Course Material – Engage Patients in Your Antibiotic Stewardship Program

Clinical Focus

Discovery of antibiotics over the past century has changed the field of medicine beyond any other discovery to date
Antibiotics are powerful drugs that have transformed health care around the world – making once deadly diseases treatable and saving millions of lives
Antibiotics are the foundation of modern medicine
Antibiotics are relied upon to treat people with the most serious infections, such as pneumonia or sepsis, and those at high risk for developing infections
Unfortunately, overuse and misuse of antibiotics have resulted in increasing resistance, creating the real and growing threat of new “super-bugs” that are increasingly difficult to treat
Studies indicate that 30-50% of antibiotics prescribed in hospitals are unnecessary or inappropriate

Patients Most at Risk for Severe Infections

Surgery – patients undergoing any type of surgery, including cardiac bypass and joint replacement, are at risk of surgical site infections
Dialysis for end-stage renal disease – infection risk is high in patients with ESRD (a condition in which kidneys are no longer working) because the patients have weakened immune systems and dialysis requires access to their bloodstream
Cancer chemotherapy – patients are often at risk for developing serious infections because the treatment weakens their immune systems
Inflammatory conditions – patients with inflammatory conditions, such as rheumatoid arthritis and inflammatory bowel disease are treated with medicines that can be associated with increased risk of infection
Organ transplants – patients receiving organ transplants are at high risk for infections because they may undergo complex surgery and most receive medicines that weaken their immune system as part of their treatment

Established Risk of Antibiotic Use

Increased infection risk – Though used to treat infections, they can also increase the risk of some types of infection such as C. difficile and Candida
Allergic reactions – Can range from mild rashes and itching to life threatening swelling of the face and throat and anaphylaxis
Drug interactions – Can interact with other drugs patients take making antibiotics less effective or giving the patient worse side effects
Antibiotic resistance – The bacteria might adapt to develop new resistance against the drug and cause resistant infections in that patient and/or spread to other people

Improving Antibiotic Use to Combat Resistance

It is a national priority to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance
Improving the way healthcare professionals prescribe antibiotics, track antibiotics, and the way we take antibiotics, helps keep us healthy now, helps fight antibiotic resistance, and ensures that these life-saving drugs will be available for future generations
www.cdc.gov/antibiotic-use

Antibiotic Resistance

Antibiotic resistance is one of the most urgent threats to the public health
Each year in the U.S., at least 2 million people get infected with antibiotic-resistant bacteria. At least 23,000 people die as a result
Antibiotic resistance does not mean the body is becoming resistant to antibiotics; it is that bacteria develop the ability to defeat the antibiotics designed to kill them
When bacteria become resistant, antibiotics cannot fight them, and the bacteria multiply
Some resistant bacteria can be harder to treat and can spread to other people

Antibiotic Stewardship

Antibiotic Stewardship is the effort
- To measure antibiotic prescribing
- To improve antibiotic prescribing by clinicians and use by patients so that antibiotics are only prescribed and used when needed
- To minimize misdiagnoses or delayed diagnoses leading to underuse of antibiotics
- To ensure that the right drug, dose and duration are selected when an antibiotic is needed
Goal of antibiotic stewardship is to maximize the benefit of antibiotic treatment while minimizing the harm both to individual persons and to communities

Antibiotics Aren’t Always the Answer

Everyone has a Role in Improving Antibiotic Use

Healthcare Providers
Patients and Families
Health Systems (hospitals, clinics, nursing homes)
Healthcare Quality Organizations
Health Insurance Companies
Healthcare Provider Professional Organizations
Federal, State, and Local Health Agencies

Healthcare Providers

Follow clinical guidelines when prescribing antibiotics – Remember to prescribe the right antibiotic, at the right dose, for the right duration, and at the right time
Protect your patients, only prescribe antibiotics when needed; You can do harm by prescribing antibiotics that aren’t needed
Place written commitments supporting antibiotic use in exam rooms to help facilitate patient communication
Tell your patients why they don’t need antibiotics for viral infection, what to do to feel better, and when to seek help if they don’t feel better
Talk to your patient and families about the possible harms from antibiotics, such as allergic reactions, C. difficile, and antibiotic-resistant infections
Review antibiotic therapy 48-72 hours after started and change orders as needed – a critical step in care
Watch for sign of sepsis (confusion, shortness of breath, high heart rate, fever or shivering, extreme pain, clammy or sweaty skin) and start antibiotics immediately
Be aware of antibiotic resistance pattern in your facility and community; use data for prescribing
Follow hand hygiene and other infection prevention measures on every patient

Patients and Families

Talk to healthcare provider about when antibiotics will and won’t help, ask about antibiotic resistance
Talk to healthcare provider about how to relieve symptoms
Ask what infection an antibiotic is treating, how long antibiotics are needed, and what side effects might happen
Take antibiotics only when prescribed and exactly as prescribed
Don’t save an antibiotic for later or share the drugs with someone else
Insist that everyone cleans their hands before touching you
Stay healthy and keeps others healthy be cleaning hands, covering coughs, staying home when sick, and getting recommended vaccines
Get vaccinated for flu and pneumonia

Symptom Relief Suggestions

Pain relievers
Fever reducers
Saline nasal spray or drops
Warm compresses
Liquids
Rest

Health Systems, Hospitals, Clinics, and Nursing Homes

Adopt and implement antibiotic stewardship policies and strategies, including CDC’s Core Elements of Antibiotic Stewardship
Designate staff members to coordinate antibiotic stewardship activities
Monitor antibiotic prescribing data to identify areas for improvement, and assess the impact of antibiotic stewardship areas
Educate staff about antibiotic resistance and strategies to optimize antibiotic prescribing

Healthcare Quality Organizations

Develop and implement standards requiring antibiotic stewardship programs and practices
Develop and adopt standards measuring the success of antibiotic stewardship programs and practices

Health Insurance Companies

Incentivize implementation of antibiotic stewardship programs and practices
Use clinical performance data on quality measures for appropriate prescribing, such as the Healthcare Effectiveness Data and Information Set (HEDIS)measures

Healthcare Provider Professional Organizations

Create and share clinical practice guidelines for the diagnosis and management of common conditions
Incorporate antibiotic stewardship principles into antibiotic use guidelines
Provide continuing medical education opportunities about antibiotic stewardship for members
Bolster nation, local, and regional initiatives promoting appropriate antibiotic prescribing and use
Highlight new research and technologies to support antibiotic stewardship

Federal, State, and Local Health Agencies

Set expectations for the implementation of antibiotic stewardship activities across the spectrum of health care
Provide data and tools to help guide stewardship activities
Connect local stakeholders and coalitions
Support partners, healthcare providers, and patients through development and dissemination of educational resources
Support innovations and research, such as diagnostic test development, that facilitate optimal antibiotic use

What Do We Know About Antibiotic Use In Outpatient Settings?

In 2015 alone, approximately 269 million antibiotic prescriptions were dispensed from outpatient pharmacies in the U.S.
Enough for five out of six people to receive one antibiotic prescription each year
At least 30% were unnecessary
Most unnecessary prescriptions are for respiratory conditions most commonly caused by viruses that do not respond to antibiotics
Data show that antibiotics are prescribed more frequently in states in the Southern and Appalachian regions
Prescribing the correct antibiotic is another area that needs attention – patients often prescribed antibiotic not recommended by current clinical guidelines
Family practice physicians prescribe the most antibiotics

Core Elements of Outpatient Antibiotic Stewardship

Commitment – Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety
Action for policy and practice – Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed
Tracking and reporting – Monitor antibiotic prescribing practices and offer regular feedback to providers, or have providers assess their own antibiotic prescribing practices
Education and expertise – Provide educational resources to providers and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing

Audience for Outpatient Antibiotic Stewardship

Primary care clinics and providers
Outpatient specialty and subspecialty clinics and providers
Emergency departments and emergency medicine providers
Retail health clinics and providers
Urgent care clinics and providers
Dental clinics and dentists
Nurse practitioners and physician assistants
Healthcare systems
Patients and their families

Antibiotic Stewardship Programs and Activities Can:

Improve patient outcomes – By reducing unnecessary antibiotic prescribing, antibiotic stewardship programs and activities can improve the treatment of infections and prevent avoidable side effects, reactions, and other problems for patients
Decrease C. Difficile infections – By reducing the use of high-risk antibiotics
Decrease antibiotic resistance – Preventing infections and improving antibiotic prescribing could save 37,000 lives from antibiotic resistant infections over 5 years
Decrease Costs – They have consistently demonstrated annual savings of $200,000 to $400,00 in hospitals and other healthcare facilities

Patient Engagement

To learn more about antibiotic prescribing and use, visit: www.cdc.gov/antibiotic-us

Engaging patients is critical to the effort to improve antibiotic use
Helping patients know what they can do to keep themselves and their loved ones safe is part of the discussion of improving antibiotic use
This means raising awareness about the side effects of antibiotics, as well as the unintended consequences of antibiotic use
CDC’s new and existing education efforts will work to ensure that antibiotics are used properly and that patients that might have sepsis are recognized and started on antibiotic quickly, and reassessed within 48 hours when the patient’s culture results are back

Patient Involvement and Empowerment

Get the facts about antibiotics. Antibiotics do not work on viruses, such as colds and flu, or runny noses, even if the mucus is thick, yellow or green. When antibiotics aren’t needed, they won’t help you, and the side effects could still hurt you
Ask doctor or nurse about the best way to feel better while your body fights off a virus (pain relievers, fever reducers, saline nasal spray or drops, warm compresses, liquids and rest may help)
If you need antibiotics, take them exactly as prescribed. Talk with your doctor if you have questions about your antibiotics, or if you develop any side effects
Stay healthy and keep others healthy by cleaning hands, covering coughs, staying home when sick, and getting the recommended vaccines, (e.g. for flu)
Patient and families are encouraged to use the education materials and learn more about antibiotics – www.cdc.gov/antibiotic-use

Patient and Family Education

Communicate strategies to educate patients about when antibiotics are and are not needed

Inform that antibiotic treatment for viral infections provides no benefit
Inform that certain bacterial infections (mild ear, sinus) might improve without antibiotics
Provide recommendations for when to seek medical care if symptoms worsen or do not improve

Educate patients about the potential harms of antibiotic treatment

Common and serious side effects
Evidence suggests that use in infancy and childhood is linked with allergic, infectious, and autoimmune diseases

Provide patient education materials

Information on appropriate antibiotic use, adverse drug events, and resources regarding symptomatic relief for common infections
CDC http://www.cdc.gov/getsmart

Leadership Commitment

Dedicating necessary human, financial and information technology resources
Write statements in support of improving antibiotic use to be shared with staff and families
Include stewardship-related duties in position job descriptions
Communicate with nursing staff and prescribing clinicians the facilities’ expectations about use, monitoring, and enforcement of stewardship policies
Create a culture through messaging, education and celebrating improvement, which promotes stewardship

In Summary

Efforts to improve antibiotic use will succeed only if everyone plays a role
Antibiotics save lives. – When a patient needs antibiotics, the benefits outweigh the risks of side effects and antibiotic resistance.
Improving the way we take antibiotics helps keep us healthy now, helps fight antibiotic resistance, and ensures that life-saving antibiotics will be available for future generations

Citations

CDC. Antibiotic Use in the United States, 2017: progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2017.
Sanchez, G.V., Fleming-Dutra, K.E., Roberts, R.M., Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1-12
CDC. The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. Available at: http://cdc.gov/longtermcare/index.html
CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC: 2014. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
National Quality Forum: Antibiotic Stewardship in Acute Care
www.qualityforum.org
www.cdc.gov/antibiotic-use