations (mics)
Antimicrobial Resistance
Surveillance Project - 2004
New Surveillance Advantages
• More patient information available
– Inpatient/outpatient
– Gender and age
• Ten local hospitals/laboratories have agreed
to participate
Nevadans for Antibiotic
Awareness Surveillance
Project - 2004
New Surveillance Disadvantages
• Computer program design is time
consuming
• Technical difficulties obtaining data
• HIPAA misinterpretation
Nevadans for Antibiotic
Awareness Surveillance Project
2004
Goals
• Provide an antibiogram specific to each
participating facility
• Provide clinicians with a county wide
antibiogram
• Provide rapid reporting on a quarterly basis
• Identify emerging resistant organisms
Nevadans for Antibiotic
Awareness Surveillance Project
2004
Goals
• Follow resistance development within a
sensitivity category (S, I, R)
• Identify the development of resistance
within a patient
• Provide a better understanding of antibiotic
resistance in both community acquired and
nosocomial illness
Nevadans for
Antibiotic Awareness
Christine Petersen, MD, MBA
2004 Partner Conference
April 9, 2004
Nevada Antibiotic Usage
Trends
• Data collected from 4 health plans
• Represents 382,252 members throughout
the state
• Includes oral outpatient antibiotic scripts
• Excludes antifungals, topical and
antituberculosis medications
• Baseline year 2000 and the first 2 quarters
of 2001
Outpatient Antibiotic Scripts
per Member per Month
368,252 Health Plan Members
2000 –2003
2000
2001
2002
2003
0.085
0.080
0.075
0.070
0.065
0.060
0.055
0.050
0.045
Quarter 1
Quarter 2
Quarter 3
Quarter 4