WEBVTT

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&gt;&gt; Thank you for joining.

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We would, well, we would like
to welcome you to our annual CDC

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and Federal Office of Rural
Health Policy webinar,

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celebrating U.S.
Antibiotic Awareness Week

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and National Rural
Health Day This year,

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we are also partnering with the
Agency for Healthcare, Research

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and Quality, to showcase how the
AHRQ Safety Program Toolkit can

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be implemented in
critical access hospitals.

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My name is Linda Neuhauser,
and I am the pharmacist

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and acute care lead
for CDC's Office

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of Antibiotic Stewardship, and
I'll be the moderator today.

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And at this time, I would like
to introduce our speakers.

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Very thrilled to be
joined by Natalia Vargas,

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who is program lead for the
Medicare Beneficiaries Quality

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Improvement Program in
HRSA's Federal Office

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of Rural Health Policy, who
will discuss the recent efforts

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to support improvements

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in antibiotic use
in rural facilities.

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Next, we'll discuss
the four moments

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of antibiotic prescribing
in critical access hospitals

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with Dr. Melissa Miller, who
is a physician in the Division

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of Healthcare Associated
Infections in the Agency

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for Healthcare, Research
and Quality.

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Dr. Pranita Tamma is an
infectious disease physician

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and director of the Pediatric
Antimicrobial Stewardship

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Program at the Johns
Hopkins Hospital.

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And then Dr. Sara Cosgrove is
also an infectious diseases

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physician and director

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of the adult Antimicrobial
Stewardship Program

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at the Johns Hopkins Hospitals.

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At this time, I would
like to introduce Natalia

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to provide her presentation.

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&gt;&gt; Thank you, Linda.

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I really appreciate
the introduction.

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And would like to thank CDC

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for the opportunity
to be here today.

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I will be presenting our recent
efforts to support improvements

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in antibiotic use
in rural facilities.

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So, my goal with today's
presentation is to set the stage

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for what you will hear
next from the presenters

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that we have lined up today.

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And we have three
objectives to cover

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in this portion of the webinar.

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And that is first I would like
to review the national reach

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and overarching goals

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of our Medicare Beneficiaries
Quality Improvement Program.

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And then provide an overview
of the healthcare delivery

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and quality improvement
context in rural facilities.

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And then end with a short
discussion on how we aim

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to collaborate across levels
of the healthcare system

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so that we can reach
these program goals

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and improve quality of
care for rural populations.

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This is just to give you
a snapshot of what it's

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like to serve the hospitals
across the country, we have,

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where you see on the right
side, all of those dots,

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the colored dots on the map,

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are the critical access
hospitals that we serve.

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They comprise over 75%

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of overall hospitals
in the United States.

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We, through, and equip, are
able to support these hospitals

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in providing high quality
care to rural populations.

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These small hospitals are
limited to only 25 beds.

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So, unlike traditional
hospitals pay it

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through the perspective
payment system,

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Medicare pays critical access
hospitals based on each

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of the hospitals'
reported costs.

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Therefore, with this context,
you can, you can see that,

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you know, we tried to
really provide the support

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for this small rural
hospitals to report measures

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so that we can, we can use those
measures to improve quality

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of care for populations.

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The primary goal of our program
is to enhance the reporting

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of quality data, and then have
the hospitals use that data

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for quality improvement
activities,

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and support quality
improvement measurements

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and quality improvement
activities

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across all of those hospitals.

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We have about 1,350 hospitals

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that are currently
participating in our program.

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And through our program,

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we established this
national tracking system

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for the first time so
that these hospitals

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that are voluntarily report
quality measures to CMS are able

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to be supported through
our program,

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and have additional
access to funds

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that support quality
improvement activities.

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So, we work at the
intersection of various levels

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of the healthcare system.

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The national, state,
and facility levels.

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And antibiotic stewardship is
one of those successful examples

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of how we have used one of the
measures to enhance reporting,

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that then drives
improvements at the local level,

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at the hospital level,

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by expanding those
activities for quality.

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So, the healthcare delivery
context in rural facilities is

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that essentially we
have a mandate to serve

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over 60 million people
with very little resources.

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And unfortunately these
are competing priorities

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that we have access,
quality and costs,

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are always competing
in rural settings.

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So, what we hear most
in terms of challenges

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from our hospitals is
that there is scarcity

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of infectious disease
physicians and pharmacists.

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There is a little bit of
lack of provider engagement

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in antimicrobial stewardship due

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to the competing
priorities that I mentioned.

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We have also come
across deficiencies

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in staff understanding

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of antibiograms sensitivity
reports, drug classes,

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how to use antibiotics properly.

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And also we have
limited capabilities

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of EMRs to man data for QI.

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Despite all of these challenges,

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we have some real implementation
come examples here

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that I have linked for you.

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We are really focused on
pushing the accountability

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for optimizing antibiotic use
in critical access hospitals

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and increasing the
number of interventions

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at the hospital per week.

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Some hospitals have
also reported

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that through the implementation

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of antibiotic use
focused activities,

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they have reported
decreases in cases,

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but also they have
decreased the costs

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of purchasing antibiotics
at the hospital.

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Underpinning all of these
efforts is actually the

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collaboration approaches
that they have used

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for antibiotic stewardship, such
as sharing education, resources,

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and tools to better
equip the providers.

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And that strategy has been one
of the most successful ones

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to be used in critical
access hospital facilities

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to overcome those challenges

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and support those
implementation outcomes

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that I have outlined above.

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So, with that is of key
importance to our program

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that we better collaborate
across the levels

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of the healthcare system.

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And that is what brings
this presentation today.

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As you can see, we have joined
efforts with our CDC colleagues,

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with our, with agency
for healthcare research

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and quality colleagues,

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to really address the
improvement goals that we have

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in our program that
we see, you know,

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through this chart you can
see there is a microlevel,

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a mesolevel, and a macrolevel.

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This is adopted from
a pediatric,

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from an academic
pediatrics journal article.

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And basically what it does is
that it shows the connection

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for why it is important to have,

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to connect those dots
across the systems.

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We set priorities at the federal
level, but we most work together

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in order to reach those goals.

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We have to better understand the
role of managed care delivery

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at the mesolevel in order to
really impact what happens

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at the microlevel,
to provide evidence,

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evidence based treatments,
and services

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that support patient care

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and improve health
outcomes in rural areas.

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So, as we look ahead in our
program goals, we are hoping

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to identify all the
rural relevant measures

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that establish, in order

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to establish a curated
measure sent one

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of the broad priority areas

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that we have is actually
patient safety.

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So, the work that we're doing
in this space is very important.

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We also hope to continue
supporting critical access

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hospitals to report measures
that align with CMS IPP rules.

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And one of the priority areas
will involve antibiotic use.

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We also hope to continue
supporting the states

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in building capacity for
conducting QI, building the work

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that space has completed so
far as part of QI projects

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that they are implementing,
and co designing

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with the critical
access hospitals,

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including antibiotic
stewardship.

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And also integrating a systems
level approach to the work

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that we do to the
strategies that we implement

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at the program level,
which involves this type

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of collaboration today.

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So, today I'm just
really pleased to be here

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in celebrating what we call
National Rural Health Day,

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that is actually tomorrow.

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And the theme for this
year is driving change,

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going the extra mile.

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And that's what we're hoping
that this presentation brings

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to you today is just
driving changes

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in critical access
hospitals in a way

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that helps contextualize
the care that we support

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in this rural communities.

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So, with that, I will leave
my contact information here,

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and I will pass it onto
my colleague at AHRQ

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who will be speaking and
introducing herself next.

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So, Dr. Miller, thank you.

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&gt;&gt; Thank you, Natalia.

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And thank you to HRSA and to
CDC for having us here today.

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We are looking forward

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to sharing our toolkit
and work with you.

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Oh, and so today we're going
to review the overarching goals

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of the AHRQ safety program
for improving antibiotic use.

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We'll provide an overview
of the safety program,

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and review the findings from
the one year acute care AHRQ

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safety program.

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And discuss how to
apply the four moments

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of antibiotic decision making

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in clinical practice using
a case based approach

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for community acquired pneumonia
and urinary tract infections.

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So, first, to review the
overarching goals, next,

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antibiotic stewardship, or
antibiotic stewardship programs,

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or ASPs, have traditionally
used a top down approach

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to improve antibiotic use
in acute care settings.

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For example, an administrative
decision to use one antibiotic

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versus another, or a service
that guides the antibiotic use,

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such as, you know, a traditional
antibiotic stewardship program,

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our AHRQ safety program

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for improving antibiotic
use challenges this approach

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by equipping frontline
clinicians with tools

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to incorporate stewardship
practices

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into their daily
decision making.

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So, the AHRQ safety program

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for improving antibiotic
use aimed initially

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to improve antibiotic use in
acute care, long term care,

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and ambulatory care settings,
in a phased approach.

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What we're presenting today
represents the experiences

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of the first large cohort of
over 400 acute care hospitals,

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including critical
access hospitals.

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The goals were to assist
facilities with establishing

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or strengthening ASPs to provide
frontline clinicians with tools

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to incorporate stewardship
principles

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into routine decision making
by underscoring the importance

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of communication and teamwork
around antibiotic prescribing,

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and to equip frontline
clinicians with best practices

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in the diagnosis and treatment
of common infectious processes.

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So, next I'm going to hand
it over to my colleague,

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Dr. Pranita Tamma, to
provide you with an overview

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of the safety program.

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&gt;&gt; Thanks so much, Melissa.

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And I'm excited to talk
a little more in depth

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about the acute care portion
of the AHRQ safety program.

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So, just very briefly, this
was a one year program.

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It occurred in the
calendar year 2018.

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And the goal was to include at
least 250 acute care facilities

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across the United States.

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And recruitment efforts
included social media campaigns,

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engagement of federal partners,
including the CDC and HRSA

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and professional societies.

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And we invited either
retired hospitals,

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which was generally the case
for critical access hospitals,

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or individual units within
a hospital, to participate.

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And Sara Cosgrove and I
delivered all the webinars.

00:13:32.576 --> 00:13:36.116 A:middle
It was usually about
two webinars per month,

00:13:36.346 --> 00:13:38.256 A:middle
each delivered about three times

00:13:38.256 --> 00:13:40.426 A:middle
to accommodate different
work schedules,

00:13:40.426 --> 00:13:42.626 A:middle
and time zone differences.

00:13:42.626 --> 00:13:45.616 A:middle
And we invited all members
of the healthcare team

00:13:45.616 --> 00:13:48.846 A:middle
to participate, including
physicians, mid level providers,

00:13:48.846 --> 00:13:52.516 A:middle
pharmacists, nurses, and
anyone else who was involved

00:13:52.516 --> 00:13:55.076 A:middle
in the process of
antibiotic decision making.

00:13:55.396 --> 00:13:58.896 A:middle
We also included two
office hours every month

00:13:59.176 --> 00:14:02.396 A:middle
where participants had the
opportunity to ask questions

00:14:02.396 --> 00:14:04.986 A:middle
about implementing
stewardship programs,

00:14:04.986 --> 00:14:07.316 A:middle
or even just management
questions related

00:14:07.316 --> 00:14:09.406 A:middle
to particular patients.

00:14:09.406 --> 00:14:11.036 A:middle
And we were very
fortunate to partner

00:14:11.036 --> 00:14:14.036 A:middle
with quality improvement
experts that came

00:14:14.036 --> 00:14:15.716 A:middle
from health quality innovators,

00:14:15.716 --> 00:14:19.186 A:middle
health services advisory
group, and stratus health.

00:14:19.186 --> 00:14:21.546 A:middle
And one quality improvement
expert was assigned

00:14:21.546 --> 00:14:25.366 A:middle
to each participating hospital
to assist them with some

00:14:25.366 --> 00:14:28.796 A:middle
of the day to day stewardship
implementation work.

00:14:28.796 --> 00:14:31.036 A:middle
So, I'm going to
go a little further

00:14:31.036 --> 00:14:33.976 A:middle
into what actually took place
during the one year period.

00:14:34.046 --> 00:14:39.656 A:middle
And fortunately, AHRQ did a
very nice job on their website

00:14:39.656 --> 00:14:44.186 A:middle
of developing a toolkit where
the material can be accessed

00:14:44.186 --> 00:14:46.696 A:middle
so that even for sites
that didn't participate

00:14:46.696 --> 00:14:49.646 A:middle
in this one year program,
they would have the ability

00:14:49.646 --> 00:14:52.466 A:middle
to access all of the content
developed for the program.

00:14:52.466 --> 00:14:54.836 A:middle
And on the website,
there's some guidance

00:14:54.836 --> 00:14:57.926 A:middle
on how you could implement
the toolkit locally

00:14:57.926 --> 00:14:59.786 A:middle
to emulate the one year program.

00:14:59.786 --> 00:15:03.586 A:middle
So, just very briefly, there
were three general domains

00:15:03.586 --> 00:15:06.176 A:middle
as part of this acute
care safety program.

00:15:06.176 --> 00:15:08.426 A:middle
The first was assisting sites

00:15:08.426 --> 00:15:10.686 A:middle
with developing stewardship
programs.

00:15:10.796 --> 00:15:13.856 A:middle
Some sites did already
have a stewardship program

00:15:13.856 --> 00:15:16.616 A:middle
that was maybe in its early
phases, and we assisted them

00:15:16.616 --> 00:15:18.926 A:middle
with how they could sort of
take it to the next level.

00:15:18.926 --> 00:15:22.106 A:middle
Part of this involved
identifying a

00:15:22.106 --> 00:15:23.436 A:middle
leadership structure.

00:15:23.766 --> 00:15:29.006 A:middle
Ideally we preferred a
clinician and a pharmacist lead.

00:15:29.006 --> 00:15:31.276 A:middle
Not necessarily trained in
infectious diseases, because,

00:15:31.276 --> 00:15:34.046 A:middle
of course, that's just not
feasible in many sites.

00:15:34.046 --> 00:15:36.486 A:middle
And how they could
identify senior leadership

00:15:36.486 --> 00:15:40.696 A:middle
to Garner the support amongst
other healthcare practitioners

00:15:40.696 --> 00:15:42.416 A:middle
within that facility.

00:15:42.416 --> 00:15:46.106 A:middle
We also assisted them
with identifying how

00:15:46.466 --> 00:15:50.606 A:middle
to develop metrics to
collect data for metrics,

00:15:50.606 --> 00:15:52.356 A:middle
which I'll talk about.

00:15:52.356 --> 00:15:55.756 A:middle
And to use these metrics
by tracking them over time

00:15:55.756 --> 00:15:57.196 A:middle
to guide intervention.

00:15:57.196 --> 00:15:58.456 A:middle
So, for example, if you notice

00:15:58.456 --> 00:16:01.986 A:middle
that Vancomycin uses
extremely high in an ICU,

00:16:02.206 --> 00:16:04.226 A:middle
what kinds of interventions
can you think

00:16:04.226 --> 00:16:06.366 A:middle
about to help reduce that use.

00:16:06.366 --> 00:16:09.876 A:middle
The second main domain was
trying to develop a culture

00:16:09.876 --> 00:16:12.256 A:middle
of safety around
antibiotic prescribing.

00:16:12.346 --> 00:16:15.536 A:middle
We realize that a lot of times
there's a social etiquette

00:16:15.536 --> 00:16:16.776 A:middle
involved around prescribing

00:16:16.776 --> 00:16:20.886 A:middle
or perhaps one prescriber
starts an antibiotic,

00:16:20.886 --> 00:16:22.606 A:middle
and another clinician comes on

00:16:22.606 --> 00:16:25.356 A:middle
and might feel strange
stopping an antibiotic

00:16:25.356 --> 00:16:26.886 A:middle
if a colleague started it,

00:16:26.886 --> 00:16:28.696 A:middle
because it might be
deemed disrespectful.

00:16:28.696 --> 00:16:34.946 A:middle
Or perhaps during clinical
rounds, a physician is rounding,

00:16:34.946 --> 00:16:38.386 A:middle
assessing the patient, and
a nurse might feel a little,

00:16:38.386 --> 00:16:39.906 A:middle
might not feel as
empowered to mention

00:16:39.906 --> 00:16:40.976 A:middle
that the patient is
still on Vancomycin.

00:16:41.076 --> 00:16:44.686 A:middle
Is this really still necessary?

00:16:44.686 --> 00:16:47.236 A:middle
So, we wanted to help
with improving teamwork

00:16:47.236 --> 00:16:49.516 A:middle
and communication between
healthcare providers,

00:16:49.516 --> 00:16:52.336 A:middle
as well as between healthcare
providers and patients

00:16:52.336 --> 00:16:55.706 A:middle
and families who might be
expecting an antibiotic.

00:16:55.706 --> 00:16:58.666 A:middle
And finally, the
third domain dealt

00:16:58.666 --> 00:17:01.676 A:middle
with teaching frontline
providers

00:17:01.676 --> 00:17:05.256 A:middle
with learning best practices in
the management and the diagnosis

00:17:05.256 --> 00:17:08.346 A:middle
and management of common
infectious diseases syndromes.

00:17:08.346 --> 00:17:12.096 A:middle
And we've decided to focus on
syndromes and nonantibiotics

00:17:12.096 --> 00:17:14.706 A:middle
because clinicians are
generally much more excited

00:17:14.706 --> 00:17:19.346 A:middle
if you say would you like to
learn about the latest data

00:17:19.536 --> 00:17:23.246 A:middle
in managing community acquired
pneumonia versus would you

00:17:23.246 --> 00:17:26.786 A:middle
like to learn how to use
Vancomycin more appropriately.

00:17:26.786 --> 00:17:29.746 A:middle
And for all of the
syndrome based content,

00:17:29.826 --> 00:17:33.496 A:middle
we organize the material using
a framework we developed as part

00:17:33.496 --> 00:17:35.526 A:middle
of this program called
the four moments

00:17:35.526 --> 00:17:39.016 A:middle
of antibiotic decision
making, which I'll summarize.

00:17:39.016 --> 00:17:44.456 A:middle
So, this is a snapshot
of, from the AHRQ website.

00:17:44.456 --> 00:17:47.016 A:middle
In the develop and improve
stewardship content that's

00:17:47.016 --> 00:17:49.996 A:middle
really targeting the
stewardship leader, so, again,

00:17:49.996 --> 00:17:55.056 A:middle
ideally a clinician and a
pharmacist, a physician,

00:17:55.056 --> 00:17:57.646 A:middle
and if a physician's not
available, a mid level provider,

00:17:57.646 --> 00:18:00.226 A:middle
like a nurse practitioner
or physician assistant,

00:18:00.226 --> 00:18:03.306 A:middle
along with a pharmacist,
and we have content in how

00:18:03.306 --> 00:18:06.826 A:middle
to develop the program,
how to effective,

00:18:06.866 --> 00:18:09.426 A:middle
make behavior /KHAEUFPBLGZ
around prescribing.

00:18:09.426 --> 00:18:11.666 A:middle
And after the program
is developed,

00:18:11.666 --> 00:18:14.986 A:middle
have a sustained
stewardship activities

00:18:14.986 --> 00:18:16.946 A:middle
so that this program
will continue

00:18:16.946 --> 00:18:19.306 A:middle
to exist and be impactful.

00:18:19.306 --> 00:18:22.746 A:middle
And these content are available

00:18:22.746 --> 00:18:25.686 A:middle
as PowerPoint slides
on the website.

00:18:25.766 --> 00:18:27.896 A:middle
There's also what we
call facilitator guide,

00:18:27.896 --> 00:18:31.646 A:middle
which includes a detailed
script for each slide,

00:18:31.646 --> 00:18:34.436 A:middle
so that the content
can be used locally.

00:18:34.436 --> 00:18:38.206 A:middle
In terms of the developing
culture of safety

00:18:38.206 --> 00:18:43.216 A:middle
around prescribing, there's
four targeted PowerPoint slides

00:18:43.216 --> 00:18:43.976 A:middle
with facilitator guides.

00:18:44.826 --> 00:18:48.676 A:middle
For each of these, and these
are targeting mostly frontline

00:18:48.676 --> 00:18:52.886 A:middle
providers, for each of these,
we used case based approaches,

00:18:52.936 --> 00:18:55.366 A:middle
because we think that that's
probably most engaging

00:18:55.366 --> 00:18:57.086 A:middle
to healthcare providers.

00:18:57.086 --> 00:19:00.716 A:middle
And finally, for best
practices, as you can see here,

00:19:00.716 --> 00:19:02.536 A:middle
we target a variety of syndromes

00:19:02.536 --> 00:19:04.946 A:middle
that we think are
common problems,

00:19:04.946 --> 00:19:06.926 A:middle
both in large academic
facilities,

00:19:06.926 --> 00:19:11.016 A:middle
as well as small critical
care access hospitals.

00:19:11.016 --> 00:19:13.996 A:middle
And for all of these, again,
we have slides available,

00:19:13.996 --> 00:19:15.886 A:middle
as well as the facilitator
guide.

00:19:15.886 --> 00:19:20.146 A:middle
And we also have several other
types of content available,

00:19:20.146 --> 00:19:21.836 A:middle
which I'll show you in
the next few slides.

00:19:21.836 --> 00:19:25.636 A:middle
But for all of these
best practices topics,

00:19:25.856 --> 00:19:27.656 A:middle
we Lutz what we call
the four moments

00:19:27.656 --> 00:19:29.366 A:middle
of antibiotic decision making.

00:19:29.366 --> 00:19:31.806 A:middle
So, these are the four moments

00:19:31.806 --> 00:19:37.056 A:middle
when we think clinicians
should review when deciding

00:19:37.056 --> 00:19:38.536 A:middle
if a patient needs antibiotics,

00:19:38.536 --> 00:19:41.066 A:middle
and if antibiotics
need to be continued.

00:19:41.066 --> 00:19:44.666 A:middle
So, very briefly, the
first moment asks,

00:19:44.666 --> 00:19:46.546 A:middle
does my patient have
an infection

00:19:46.546 --> 00:19:48.006 A:middle
that requires antibiotics?

00:19:48.006 --> 00:19:52.136 A:middle
And this might just be stopping
and thinking about the patients.

00:19:52.136 --> 00:19:54.326 A:middle
Maybe the patient has a cough.

00:19:54.586 --> 00:19:56.346 A:middle
Maybe they're having a
little bit of chest pain.

00:19:56.346 --> 00:19:58.546 A:middle
But is this a pulmonary
embolism?

00:19:58.546 --> 00:20:00.116 A:middle
Is this congestive
heart failure?

00:20:00.116 --> 00:20:02.696 A:middle
Doesn't necessarily have
to be bacterial pneumonia.

00:20:02.696 --> 00:20:05.276 A:middle
So, it's really asking
clinicians to stop

00:20:05.276 --> 00:20:07.196 A:middle
and think about, is it
more likely than not

00:20:07.196 --> 00:20:10.106 A:middle
that this patient has
a bacterial infection.

00:20:10.416 --> 00:20:13.006 A:middle
The second moment
has two questions.

00:20:13.006 --> 00:20:15.306 A:middle
Have I ordered appropriate
cultures before

00:20:15.306 --> 00:20:16.636 A:middle
starting antibiotics?

00:20:16.636 --> 00:20:19.156 A:middle
For example, do I
need blood cultures?

00:20:19.156 --> 00:20:20.346 A:middle
Do I need urine cultures?

00:20:20.346 --> 00:20:21.856 A:middle
Do I need a sputum culture?

00:20:21.856 --> 00:20:26.076 A:middle
And the second question asks
what empiric therapy should

00:20:26.076 --> 00:20:27.266 A:middle
I initiate?

00:20:27.266 --> 00:20:32.676 A:middle
And for each of the infectious
syndromes, we include guidance

00:20:32.676 --> 00:20:34.976 A:middle
on what we would
consider empiric therapy

00:20:34.976 --> 00:20:37.316 A:middle
for your routine patients.

00:20:37.316 --> 00:20:38.606 A:middle
And then what about patients

00:20:38.606 --> 00:20:41.916 A:middle
who might have a severe
Penicillin allergy, who might,

00:20:41.916 --> 00:20:46.116 A:middle
maybe there's concerns for MRSA
or concerns for pseudomonas.

00:20:46.116 --> 00:20:47.326 A:middle
And in those patients,

00:20:47.326 --> 00:20:49.976 A:middle
the empiric therapy
regimens might be different.

00:20:50.026 --> 00:20:52.416 A:middle
The third moments
has three questions.

00:20:52.416 --> 00:20:55.836 A:middle
After more clinical and
diagnostic data are available.

00:20:55.836 --> 00:20:58.816 A:middle
And these include can I stop
antibiotics, particularly

00:20:58.816 --> 00:21:00.286 A:middle
if cultures are negative,

00:21:00.286 --> 00:21:03.116 A:middle
and an alternative diagnosis
has been established.

00:21:03.186 --> 00:21:05.146 A:middle
Can I narrow therapy or change

00:21:05.146 --> 00:21:08.456 A:middle
from an intravenous
to an oral agent?

00:21:08.456 --> 00:21:11.426 A:middle
And finally, the fourth
question asks about the duration

00:21:11.426 --> 00:21:12.866 A:middle
of antibiotic therapy.

00:21:12.866 --> 00:21:17.896 A:middle
For all of the best practices
topics, we include evidence

00:21:17.896 --> 00:21:21.886 A:middle
that supports what the
available data suggests in terms

00:21:21.886 --> 00:21:24.866 A:middle
of effective durations
of antibiotic therapy.

00:21:24.866 --> 00:21:29.916 A:middle
And then, again, for each
of the topics as an example,

00:21:29.916 --> 00:21:32.786 A:middle
we have what we call
a one page document

00:21:32.836 --> 00:21:35.196 A:middle
that summarizes some
of the data.

00:21:35.306 --> 00:21:38.206 A:middle
These are editable
on the website

00:21:38.546 --> 00:21:43.186 A:middle
so that local sites can
include recommendations here

00:21:43.286 --> 00:21:44.976 A:middle
and make these their local
treatment guidelines.

00:21:45.046 --> 00:21:47.766 A:middle
Alternatively, you
could delete these sort

00:21:47.766 --> 00:21:52.006 A:middle
of place local recommendations
here sections and post these

00:21:52.006 --> 00:21:55.786 A:middle
in common work areas, send
them as e mails or other ways

00:21:55.786 --> 00:21:57.246 A:middle
to disseminate this knowledge

00:21:57.406 --> 00:22:00.206 A:middle
between the healthcare
providers in your facility.

00:22:01.086 --> 00:22:04.496 A:middle
We also include commitments
posters on the website.

00:22:04.496 --> 00:22:08.956 A:middle
And we suggest that people
put the pictures of providers,

00:22:08.956 --> 00:22:12.656 A:middle
their signatures, maybe pictures
and signatures of leadership.

00:22:12.656 --> 00:22:15.066 A:middle
And this is meant to
show that to patients,

00:22:15.066 --> 00:22:17.356 A:middle
as well as to just all
healthcare providers

00:22:17.356 --> 00:22:20.116 A:middle
within the institution,
that your facility committed

00:22:20.116 --> 00:22:22.736 A:middle
to the judicious
use of antibiotics.

00:22:22.736 --> 00:22:25.956 A:middle
And similar to this commitment
poster, we also have posters

00:22:25.956 --> 00:22:28.276 A:middle
with the four moments,
screensavers

00:22:28.276 --> 00:22:32.536 A:middle
for the four moments that are
available on the AHRQ websites.

00:22:32.536 --> 00:22:35.186 A:middle
And then another
document we developed

00:22:35.186 --> 00:22:37.996 A:middle
that we thought was particularly
helpful in settings a lot

00:22:37.996 --> 00:22:41.776 A:middle
of critical access hospitals are
what we call the team antibiotic

00:22:41.776 --> 00:22:42.606 A:middle
review forum.

00:22:42.606 --> 00:22:45.926 A:middle
So, the goal of these forums
would be every month we would

00:22:45.926 --> 00:22:50.146 A:middle
ask sites to retrospectively
pick five, ten patients

00:22:50.426 --> 00:22:53.706 A:middle
who are receiving antibiotics,
and as a group to go

00:22:53.706 --> 00:22:57.236 A:middle
through these questions that use
the format of the four moments,

00:22:57.236 --> 00:22:59.366 A:middle
so that you can look
for areas for maybe

00:22:59.366 --> 00:23:02.466 A:middle
where there should be
improvement for the next patient

00:23:02.466 --> 00:23:03.706 A:middle
who started antibiotics.

00:23:03.706 --> 00:23:07.056 A:middle
So, it might be caught that
perhaps Vancomycin was continued

00:23:07.056 --> 00:23:09.386 A:middle
for too long, or
a duration longer

00:23:09.386 --> 00:23:11.716 A:middle
than the evidence suggests
is necessary might have

00:23:11.716 --> 00:23:12.396 A:middle
been prescribed.

00:23:12.396 --> 00:23:16.896 A:middle
And the hope would be that as a
group, again, including nursing,

00:23:16.896 --> 00:23:20.426 A:middle
pharmacists, physicians, and
anyone at a team meeting,

00:23:20.426 --> 00:23:22.306 A:middle
that lessons could be learned

00:23:22.306 --> 00:23:24.196 A:middle
to improve care for
the next patient.

00:23:24.196 --> 00:23:27.256 A:middle
So, for the sites
that participated

00:23:27.256 --> 00:23:29.526 A:middle
in this one year program.

00:23:29.876 --> 00:23:34.276 A:middle
We requested that they submitted
antibiotic use data as days

00:23:34.276 --> 00:23:37.086 A:middle
of antibiotic therapy for
per thousands patient days,

00:23:37.086 --> 00:23:39.836 A:middle
and they submitted these
data on a monthly basis.

00:23:40.286 --> 00:23:46.806 A:middle
We also requested the submitted
C difficile lab ID event per

00:23:46.806 --> 00:23:48.216 A:middle
10,000 patient days.

00:23:48.216 --> 00:23:49.696 A:middle
So, basically this is looking

00:23:49.696 --> 00:23:53.556 A:middle
for if a lab test indicated
positive C difficile testing,

00:23:53.556 --> 00:23:56.036 A:middle
of course this is
not a perfect proxy

00:23:56.036 --> 00:23:58.016 A:middle
for clinical C difficile
infections,

00:23:58.016 --> 00:24:00.926 A:middle
because some patients might
be colonized, but we thought

00:24:00.926 --> 00:24:03.006 A:middle
that this would still be
helpful to get a sense

00:24:03.006 --> 00:24:05.706 A:middle
of if we could impact
C difficile rates

00:24:05.756 --> 00:24:07.976 A:middle
by reducing antibiotic use,

00:24:07.976 --> 00:24:10.936 A:middle
or really optimizing
antibiotic use, I should say.

00:24:10.936 --> 00:24:15.566 A:middle
And then we requested up to 10
team antibiotic review forums

00:24:15.566 --> 00:24:16.186 A:middle
per month.

00:24:16.406 --> 00:24:19.266 A:middle
For some hospitals, particularly
critical access hospitals,

00:24:19.386 --> 00:24:20.756 A:middle
they might have actually
had less

00:24:20.756 --> 00:24:21.976 A:middle
than 10 patients a
month on antibiotics.

00:24:22.176 --> 00:24:26.016 A:middle
And, of course, that was
perfectly acceptable too.

00:24:26.016 --> 00:24:31.106 A:middle
And for all sites, and we talk
a lot about on the website how

00:24:31.106 --> 00:24:34.516 A:middle
to collect the data, how to
report data to clinicians

00:24:34.516 --> 00:24:38.446 A:middle
within your institution,
but we, what we would do

00:24:38.446 --> 00:24:42.266 A:middle
with the program was
feedback quarterly reports

00:24:42.356 --> 00:24:44.746 A:middle
so you could compare
yourself over time,

00:24:44.746 --> 00:24:47.616 A:middle
and also compare yourself
to like facilities.

00:24:47.616 --> 00:24:50.156 A:middle
So, for example, for
critical access hospitals,

00:24:50.156 --> 00:24:53.356 A:middle
we compared them to other
critical access hospitals.

00:24:53.356 --> 00:24:56.796 A:middle
And, of course, not large
academic medical centers.

00:24:57.036 --> 00:25:00.446 A:middle
I'll move on to very
briefly summarized findings

00:25:00.446 --> 00:25:03.676 A:middle
of the project before I hand
it over to Sara Cosgrove.

00:25:03.676 --> 00:25:06.216 A:middle
But there were 402 hospitals

00:25:06.216 --> 00:25:08.636 A:middle
that completed the one
year safety program.

00:25:08.836 --> 00:25:12.176 A:middle
Over 90% of facilities
that started the program,

00:25:12.176 --> 00:25:14.206 A:middle
which we were very happy to see.

00:25:14.206 --> 00:25:17.076 A:middle
And for those that weren't
able to complete it was often

00:25:17.076 --> 00:25:19.556 A:middle
because they had staff turnover,

00:25:19.556 --> 00:25:21.796 A:middle
didn't have the resources
to stay engaged.

00:25:21.796 --> 00:25:26.056 A:middle
In terms of the types of
hospitals that participated,

00:25:26.056 --> 00:25:28.856 A:middle
about 20% were critical
access hospitals.

00:25:28.856 --> 00:25:32.706 A:middle
And about 40% of hospitals
had less than 100 beds.

00:25:32.706 --> 00:25:36.676 A:middle
So, it was really a variety
of types of hospitals

00:25:36.676 --> 00:25:38.326 A:middle
that participated
in the program.

00:25:38.576 --> 00:25:42.986 A:middle
And what we saw was that
antibiotic use decreased

00:25:42.986 --> 00:25:44.366 A:middle
in that, in that first quarter,

00:25:44.366 --> 00:25:46.876 A:middle
and then this first quarter
we were actually relatively

00:25:46.876 --> 00:25:49.026 A:middle
aggressive with the
number of webinars

00:25:49.026 --> 00:25:51.246 A:middle
and engagement we
had with sites.

00:25:51.246 --> 00:25:54.486 A:middle
And then after that
antibiotic use plateaued,

00:25:54.486 --> 00:25:57.676 A:middle
and basically stayed
relatively consistent.

00:25:57.676 --> 00:26:01.026 A:middle
We actually were able to
compare these data with data

00:26:01.026 --> 00:26:03.126 A:middle
from premier, which
included large number

00:26:03.126 --> 00:26:05.446 A:middle
of hospitals not
participating in the program.

00:26:05.446 --> 00:26:09.776 A:middle
And basically that data
suggested that antibiotic use

00:26:09.776 --> 00:26:13.386 A:middle
in nonparticipating
programs started off high

00:26:13.386 --> 00:26:16.956 A:middle
and remained relatively
consistent [inaudible] the

00:26:16.956 --> 00:26:17.436 A:middle
one year.

00:26:17.436 --> 00:26:20.906 A:middle
So, they didn't have this sort
of drop in that first quarter.

00:26:20.906 --> 00:26:22.726 A:middle
Now, obviously it's not
a perfect comparison,

00:26:22.726 --> 00:26:26.006 A:middle
but it just gives you a sense
of what was happening nationally

00:26:26.186 --> 00:26:28.166 A:middle
in other institutions
at the same time.

00:26:28.166 --> 00:26:32.856 A:middle
We did find that antibiotic
use significantly decreased

00:26:32.856 --> 00:26:37.076 A:middle
when we looked at the
data in various subgroups.

00:26:37.076 --> 00:26:39.726 A:middle
And I highlighted in red here
critical access hospitals

00:26:39.726 --> 00:26:43.266 A:middle
where we did see a significant
reduction in antibiotic use.

00:26:43.266 --> 00:26:46.566 A:middle
And also across the cohort,
we saw significant reduction

00:26:46.566 --> 00:26:48.836 A:middle
in C difficile lab ID rates.

00:26:48.836 --> 00:26:50.956 A:middle
So, I'll hand is over to Sara.

00:26:51.106 --> 00:26:54.726 A:middle
And before I do so, again,
I just want to stress

00:26:54.726 --> 00:26:59.706 A:middle
that we really do encourage
people to go to the AHRQ website

00:26:59.976 --> 00:27:02.316 A:middle
to look at the content
of this program,

00:27:02.316 --> 00:27:05.616 A:middle
because I really do think that
there's, this can be sizeable,

00:27:05.616 --> 00:27:07.316 A:middle
scalable for all institutions,

00:27:07.316 --> 00:27:09.356 A:middle
including critical
access hospitals.

00:27:09.716 --> 00:27:10.826 A:middle
So, thank you very much.

00:27:12.276 --> 00:27:14.186 A:middle
&gt;&gt; Thanks, Pranita.

00:27:14.286 --> 00:27:17.706 A:middle
We'll start the last portion
of this with a clinical case.

00:27:18.026 --> 00:27:21.246 A:middle
And then basically
go through this case,

00:27:21.246 --> 00:27:24.036 A:middle
showing how you could
apply the four moments

00:27:24.196 --> 00:27:28.396 A:middle
in everyday decision
making around antibiotics.

00:27:28.456 --> 00:27:31.926 A:middle
So, this is a case in a 54
year old man with diabetes

00:27:31.926 --> 00:27:36.436 A:middle
and hypertension who presents
with two days of fever, a cough,

00:27:36.506 --> 00:27:38.366 A:middle
and left sided chest pain.

00:27:38.366 --> 00:27:40.176 A:middle
He's febrile.

00:27:40.356 --> 00:27:42.216 A:middle
His blood pressure
is fairly normal.

00:27:42.396 --> 00:27:44.546 A:middle
But his heart rate is elevated.

00:27:44.546 --> 00:27:48.716 A:middle
And his respiratory rate at
24 is certainly elevated.

00:27:48.896 --> 00:27:53.446 A:middle
He has a normal oxygen
saturation of 95% [inaudible].

00:27:53.876 --> 00:27:58.936 A:middle
And on other [inaudible]
exam, he's tired, appearing,

00:27:59.166 --> 00:28:03.226 A:middle
and has crackles over the
lower left lung field.

00:28:04.166 --> 00:28:07.366 A:middle
So, going through
the four moments,

00:28:07.366 --> 00:28:10.056 A:middle
remember that the first moment
is does my patient have an

00:28:10.056 --> 00:28:12.396 A:middle
infection that requires
antibiotics.

00:28:12.496 --> 00:28:18.116 A:middle
So, thinking about this patient,
he needs a lot of criteria

00:28:18.116 --> 00:28:19.736 A:middle
for community acquired
pneumonia.

00:28:19.736 --> 00:28:23.156 A:middle
And, therefore, in
him, CAP is likely.

00:28:23.156 --> 00:28:27.466 A:middle
But if some of this presentation
were slightly different,

00:28:27.656 --> 00:28:29.486 A:middle
he might actually have something

00:28:29.486 --> 00:28:34.306 A:middle
that is not community acquired
pneumonia, and may mimic some

00:28:34.306 --> 00:28:36.686 A:middle
of the signs and symptoms of
community acquired pneumonia,

00:28:36.686 --> 00:28:38.486 A:middle
so we always say, you know,

00:28:38.486 --> 00:28:40.256 A:middle
think about other
potential causes

00:28:40.256 --> 00:28:42.016 A:middle
of someone's presentation.

00:28:42.246 --> 00:28:44.246 A:middle
And just some examples of things

00:28:44.246 --> 00:28:47.316 A:middle
that would also be
considerations

00:28:47.316 --> 00:28:50.046 A:middle
on the differential here
are viral respiratory tract

00:28:50.046 --> 00:28:52.936 A:middle
infections, aspiration,
pneumonitis,

00:28:53.076 --> 00:28:56.666 A:middle
chronic obstructive pulmonary
disease exacerbation,

00:28:56.666 --> 00:28:58.886 A:middle
asthma exacerbation,
congestive heart failure,

00:28:58.886 --> 00:29:00.086 A:middle
and pulmonary embolism.

00:29:00.086 --> 00:29:02.856 A:middle
I'm not saying that
that's what I think he has.

00:29:03.106 --> 00:29:05.796 A:middle
But a lot of times people
present with symptoms

00:29:05.796 --> 00:29:08.776 A:middle
that are a little more
nonspecific than what he has.

00:29:08.986 --> 00:29:12.156 A:middle
And so these other items
should certainly be

00:29:12.156 --> 00:29:14.916 A:middle
on the differential,
and the majority

00:29:14.916 --> 00:29:19.976 A:middle
of them do not require
antibiotic therapy.

00:29:20.226 --> 00:29:22.176 A:middle
You know, and I think our
next [inaudible] management

00:29:22.176 --> 00:29:24.816 A:middle
of this patient would be
to obtain a chest x ray.

00:29:24.816 --> 00:29:27.776 A:middle
And it's also important to
know while you're thinking

00:29:27.776 --> 00:29:30.426 A:middle
about does the patient
need antibiotics or not

00:29:30.426 --> 00:29:34.336 A:middle
that if there's no infiltrate on
a chest x ray, with the patient

00:29:34.336 --> 00:29:36.916 A:middle
in general, it's
much less likely

00:29:36.916 --> 00:29:38.426 A:middle
to have community
acquired pneumonia.

00:29:38.736 --> 00:29:40.956 A:middle
So, moving on to moment two,

00:29:40.956 --> 00:29:43.246 A:middle
remember moment two
has two questions.

00:29:43.246 --> 00:29:45.346 A:middle
Have I ordered appropriate
cultures before

00:29:45.346 --> 00:29:47.146 A:middle
starting antibiotics?

00:29:47.276 --> 00:29:50.496 A:middle
And what empiric therapy
should I initiate?

00:29:50.656 --> 00:29:51.816 A:middle
Remembering, of course,

00:29:51.816 --> 00:29:55.156 A:middle
that empiric therapy
ideally should be based

00:29:55.156 --> 00:29:58.436 A:middle
on local empiric
treatment guidelines

00:29:58.436 --> 00:30:00.966 A:middle
that have been developed
by the stewardship program

00:30:00.966 --> 00:30:03.536 A:middle
in conjunction with
frontline providers.

00:30:03.536 --> 00:30:06.416 A:middle
So, first with diagnostic
testing

00:30:06.416 --> 00:30:07.966 A:middle
in community acquired pneumonia.

00:30:07.966 --> 00:30:11.656 A:middle
A sputum gram stain and
culture is recommended

00:30:11.656 --> 00:30:15.026 A:middle
if the patient is able
to produce sputum.

00:30:15.496 --> 00:30:18.006 A:middle
And blood cultures are really

00:30:18.006 --> 00:30:21.036 A:middle
at this point not
recommended for all patients.

00:30:21.826 --> 00:30:25.296 A:middle
They used to be part of
a core measure that led

00:30:25.506 --> 00:30:28.256 A:middle
to people getting blood cultures
all the time in patients

00:30:28.256 --> 00:30:29.686 A:middle
with community acquired
pneumonia.

00:30:29.686 --> 00:30:32.546 A:middle
That is no longer a requirement.

00:30:32.546 --> 00:30:35.416 A:middle
However, if the patient
is quite ill,

00:30:35.416 --> 00:30:38.966 A:middle
or they have any abnormal
chest imaging findings,

00:30:38.966 --> 00:30:41.506 A:middle
such as a long abscess or
a parapneumonic infusion,

00:30:41.506 --> 00:30:42.976 A:middle
then it's reasonable to
consider blood cultures.

00:30:43.046 --> 00:30:46.616 A:middle
But in the average patient
presenting with CAP,

00:30:46.766 --> 00:30:49.286 A:middle
blood cultures are likely
to be a very low yield.

00:30:49.286 --> 00:30:54.156 A:middle
It also can be useful to obtain
a respiratory virus panel,

00:30:54.426 --> 00:30:57.496 A:middle
because that can be an
alternative explanation

00:30:57.496 --> 00:30:59.186 A:middle
for our patient's
clinical symptoms,

00:30:59.186 --> 00:31:02.016 A:middle
particularly during
respiratory virus season.

00:31:02.696 --> 00:31:04.266 A:middle
And, you know, in institutions

00:31:04.266 --> 00:31:07.966 A:middle
that have the strep
pneumourinary antigen test,

00:31:08.226 --> 00:31:09.726 A:middle
that can be considered.

00:31:09.896 --> 00:31:12.356 A:middle
Many institutions don't
have this available.

00:31:12.356 --> 00:31:16.956 A:middle
We actually do use it in our
institution, because we find

00:31:16.956 --> 00:31:19.956 A:middle
that it can be helpful
if positive to say

00:31:19.956 --> 00:31:22.526 A:middle
that the patient has
pneumococcal pneumonia

00:31:22.656 --> 00:31:25.346 A:middle
and not some other kind of
pneumonia, and that allows us

00:31:25.346 --> 00:31:29.856 A:middle
to comfortably narrow antibiotic
therapy to Amoxicillin.

00:31:29.856 --> 00:31:33.556 A:middle
And then, again, on the, on the
theme of urinary antigen tests,

00:31:33.556 --> 00:31:37.066 A:middle
if Legionella urinary
antigen testing is available,

00:31:37.066 --> 00:31:39.676 A:middle
it can be considered for
patients with moderate

00:31:39.676 --> 00:31:43.076 A:middle
to severe symptoms,
people who smoke,

00:31:43.236 --> 00:31:47.676 A:middle
immunocompromised patients, or
patients over 50 years of age.

00:31:48.856 --> 00:31:52.046 A:middle
So, remember the other part of
moment two is empiric therapy.

00:31:52.046 --> 00:31:54.806 A:middle
Empiric therapy for
community acquired pneumonia

00:31:54.806 --> 00:31:59.916 A:middle
in the United States is largely
driven by existing guidelines

00:31:59.916 --> 00:32:02.436 A:middle
from the American
Thoracic Society

00:32:02.436 --> 00:32:05.256 A:middle
and the Infectious
Diseases Society of America.

00:32:05.256 --> 00:32:10.786 A:middle
And these recommend coverage
for typical bacterial pathogens

00:32:10.786 --> 00:32:14.876 A:middle
such as streptococcus pneumoniae
and haemophilus influenzae.

00:32:14.876 --> 00:32:18.756 A:middle
And the U.S. guidelines
also suggests a coverage

00:32:18.756 --> 00:32:22.526 A:middle
for atypical organisms,
such as Legionella.

00:32:22.696 --> 00:32:29.886 A:middle
So, regimens to consider are
Ampicillin or Ceftriaxone,

00:32:30.096 --> 00:32:33.076 A:middle
as your beta lactam agents.

00:32:33.076 --> 00:32:36.926 A:middle
Plus, either Azithromycin
or Doxycycline.

00:32:36.926 --> 00:32:39.846 A:middle
The guidelines will tell us
that there is more evidence

00:32:39.846 --> 00:32:43.786 A:middle
for Azithromycin than
there is for Doxycycline.

00:32:43.786 --> 00:32:49.126 A:middle
However, many institutions
preferentially use Doxycycline

00:32:49.126 --> 00:32:52.136 A:middle
because it is less
commonly associated

00:32:52.136 --> 00:32:54.726 A:middle
with Clostridium
difficile infection

00:32:54.896 --> 00:32:58.346 A:middle
than other antibiotics.

00:32:58.456 --> 00:33:01.716 A:middle
In general, and as part
of the safety program,

00:33:01.846 --> 00:33:06.506 A:middle
we discouraged use of
fluroquinolones for the majority

00:33:06.506 --> 00:33:07.856 A:middle
of patients, not
just for patients

00:33:07.856 --> 00:33:10.246 A:middle
with community acquired
pneumonia.

00:33:10.246 --> 00:33:12.946 A:middle
And one of the findings
in our safety program was

00:33:12.946 --> 00:33:17.046 A:middle
that decreases in
antibiotic use were driven

00:33:17.046 --> 00:33:19.526 A:middle
by reductions in
fluroquinolones.

00:33:19.526 --> 00:33:21.366 A:middle
So, for community
acquired pneumonia,

00:33:21.486 --> 00:33:24.976 A:middle
even though historically I think
many providers have reached

00:33:24.976 --> 00:33:28.546 A:middle
for fluroquinolones, because
they think, oh, it's easier,

00:33:28.546 --> 00:33:34.476 A:middle
it's just one agent, we really
recommend, as do the guidelines

00:33:34.476 --> 00:33:37.556 A:middle
against these being
first line agents,

00:33:37.696 --> 00:33:42.436 A:middle
and instead limiting
them to patients

00:33:42.436 --> 00:33:44.886 A:middle
with severe Penicillin
allergies.

00:33:44.886 --> 00:33:48.816 A:middle
And as I mentioned, you know,
most antibiotics are associated

00:33:48.816 --> 00:33:53.526 A:middle
with C diff, but fluroquinolones
in particular can be associated

00:33:53.526 --> 00:33:55.246 A:middle
with C diff infections.

00:33:55.466 --> 00:33:59.836 A:middle
And other side effects, such
as prolonged QTC intervals,

00:33:59.836 --> 00:34:02.566 A:middle
tendinopathies, altered
mental status changes.

00:34:02.566 --> 00:34:06.766 A:middle
And this is particularly an
issue in the elderly population,

00:34:06.766 --> 00:34:11.116 A:middle
so I really do try to avoid
quinolones in that population.

00:34:11.686 --> 00:34:15.676 A:middle
I think a common question
that comes up is is it,

00:34:15.676 --> 00:34:17.576 A:middle
is it okay to cover patients

00:34:17.576 --> 00:34:19.946 A:middle
with community acquired
pneumonia with all those agents

00:34:19.946 --> 00:34:21.986 A:middle
that we just discussed?

00:34:22.156 --> 00:34:24.646 A:middle
Should we be concerned
about patients' risk

00:34:24.716 --> 00:34:27.736 A:middle
for Methicillin resistant
staph aureus?

00:34:27.806 --> 00:34:31.656 A:middle
Or risk for pseudomonas
aeruginosa?

00:34:31.656 --> 00:34:35.346 A:middle
And I just want to say, for
both of these organisms,

00:34:35.456 --> 00:34:38.986 A:middle
which are the source of much
handwringing and worrying

00:34:38.986 --> 00:34:45.466 A:middle
in the hospital, as we all
know, that CAP is very unlikely

00:34:45.466 --> 00:34:49.386 A:middle
to be caused by MRSA, and
very unlikely to be caused

00:34:49.386 --> 00:34:51.576 A:middle
by pseudomonas aeruginosa.

00:34:51.726 --> 00:34:53.596 A:middle
And frankly, patients

00:34:53.596 --> 00:34:58.326 A:middle
who ultimately do have these
organisms isolated probably

00:34:58.326 --> 00:35:01.366 A:middle
didn't have what we would call
community acquired pneumonia.

00:35:02.056 --> 00:35:05.776 A:middle
They probably had pneumonia
that was associated with contact

00:35:05.776 --> 00:35:08.136 A:middle
with some kind of
healthcare facility.

00:35:08.136 --> 00:35:12.066 A:middle
I think another interesting
point for MRSA is

00:35:12.066 --> 00:35:16.246 A:middle
that there have been
many studies

00:35:16.246 --> 00:35:20.026 A:middle
that both tell us it is
uncommon as a cause of CAP,

00:35:20.156 --> 00:35:21.756 A:middle
and then a large
study that showed

00:35:21.756 --> 00:35:25.676 A:middle
that empiric anti MRSA
therapy was not associated

00:35:25.676 --> 00:35:28.646 A:middle
with reduced mortality
in patients with CAP.

00:35:28.766 --> 00:35:31.146 A:middle
So, I think there's just
a couple of considerations

00:35:31.146 --> 00:35:33.426 A:middle
for when you might
use this agent.

00:35:33.726 --> 00:35:37.816 A:middle
And they include patients
who present fairly ill

00:35:37.816 --> 00:35:40.356 A:middle
and have a cavitary or
a necrotizing pneumonia

00:35:40.816 --> 00:35:43.236 A:middle
on chest x ray or chest CT.

00:35:43.396 --> 00:35:46.586 A:middle
And in patients that
have MRSA risk factors,

00:35:46.636 --> 00:35:49.836 A:middle
perhaps if the sputum gram
stain has gram positive cocci

00:35:49.836 --> 00:35:51.576 A:middle
and clusters on it.

00:35:51.736 --> 00:35:55.556 A:middle
You know, the standard CAP
regimens don't include coverage

00:35:55.556 --> 00:35:59.016 A:middle
for MRSA, so, you know, if
MRSA coverage is indicated,

00:35:59.016 --> 00:36:01.486 A:middle
this would be Vancomycin,
Manazalib [phonetic],

00:36:01.486 --> 00:36:03.676 A:middle
or Trimethyl [inaudible]
Mathoxazole [phonetic].

00:36:03.676 --> 00:36:06.226 A:middle
And then for pseudomonas, again,

00:36:06.226 --> 00:36:08.836 A:middle
I think I've mentioned
now several times

00:36:08.836 --> 00:36:11.036 A:middle
that pseudomonas
CAP is very rare.

00:36:11.576 --> 00:36:14.406 A:middle
In general, you would
think about it in patients

00:36:14.546 --> 00:36:18.176 A:middle
who had a fairly severe
underlying lung disease,

00:36:18.176 --> 00:36:21.546 A:middle
such as Bronchiectasis,
or severe COPD,

00:36:21.636 --> 00:36:24.406 A:middle
where they have likely been
exposed to multiple courses

00:36:24.406 --> 00:36:27.156 A:middle
of different antibiotics
over several years.

00:36:27.246 --> 00:36:31.036 A:middle
And then the other groups
of people who have this,

00:36:31.126 --> 00:36:34.276 A:middle
in general, they don't have
CAP, they have some kind

00:36:34.276 --> 00:36:36.036 A:middle
of healthcare associated
pneumonia,

00:36:36.036 --> 00:36:39.206 A:middle
so recent received a broad
spectrum antibiotic therapy,

00:36:39.206 --> 00:36:40.916 A:middle
recent full on hospitalization,

00:36:40.916 --> 00:36:44.836 A:middle
admission from a skilled nursing
facility or nursing home,

00:36:45.386 --> 00:36:48.036 A:middle
or people with significant
immunocompromise.

00:36:48.176 --> 00:36:51.766 A:middle
And, of course, coverage
for pseudomonas would be

00:36:51.766 --> 00:36:55.046 A:middle
with Sethapime [phonetic] or
Piperacillin and Tazobactam.

00:36:56.736 --> 00:36:58.956 A:middle
So, we'll move on
to moment three.

00:36:59.016 --> 00:37:02.386 A:middle
And so this is a moment
that should happen every day

00:37:02.386 --> 00:37:04.476 A:middle
that a patient is
on antibiotics.

00:37:04.666 --> 00:37:08.056 A:middle
So, a day or moment has passed,
can I stop, can I narrow,

00:37:08.326 --> 00:37:10.506 A:middle
or can I change from
IV to oral therapy.

00:37:10.546 --> 00:37:17.996 A:middle
And so for community acquired
pneumonia, here we go,

00:37:17.996 --> 00:37:23.746 A:middle
transitioning to oral
therapy is recommended as soon

00:37:23.746 --> 00:37:26.376 A:middle
as the patient is starting
to have clinical improvement,

00:37:26.376 --> 00:37:27.976 A:middle
and able to tolerate
oral medications.

00:37:28.046 --> 00:37:30.566 A:middle
So, in community
acquired pneumonia,

00:37:30.566 --> 00:37:33.266 A:middle
there's no requirement
for prolonged IV therapy.

00:37:33.266 --> 00:37:37.606 A:middle
So, when, you know, when their
vital signs parameters are

00:37:37.716 --> 00:37:43.936 A:middle
starting to normalize,
it's perfectly reasonable

00:37:43.936 --> 00:37:46.146 A:middle
to transition to oral therapy.

00:37:46.196 --> 00:37:47.056 A:middle
We, in general, transition

00:37:47.136 --> 00:37:50.346 A:middle
to an oral third
generation Cephalosporin, or,

00:37:50.346 --> 00:37:53.256 A:middle
as I mentioned, if you know that
the patient has pneumococcus

00:37:53.256 --> 00:37:56.246 A:middle
in general, it's safe to
transition to Amoxycillin.

00:37:56.246 --> 00:38:00.996 A:middle
If the I think we've
covered that.

00:38:01.146 --> 00:38:03.616 A:middle
So, now we can move
on to moment four.

00:38:03.616 --> 00:38:05.826 A:middle
What is the duration
of antibiotic therapy

00:38:05.826 --> 00:38:07.786 A:middle
for my patient's diagnosis?

00:38:07.786 --> 00:38:10.626 A:middle
And fortunately for
community acquired pneumonia,

00:38:11.046 --> 00:38:15.806 A:middle
we now have multiple
randomized control trials,

00:38:15.996 --> 00:38:18.876 A:middle
and observational trials
that indicate that five days

00:38:18.876 --> 00:38:21.396 A:middle
of antibiotic therapy is
sufficient for most patients

00:38:21.396 --> 00:38:22.936 A:middle
with community acquired
pneumonia.

00:38:22.936 --> 00:38:27.286 A:middle
And, you know, and this
should really be the standard,

00:38:27.416 --> 00:38:29.746 A:middle
five days, we should drill

00:38:29.746 --> 00:38:32.686 A:middle
that into everyone's head,
five days of therapy.

00:38:32.686 --> 00:38:35.206 A:middle
There are, you know,
occasionally cases

00:38:35.206 --> 00:38:37.876 A:middle
where someone has severely
immunocompromised, has severe

00:38:37.876 --> 00:38:40.156 A:middle
or underlying structural
lung disease,

00:38:40.686 --> 00:38:44.006 A:middle
or had inadequate
clinical response,

00:38:44.006 --> 00:38:46.416 A:middle
or ended up growing an organism
that you weren't covering

00:38:46.416 --> 00:38:48.846 A:middle
where you might prolong
therapy to seven days.

00:38:48.846 --> 00:38:51.216 A:middle
But the vast majority
of patients

00:38:51.216 --> 00:38:54.476 A:middle
with CAP should be
treated for five days.

00:38:54.476 --> 00:38:57.286 A:middle
If you started a
combination regimen

00:38:57.286 --> 00:38:59.286 A:middle
with the beta lactam
and Azithromycin.

00:38:59.596 --> 00:39:01.816 A:middle
Remember that you
don't need to give more

00:39:01.816 --> 00:39:02.976 A:middle
than three days of Azithromycin.

00:39:03.086 --> 00:39:05.536 A:middle
It has an incredibly
long half life.

00:39:05.536 --> 00:39:09.906 A:middle
And so it's actually, you know,
three days, sticking around in

00:39:09.906 --> 00:39:12.926 A:middle
that person's body
for probably 10 days.

00:39:13.506 --> 00:39:17.936 A:middle
So, remember to encourage
discontinuation of Azithromycin

00:39:17.936 --> 00:39:21.576 A:middle
after three days if it was
part of the empiric regimen,

00:39:21.576 --> 00:39:23.616 A:middle
unless the patient is
diagnosed with Legionella,

00:39:23.776 --> 00:39:27.696 A:middle
in which case longer courses of
Azithromycin would be indicated.

00:39:27.856 --> 00:39:33.776 A:middle
Also, you know, remember, and
remember to remind patients

00:39:33.776 --> 00:39:37.216 A:middle
that they may feel tired, they
may have a cough that goes

00:39:37.216 --> 00:39:41.066 A:middle
on for, you know, quite
a few days after a bout

00:39:41.066 --> 00:39:42.646 A:middle
with community acquired
pneumonia.

00:39:42.646 --> 00:39:45.526 A:middle
And it's going to take a
while for them to get better.

00:39:45.826 --> 00:39:50.786 A:middle
But don't rework them
up for this, you know,

00:39:50.786 --> 00:39:53.776 A:middle
by getting chest x
rays and more sputum,

00:39:53.776 --> 00:39:57.686 A:middle
because chest x rays can
take a long time to improve.

00:39:57.946 --> 00:40:02.786 A:middle
And, you know, so it
should be considered as part

00:40:02.786 --> 00:40:05.766 A:middle
of the natural history that
cough and fatigue can go

00:40:05.766 --> 00:40:09.276 A:middle
on for a few weeks after a
patient has community acquired

00:40:09.276 --> 00:40:12.236 A:middle
pneumonia, and is not a
reason to prolong antibiotics.

00:40:12.896 --> 00:40:18.216 A:middle
So, I think we have time to one
through quickly a second case,

00:40:18.736 --> 00:40:25.536 A:middle
just to give another idea of how
you can use the four moments.

00:40:25.646 --> 00:40:30.126 A:middle
This is a case of a 31 year
old woman who is healthy

00:40:30.126 --> 00:40:32.886 A:middle
and presents with
dysuria, fever, rigors,

00:40:32.886 --> 00:40:35.096 A:middle
and left sided flank pain.

00:40:35.096 --> 00:40:39.216 A:middle
She, you know, also has
evidence of being infected

00:40:39.216 --> 00:40:42.556 A:middle
with a temperature of
101, low blood pressure,

00:40:42.556 --> 00:40:47.376 A:middle
elevated heart rate,
and is standing normally

00:40:47.376 --> 00:40:48.276 A:middle
and breathing normally.

00:40:48.276 --> 00:40:52.416 A:middle
On exam, she is ill
appearing, but able to carry

00:40:52.416 --> 00:40:54.316 A:middle
on a normal conversation.

00:40:54.596 --> 00:40:57.646 A:middle
So, for this patient, the first
question is does my patient have

00:40:57.646 --> 00:41:00.916 A:middle
an infection that
requires antibiotics?

00:41:00.916 --> 00:41:03.216 A:middle
In this case, the patient
has signs and symptoms

00:41:03.216 --> 00:41:05.846 A:middle
that are concerning
for pyelonephritis.

00:41:06.076 --> 00:41:08.626 A:middle
So, in this particular
case, the answer is yes.

00:41:08.626 --> 00:41:12.076 A:middle
But, in general, for
urinary tract infections,

00:41:12.306 --> 00:41:14.046 A:middle
there are many situations

00:41:14.046 --> 00:41:18.586 A:middle
where patients do not
necessarily have an infection,

00:41:18.586 --> 00:41:21.936 A:middle
even if they have
abnormalities with their urine.

00:41:21.936 --> 00:41:25.966 A:middle
So, remember that foul
smelling urine, cloudy urine,

00:41:26.746 --> 00:41:30.976 A:middle
or isolated mental status
changes, in the absence

00:41:30.976 --> 00:41:34.376 A:middle
of other clinical symptoms
of a urinary tract infection,

00:41:34.586 --> 00:41:38.056 A:middle
are not indications to
obtain urine cultures.

00:41:38.326 --> 00:41:42.916 A:middle
And if a urine culture
is obtained,

00:41:42.916 --> 00:41:47.176 A:middle
and comes back positive, it's
always important to go back

00:41:47.296 --> 00:41:51.046 A:middle
to the patient and ask about
symptoms, because a lot of time

00:41:51.046 --> 00:41:53.796 A:middle
in medical care, urine
cultures get sent all the time,

00:41:54.026 --> 00:41:57.956 A:middle
and then no one remembers why
that urine culture was sent,

00:41:58.126 --> 00:42:00.416 A:middle
and, you know, positive urine
cultures can trigger antibiotic

00:42:00.416 --> 00:42:03.306 A:middle
therapy, when antibiotic
therapy is not needed at all.

00:42:03.406 --> 00:42:06.316 A:middle
So, moving on to moment two.

00:42:06.316 --> 00:42:08.096 A:middle
Have I ordered appropriate
cultures before

00:42:08.096 --> 00:42:09.376 A:middle
starting antibiotics?

00:42:09.376 --> 00:42:12.226 A:middle
And what empiric therapy
should I initiate?

00:42:13.296 --> 00:42:17.276 A:middle
You know, just some more
information about interpreting,

00:42:17.276 --> 00:42:22.196 A:middle
sending and interpreting
urinalysis and urine cultures,

00:42:22.196 --> 00:42:25.326 A:middle
you know, there are,
in general, in labs,

00:42:25.326 --> 00:42:28.606 A:middle
cut offs for positive
UAs, you know,

00:42:28.606 --> 00:42:30.926 A:middle
and so your lab might differ.

00:42:30.926 --> 00:42:33.596 A:middle
But, you know, in general, this
is usually considered greater

00:42:33.596 --> 00:42:37.446 A:middle
than or equal to 10 white
cells per high powered field.

00:42:38.016 --> 00:42:41.066 A:middle
In patients with very small
numbers of white cells

00:42:41.066 --> 00:42:45.326 A:middle
in their urine, a UTI
is, in general, unlikely.

00:42:46.506 --> 00:42:48.896 A:middle
In our patient with
pyelonephritis,

00:42:48.896 --> 00:42:52.286 A:middle
a urine culture should
be obtained.

00:42:52.286 --> 00:42:57.516 A:middle
But a lot of patients get urine
cultures as I, as I mentioned,

00:42:57.516 --> 00:43:00.866 A:middle
and, you know, it's
really important to look

00:43:00.866 --> 00:43:03.196 A:middle
at colony counts in
these urine cultures

00:43:03.506 --> 00:43:08.056 A:middle
when assessing whether they
are clinically significant.

00:43:08.756 --> 00:43:11.626 A:middle
If patients do not
have symptoms,

00:43:11.626 --> 00:43:15.496 A:middle
and have low colony counts,
again, highly unlikely

00:43:15.496 --> 00:43:18.656 A:middle
to be a urinary tract infection.

00:43:18.656 --> 00:43:20.936 A:middle
And then with regard
to blood cultures,

00:43:21.086 --> 00:43:26.986 A:middle
most patients do not
need blood cultures.

00:43:26.986 --> 00:43:28.366 A:middle
Certainly patients with concern

00:43:28.366 --> 00:43:30.866 A:middle
for cystitis don't
need blood cultures.

00:43:31.076 --> 00:43:32.926 A:middle
And patients being
treated for pyelonephritis

00:43:32.926 --> 00:43:35.776 A:middle
as outpatients don't
need blood cultures.

00:43:35.986 --> 00:43:39.256 A:middle
If patients are hospitalized
for pyelonephritis,

00:43:39.256 --> 00:43:41.606 A:middle
a urine culture is still
the most useful culture.

00:43:41.606 --> 00:43:44.746 A:middle
But if there's any concern about
getting that urine culture,

00:43:44.746 --> 00:43:46.416 A:middle
difficult to getting
that urine culture,

00:43:46.416 --> 00:43:48.496 A:middle
or if the patient has
evidence of sepsis,

00:43:48.526 --> 00:43:50.836 A:middle
then blood culture
should be obtained.

00:43:52.046 --> 00:43:55.696 A:middle
So, moving onto the empiric
therapy part of moment two,

00:43:55.696 --> 00:43:59.316 A:middle
you know, for patients
being hospitalized

00:43:59.416 --> 00:44:03.186 A:middle
with pyelonephritis, you know,
currently, we recommend use

00:44:03.186 --> 00:44:12.036 A:middle
of Ceftriaxone if a patient has
risk factors for pseudomonas

00:44:12.036 --> 00:44:15.206 A:middle
or structural or functional
urologic abnormalities,

00:44:15.206 --> 00:44:15.996 A:middle
then Sethapime [phonetic].

00:44:15.996 --> 00:44:19.186 A:middle
And if patients have histories

00:44:19.186 --> 00:44:22.356 A:middle
of extended spectrum beta
lactamase producing organisms,

00:44:22.356 --> 00:44:26.496 A:middle
particularly E. Coli, then
recommend use of a Carbapenem.

00:44:27.346 --> 00:44:29.426 A:middle
For severe Penicillin allergy,

00:44:29.426 --> 00:44:34.436 A:middle
it can be either
Aztreonam or Gentamicin.

00:44:34.436 --> 00:44:37.426 A:middle
If you look at national
guidelines

00:44:37.426 --> 00:44:40.336 A:middle
for urinary tract
infections, quinolones

00:44:40.336 --> 00:44:43.276 A:middle
and Trimethoprim
sulfamethoxazole are still high

00:44:43.276 --> 00:44:45.696 A:middle
on the list for empiric
treatment.

00:44:45.896 --> 00:44:50.396 A:middle
These guidelines are now
over 10 years out of date.

00:44:50.616 --> 00:44:52.686 A:middle
And while fluroquinolones

00:44:52.686 --> 00:44:55.316 A:middle
and Trimethoprim
sulfamethoxazole have excellent

00:44:55.316 --> 00:45:00.166 A:middle
kidney and urine penetration,
the big issue with them is

00:45:00.166 --> 00:45:03.676 A:middle
that we have seen increasing
resistance, particularly

00:45:03.676 --> 00:45:05.846 A:middle
in E. Coli, over
the past decade.

00:45:06.136 --> 00:45:10.176 A:middle
And this is in many parts of
the United States, although not

00:45:10.176 --> 00:45:12.336 A:middle
in all of the United States.

00:45:12.636 --> 00:45:16.796 A:middle
So, if resistance rates are
known to be low, ideally less

00:45:16.796 --> 00:45:20.386 A:middle
than 10%, then these agents
can certainly be considered

00:45:20.386 --> 00:45:21.536 A:middle
for empiric therapy.

00:45:21.536 --> 00:45:26.206 A:middle
The problem is many parts of the
country, the resistance rates

00:45:26.206 --> 00:45:29.276 A:middle
for fluroquinolones and
Trimethoprim sulfamethoxazole

00:45:29.276 --> 00:45:34.036 A:middle
for E. Coli are now,
you know, 30 to 40%.

00:45:34.126 --> 00:45:36.656 A:middle
So, moving onto the
third moment,

00:45:36.656 --> 00:45:37.556 A:middle
a day or more has passed.

00:45:37.656 --> 00:45:38.226 A:middle
Can I stop?

00:45:38.226 --> 00:45:38.856 A:middle
Can I narrow?

00:45:38.856 --> 00:45:40.186 A:middle
Can I change to oral?

00:45:40.186 --> 00:45:46.616 A:middle
So, in patients admitted
with pyelonephritis,

00:45:46.616 --> 00:45:50.286 A:middle
therapy should be transitioned
to oral therapy, again,

00:45:50.286 --> 00:45:52.376 A:middle
as soon as the patient
is feeling better,

00:45:52.376 --> 00:45:56.016 A:middle
and whenever the patient
can tolerate oral therapy.

00:45:56.376 --> 00:46:02.236 A:middle
This is one situation
where we actually favor use

00:46:02.236 --> 00:46:02.956 A:middle
of quinolones.

00:46:02.956 --> 00:46:05.616 A:middle
I know I always talk about
not using quinolones.

00:46:05.616 --> 00:46:09.406 A:middle
But because of their
outstanding urinary penetration,

00:46:09.616 --> 00:46:13.476 A:middle
I think they are very reasonable
to use in stepdown therapy

00:46:13.476 --> 00:46:15.546 A:middle
for patients with
pyelonephritis,

00:46:15.616 --> 00:46:20.336 A:middle
because you can give a pretty
short duration of therapy.

00:46:20.336 --> 00:46:22.266 A:middle
But it's important.

00:46:22.266 --> 00:46:26.216 A:middle
Whether using quinolones
or Trim sulfa to make sure

00:46:26.216 --> 00:46:28.196 A:middle
that the organism
is susceptible.

00:46:28.196 --> 00:46:31.536 A:middle
If you can't use these agents

00:46:31.536 --> 00:46:35.336 A:middle
because of susceptibility
issues, then, in general,

00:46:35.336 --> 00:46:37.196 A:middle
we use oral cephalosporins.

00:46:37.676 --> 00:46:42.136 A:middle
And then finally, the fourth
moment is what duration

00:46:42.136 --> 00:46:44.016 A:middle
of therapy is needed?

00:46:44.166 --> 00:46:46.486 A:middle
In this case, durations
for pyelonephritis,

00:46:46.486 --> 00:46:48.586 A:middle
and as I mentioned,
quinolones can be attractive

00:46:48.586 --> 00:46:51.696 A:middle
in these situations, because
patients can be treated

00:46:51.916 --> 00:46:53.876 A:middle
with five to seven
days of therapy.

00:46:53.876 --> 00:46:57.166 A:middle
In contrast, we don't
have clinical studies

00:46:57.166 --> 00:47:01.096 A:middle
that support these short courses
of therapy for other agents.

00:47:01.326 --> 00:47:03.306 A:middle
So, even for Trim
sulfa, which, again,

00:47:03.306 --> 00:47:05.486 A:middle
has excellent urinary
penetration,

00:47:05.486 --> 00:47:07.486 A:middle
we unfortunately don't
have a lot of studies

00:47:07.486 --> 00:47:10.106 A:middle
that say we can use these
shorter courses of therapy.

00:47:10.106 --> 00:47:12.636 A:middle
And then for oral
cephalosporins,

00:47:12.826 --> 00:47:15.146 A:middle
there probably is a
bit higher failure rate

00:47:15.146 --> 00:47:15.976 A:middle
for oral cephalosporins.

00:47:16.266 --> 00:47:21.106 A:middle
And so if you're using
them, again, 10 to 14 days

00:47:21.106 --> 00:47:24.516 A:middle
of total therapy, of
course including the days

00:47:24.516 --> 00:47:28.636 A:middle
that the patient
received in the hospital.

00:47:28.636 --> 00:47:33.446 A:middle
And, you know, much like
not repeating chest x rays

00:47:33.446 --> 00:47:36.406 A:middle
and sputum cultures
in patients with CAP,

00:47:36.666 --> 00:47:39.416 A:middle
in patients who are recovering
from urinary tract infections,

00:47:39.416 --> 00:47:42.436 A:middle
they also do not need
repeat urine cultures.

00:47:44.506 --> 00:47:49.186 A:middle
So, I'm going to sum
up the presentation

00:47:49.186 --> 00:47:51.546 A:middle
for all three of the speakers.

00:47:51.596 --> 00:47:54.366 A:middle
And I hope that we
have convinced you

00:47:54.366 --> 00:47:56.956 A:middle
that implementation of
the AHRQ safety program

00:47:56.956 --> 00:48:02.316 A:middle
for improving antibiotic use
was, was valuable and useful

00:48:02.316 --> 00:48:05.376 A:middle
and associated with enhancing
antibiotic stewardship programs

00:48:05.376 --> 00:48:09.256 A:middle
and improving antibiotic
prescribing, and I want to point

00:48:09.256 --> 00:48:13.336 A:middle
out that, you know, 20%

00:48:13.336 --> 00:48:15.976 A:middle
of the participating hospitals
were critical access hospitals.

00:48:16.046 --> 00:48:19.856 A:middle
And we did see reductions
in antibiotic use

00:48:19.856 --> 00:48:24.726 A:middle
in these hospitals, you know,
because overall the amount

00:48:24.726 --> 00:48:29.376 A:middle
of use is not as high
compared to larger hospitals.

00:48:29.446 --> 00:48:34.346 A:middle
This was not a significant
finding, but the magnitude

00:48:34.346 --> 00:48:36.526 A:middle
of reduction was
actually greatest

00:48:36.526 --> 00:48:38.606 A:middle
in critical access hospitals.

00:48:38.776 --> 00:48:41.596 A:middle
So, I think if we'd have more
critical access hospitals,

00:48:41.696 --> 00:48:44.966 A:middle
ultimately I think that finding
would have been significant.

00:48:45.146 --> 00:48:48.076 A:middle
And then finally, you've heard
before, but I'll say it again,

00:48:48.076 --> 00:48:49.586 A:middle
that the AHRQ safety program

00:48:49.586 --> 00:48:53.226 A:middle
for improving antibiotic
use toolkits is available

00:48:53.226 --> 00:48:55.126 A:middle
at the AHRQ website.

00:48:55.366 --> 00:48:58.016 A:middle
And, you know, all the materials

00:48:58.016 --> 00:49:00.506 A:middle
that we've discussed today
are available for download.

00:49:00.626 --> 00:49:02.796 A:middle
Most of them are editable

00:49:02.796 --> 00:49:05.376 A:middle
so that you can customize
them for your site.

00:49:05.746 --> 00:49:10.306 A:middle
And if you're somehow
also looking for materials

00:49:10.306 --> 00:49:14.056 A:middle
for nursing homes and
materials for outpatient care,

00:49:14.056 --> 00:49:17.276 A:middle
we have toolkits with all
these same features available

00:49:17.276 --> 00:49:19.906 A:middle
for those settings
also on the website.

00:49:20.096 --> 00:49:24.636 A:middle
So, thank you for
your attention.

00:49:24.636 --> 00:49:26.466 A:middle
And I think we have
some time for questions.

00:49:26.936 --> 00:49:30.936 A:middle
&gt;&gt; Yes, thank you so much
for all our speakers.

00:49:30.936 --> 00:49:35.256 A:middle
And I could just listen
to Sara all day talking

00:49:35.256 --> 00:49:38.296 A:middle
about clinical pearls
for infections.

00:49:38.616 --> 00:49:42.566 A:middle
So, I'll actually maybe
start with you, Dr. Cosgrove.

00:49:42.566 --> 00:49:45.886 A:middle
In terms of there's a question
about the three day course

00:49:45.886 --> 00:49:48.566 A:middle
of Azithromycin for CAP.

00:49:48.566 --> 00:49:51.226 A:middle
What dose is used?

00:49:51.996 --> 00:49:55.966 A:middle
&gt;&gt; It would be 500
for three days.

00:49:56.206 --> 00:49:58.886 A:middle
&gt;&gt; Okay. Great.

00:49:59.076 --> 00:50:03.746 A:middle
And in terms of the
engagement for the office hours,

00:50:03.876 --> 00:50:06.096 A:middle
one of our audience
members was curious

00:50:06.096 --> 00:50:10.246 A:middle
of what the engagement was
like for the office hours.

00:50:10.456 --> 00:50:12.606 A:middle
&gt;&gt; We had a good time
on the office hours.

00:50:12.606 --> 00:50:19.916 A:middle
It was actually, it was really
fun to do the office hours.

00:50:19.916 --> 00:50:22.656 A:middle
I think that, and I don't
mean to like toot our own horn

00:50:22.656 --> 00:50:26.226 A:middle
or something, but I think
that people were excited

00:50:26.226 --> 00:50:30.096 A:middle
to have access to infectious
disease stewardship positions.

00:50:30.096 --> 00:50:34.416 A:middle
And, you know, I know that there
are, you know, are many places

00:50:34.416 --> 00:50:38.056 A:middle
in the country that really
don't have that access.

00:50:38.056 --> 00:50:41.646 A:middle
And so it was really just a
treat to be able to, you know,

00:50:41.646 --> 00:50:44.816 A:middle
just be there to answer
anyone's question,

00:50:44.816 --> 00:50:46.106 A:middle
because it could be anything.

00:50:46.106 --> 00:50:48.396 A:middle
It could be programmatic
stewardship stuff,

00:50:48.506 --> 00:50:51.186 A:middle
it could be I'm having this
problem with this person,

00:50:51.186 --> 00:50:53.886 A:middle
can you help me solve this
problem with this person, or,

00:50:53.886 --> 00:50:57.966 A:middle
you know, just stuff about the
evidence behind recommendations

00:50:57.966 --> 00:50:59.436 A:middle
and so forth.

00:51:00.766 --> 00:51:01.746 A:middle
&gt;&gt; Yeah, absolutely.

00:51:01.746 --> 00:51:07.766 A:middle
And getting some
questions about using days

00:51:07.766 --> 00:51:12.786 A:middle
of therapy per a thousand
patient days, particularly

00:51:12.786 --> 00:51:14.246 A:middle
in the context of
a small hospital

00:51:14.246 --> 00:51:17.096 A:middle
or critical access hospital,
and some of the limitations,

00:51:17.376 --> 00:51:20.216 A:middle
for example, one of our
audience members is saying

00:51:20.346 --> 00:51:24.886 A:middle
that one patient could really
impact your days of therapy.

00:51:25.086 --> 00:51:29.306 A:middle
And they were wondering if you
had thought about other measures

00:51:29.306 --> 00:51:33.436 A:middle
that might better capture this
excellent work that you've done.

00:51:33.956 --> 00:51:37.116 A:middle
&gt;&gt; So, I completely
agree that I think

00:51:37.116 --> 00:51:39.906 A:middle
that that is a very
challenging metric.

00:51:40.046 --> 00:51:44.166 A:middle
It's actually a challenging
metric for all hospitals,

00:51:44.166 --> 00:51:47.626 A:middle
because even if you have
tons of antibiotic use,

00:51:47.716 --> 00:51:51.526 A:middle
it's actually hard for
clinicians to understand.

00:51:51.526 --> 00:51:55.626 A:middle
You know, we've had this
experience in our institution.

00:51:55.626 --> 00:51:58.296 A:middle
Well, your Vanco
increased from this to this.

00:51:58.296 --> 00:52:00.696 A:middle
And they're like,
what does that mean?

00:52:00.696 --> 00:52:02.716 A:middle
Why do I care if
my Vanco increased

00:52:02.716 --> 00:52:05.866 A:middle
from 500 days to 600 days?

00:52:05.866 --> 00:52:07.216 A:middle
What does that mean?

00:52:07.216 --> 00:52:08.956 A:middle
And so I think we all
should be thinking

00:52:08.956 --> 00:52:13.976 A:middle
about alternative metrics,
you know, obviously those kind

00:52:13.976 --> 00:52:16.316 A:middle
of metrics are helpful
to stewardship programs

00:52:16.316 --> 00:52:16.976 A:middle
to track things over time.

00:52:17.046 --> 00:52:22.416 A:middle
But when we are trying
to engage providers,

00:52:22.496 --> 00:52:26.476 A:middle
I think it can be
more challenging.

00:52:26.576 --> 00:52:30.316 A:middle
I actually think that
what providers respond

00:52:30.316 --> 00:52:35.766 A:middle
to more is assessments of
appropriate decision making.

00:52:35.766 --> 00:52:37.776 A:middle
Or adverse events.

00:52:38.196 --> 00:52:44.706 A:middle
And so if you have the bandwidth
to look at a sample of cases,

00:52:44.706 --> 00:52:46.416 A:middle
you know, kind of like we did

00:52:46.416 --> 00:52:49.676 A:middle
with the team antibiotic
review form, or, you know,

00:52:49.676 --> 00:52:54.826 A:middle
even if you say every Friday
I'm going to look at everyone

00:52:54.826 --> 00:52:58.566 A:middle
on antibiotics and like just
do an assessment, you know,

00:52:58.566 --> 00:53:01.306 A:middle
30% of people were
guideline noncompliant,

00:53:01.306 --> 00:53:03.496 A:middle
60% of people were
guideline compliant.

00:53:03.496 --> 00:53:06.076 A:middle
Here's some of the, you
know, things I found.

00:53:06.076 --> 00:53:09.526 A:middle
But that, I think, is
actually more valuable feedback

00:53:09.526 --> 00:53:14.266 A:middle
to the frontline than days of
therapy per 1,000 patient days.

00:53:14.266 --> 00:53:18.396 A:middle
And apologies to CDC,
because obviously, you know,

00:53:18.396 --> 00:53:20.646 A:middle
that is the approach for
large scale surveillance.

00:53:20.646 --> 00:53:22.926 A:middle
But when we're talking
to frontline,

00:53:23.136 --> 00:53:25.676 A:middle
they need something they
can wrap their head around.

00:53:25.676 --> 00:53:28.456 A:middle
And, you know, and
another thing is

00:53:28.456 --> 00:53:31.826 A:middle
that if you do have C diff
cases that you can review,

00:53:31.886 --> 00:53:36.386 A:middle
we find that our focus really
kind of like to hear about,

00:53:36.386 --> 00:53:37.366 A:middle
you know, assessments

00:53:37.366 --> 00:53:39.166 A:middle
of how well they did
with managing C diff.

00:53:39.166 --> 00:53:42.566 A:middle
And that covers both the
diagnostic stewardship parts

00:53:42.566 --> 00:53:44.856 A:middle
of the C diff, like should
the patient have been tested

00:53:44.856 --> 00:53:45.806 A:middle
in the first place.

00:53:45.806 --> 00:53:51.216 A:middle
It covers, you know, were the
antibiotics non C diff related

00:53:51.216 --> 00:53:53.426 A:middle
that the patient
was on appropriate?

00:53:53.426 --> 00:53:55.136 A:middle
Or did they contribute
to the C diff?

00:53:55.136 --> 00:53:57.216 A:middle
Once they found out
about C diff,

00:53:57.216 --> 00:54:00.736 A:middle
did they modify the
antibiotics or stop them?

00:54:00.736 --> 00:54:02.736 A:middle
And then even did they
use the right approach

00:54:02.736 --> 00:54:04.276 A:middle
with the treatment
of the C diff?

00:54:04.276 --> 00:54:08.186 A:middle
So, lots of stewardship
stuff around C diff.

00:54:08.466 --> 00:54:09.096 A:middle
&gt;&gt; Absolutely.

00:54:09.286 --> 00:54:10.656 A:middle
Thank you.

00:54:10.656 --> 00:54:15.876 A:middle
Along similar lines about really
tracking antimicrobial use,

00:54:15.876 --> 00:54:19.336 A:middle
we had an audience member ask
if there's a comprehensive list

00:54:19.336 --> 00:54:23.226 A:middle
of antibiotics on a
spectrum of broad to narrow

00:54:24.026 --> 00:54:27.406 A:middle
when this individual
is doing audits,

00:54:27.406 --> 00:54:31.046 A:middle
and if a physician changes the
antibiotic, not a clear guidance

00:54:31.046 --> 00:54:33.606 A:middle
in terms of if that
was a deliberate move

00:54:33.606 --> 00:54:35.556 A:middle
to more narrow spectrum.

00:54:36.906 --> 00:54:38.766 A:middle
Do you want to [inaudible]?

00:54:38.986 --> 00:54:42.876 A:middle
&gt;&gt; I can comment real quick.

00:54:42.876 --> 00:54:42.966 A:middle
&gt;&gt; Yes.

00:54:42.966 --> 00:54:45.816 A:middle
&gt;&gt; You know, I think this is
like the question of the century

00:54:45.816 --> 00:54:49.696 A:middle
in some ways, because we talk
about, you know, narrowing.

00:54:49.696 --> 00:54:52.606 A:middle
And it is like a core
component of stewardship.

00:54:52.606 --> 00:54:56.646 A:middle
But most of the antibiotics
we use are pretty broad.

00:54:56.946 --> 00:54:59.256 A:middle
You know, when you think of
what their potential impact is

00:54:59.256 --> 00:55:00.286 A:middle
on the human microbiome.

00:55:00.286 --> 00:55:05.606 A:middle
But, in general, you can, I
think, have your class of agents

00:55:05.606 --> 00:55:09.196 A:middle
that have anti pseudomonal
coverage and have a goal

00:55:09.366 --> 00:55:13.016 A:middle
to not be on those, and to
narrow to something else

00:55:13.016 --> 00:55:15.326 A:middle
that doesn't have anti
pseudomonal coverage,

00:55:15.326 --> 00:55:17.346 A:middle
if they don't have pseudomonas.

00:55:17.346 --> 00:55:20.856 A:middle
I think that, you know,
for Vancomycin, you know,

00:55:20.856 --> 00:55:26.686 A:middle
most of narrowing of Vancomycin
is stopping Vancomycin.

00:55:26.686 --> 00:55:30.066 A:middle
So, if they don't end up
having an indication to be

00:55:30.066 --> 00:55:33.426 A:middle
on Vancomycin, no MRSA
isolated, no other thing

00:55:33.426 --> 00:55:36.006 A:middle
that might be Vanco, narrowing

00:55:36.006 --> 00:55:39.016 A:middle
of Vancomycin means
stopping Vancomycin.

00:55:39.016 --> 00:55:41.826 A:middle
And, you know, if you can
get people on Penicillin,

00:55:41.826 --> 00:55:46.256 A:middle
that is truly a pretty
narrow spectrum drug relative

00:55:46.256 --> 00:55:47.596 A:middle
to everything else.

00:55:47.776 --> 00:55:52.466 A:middle
Amoxicillin is narrower than
late generation Cephalosporin.

00:55:52.466 --> 00:55:53.976 A:middle
So, if you can get people
on Amoxicillin, that's good.

00:55:54.196 --> 00:55:58.946 A:middle
But it's not crazy narrow,
you know, it kills plenty

00:55:58.946 --> 00:56:00.566 A:middle
of gram positives
and gram negatives.

00:56:00.566 --> 00:56:02.786 A:middle
So, [inaudible] to
any other thoughts?

00:56:02.886 --> 00:56:05.456 A:middle
&gt;&gt; No, that's good.

00:56:05.686 --> 00:56:10.986 A:middle
Okay, we have like a
technical question here.

00:56:10.986 --> 00:56:14.746 A:middle
What is the recommendation for
the duration of Azithromycin

00:56:14.746 --> 00:56:17.846 A:middle
if a urine Legionella
is positive?

00:56:17.956 --> 00:56:22.796 A:middle
&gt;&gt; Yeah, so there's not
actually a recommendation,

00:56:22.796 --> 00:56:25.426 A:middle
because there's not been studies
performed on the duration.

00:56:25.426 --> 00:56:30.706 A:middle
What's kind of suggested and
up to date and some other sort

00:56:30.706 --> 00:56:34.706 A:middle
of review articles is somewhere
in the range of 7 to 14 days.

00:56:34.706 --> 00:56:37.266 A:middle
I think most people
would probably treat,

00:56:37.436 --> 00:56:39.466 A:middle
until the patient's
better, maybe a couple

00:56:39.466 --> 00:56:40.526 A:middle
of days more and stop.

00:56:41.006 --> 00:56:44.136 A:middle
Like Sara, I always
favor shorter durations

00:56:44.136 --> 00:56:45.316 A:middle
whenever possible.

00:56:45.316 --> 00:56:48.666 A:middle
So, certainly if the patient
is responding to therapy,

00:56:48.666 --> 00:56:50.286 A:middle
I think a week is probably fine.

00:56:50.286 --> 00:56:53.916 A:middle
If the patient is critically
ill in the ICU, then maybe going

00:56:53.916 --> 00:56:55.806 A:middle
to like 10 days or
so might make sense.

00:56:55.806 --> 00:56:59.566 A:middle
But there's not actually like
traditional CAP where the large,

00:56:59.806 --> 00:57:04.396 A:middle
very nicely done RCTs, that
data is just not available

00:57:04.396 --> 00:57:05.146 A:middle
with Legionella.

00:57:06.256 --> 00:57:11.056 A:middle
&gt;&gt; That you don't have to
switch someone to a quinolone,

00:57:11.056 --> 00:57:12.966 A:middle
just because they
have Legionella.

00:57:12.966 --> 00:57:13.416 A:middle
&gt;&gt; Correct.

00:57:13.416 --> 00:57:15.946 A:middle
&gt;&gt; Quinolones pretty much
have the same activity.

00:57:15.946 --> 00:57:19.056 A:middle
And so if you already
have them on the Azithro,

00:57:19.056 --> 00:57:21.466 A:middle
you can stop the
Ceftriaxone or the [inaudible]

00:57:21.556 --> 00:57:24.896 A:middle
and just keep going
with the Azithro.

00:57:25.116 --> 00:57:25.316 A:middle
&gt;&gt; Yeah.

00:57:25.316 --> 00:57:27.736 A:middle
&gt;&gt; Which is, that's one
of my CAP pet peeves,

00:57:27.736 --> 00:57:29.766 A:middle
when people switch
to quinolones.

00:57:29.946 --> 00:57:36.516 A:middle
Then they don't need to
switch to quinolones.

00:57:36.516 --> 00:57:36.583 A:middle
[ Inaudible ]

00:57:36.583 --> 00:57:40.376 A:middle
&gt;&gt; We do, for the acute
care program, you know,

00:57:40.376 --> 00:57:44.606 A:middle
I'm a pediatrician, we
definitely, the guidance that's

00:57:44.606 --> 00:57:48.206 A:middle
in there is very generalizable
to both children and adults.

00:57:48.206 --> 00:57:51.406 A:middle
And if there are exceptions,
we make note of it.

00:57:51.406 --> 00:57:54.006 A:middle
So, I would say that certainly
for the acute care content,

00:57:54.006 --> 00:57:56.636 A:middle
it is very generalizable
to children as well.

00:57:56.806 --> 00:57:58.846 A:middle
Maybe not babies,
because they're always a

00:57:58.846 --> 00:57:59.876 A:middle
little [inaudible].

00:57:59.876 --> 00:58:02.696 A:middle
&gt;&gt; Ambulatory is also for both.

00:58:02.986 --> 00:58:03.596 A:middle
&gt;&gt; Correct, yeah.

00:58:03.596 --> 00:58:05.976 A:middle
&gt;&gt; And nursing home
one, not so much.

00:58:09.506 --> 00:58:12.896 A:middle
&gt;&gt; Yes, and we, just to
address a housekeeping question.

00:58:12.936 --> 00:58:15.096 A:middle
This presentation
will be available,

00:58:15.096 --> 00:58:19.846 A:middle
along with the recorded
webinar on CDC's tune

00:58:19.846 --> 00:58:22.146 A:middle
into safe healthcare website.

00:58:22.386 --> 00:58:25.576 A:middle
And you'll be notified
when that is available.

00:58:25.576 --> 00:58:27.636 A:middle
Typically takes a
couple of weeks.

00:58:27.636 --> 00:58:32.986 A:middle
And then we also have it linked
to the CDC's antibiotic use

00:58:32.986 --> 00:58:35.236 A:middle
and stewardship websites,
specifically in the [inaudible]

00:58:35.236 --> 00:58:39.846 A:middle
and healthcare professionals
website for resources.

00:58:39.846 --> 00:58:42.626 A:middle
At this time, we're at
the top of the hour.

00:58:42.626 --> 00:58:46.356 A:middle
And once again, want to
really thank our speakers.

00:58:46.356 --> 00:58:49.626 A:middle
I enjoyed every aspect
of this presentation.

00:58:49.726 --> 00:58:52.606 A:middle
And look forward to hearing

00:58:52.606 --> 00:58:54.366 A:middle
about U.S. Antibiotic
Awareness Week

00:58:54.366 --> 00:58:55.956 A:middle
and National Rural Health Day

00:58:55.956 --> 00:58:58.526 A:middle
from everyone this
upcoming week.

00:58:58.526 --> 00:58:59.226 A:middle
Thanks again.

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