CDC’s Core Elements of Outpatient Antibiotic Stewardship

CDC’s Core Elements of Outpatient Antibiotic Stewardship


[ Music ]>>Hello, good afternoon and welcome
to today’s webinar: CDC’s Core Elements of Outpatient Antibiotic
Stewardship, hosted by CDC. CDC’s mission is to protect patients
whenever they receive their medical care. My name is Kelly O’Neill and I’m a Health
Communications Specialist leading antibiotic stewardship communications for the Division
of Healthcare Quality Promotion at CDC. This webinar is part of a series of infection
control related webinars that CDC hosts along with a variety of external partners and experts. Thank you for joining us today. Today our featured speaker is Dr. Katherine
Fleming Dutra, Medical Officer sorry, just having some slide issues Dr. Katherine
Fleming Dutra, Medical Officer in the Office of Antibiotic Stewardship in the Division
of Healthcare Quality Promotion at CDC. She will discuss implementing antibiotic
stewardship into your outpatient practice. Before we get started there a
few housekeeping items to cover. We welcome your questions. Please submit any questions or comments
you have via the chat window located on the lower left hand side of the webinar
screen anytime during the presentation. Questions will be addressed after
all presentations as time allows. To ask for help, please press the raised
hand button located on the top left hand side of the screen if you need to chat with
a meeting chairperson for assistance such as technical difficulties
during the webinar. To hear the audio please ensure that your
speakers are turned on with the volume up. The audio for today’s conference should
be coming through your computer speakers. In addition, the speaker slides from
today’s presentation will be provided to participants in a follow-up email. Thank you. Now it is my pleasure to introduce our speaker
for today, Dr. Katherine Fleming Dutra.>>Thank you and thanks for
joining us this afternoon. As far as today’s objectives, we will review
the importance of antibiotic stewardship in outpatient settings, then we will identify
four core elements of antibiotic stewardship across various outpatient settings and finally,
we will discuss evidence based strategies that can be used to implement the
core elements in your practice. So why is antibiotic stewardship so important? It’s because antibiotics really
are such important medicines. The lifesaving benefits of antibiotics in
medicine and public health are undeniable. Infectious bacterial diseases that were once
deadly are now treatable substantially reducing deaths compared to the pre antibiotic era. We should also recognize that antibiotics
are an important and crucial adjunct to modern medical advances permitting
surgical and medical treatments for a variety of serious illnesses. Antibiotics are critical tools that help make
transplants and cancer chemotherapy possible by allowing us to prevent and
treat bacterial infections. Antibiotics really are miracle drugs and we
need them and we need them to keep working. And that’s why antibiotic resistance is one of the most pressing public
health threats of our time. CDC estimates that two million
illnesses and 23,000 deaths are caused by antibiotic resistant infections
each year in the U.S., and antibiotic resistant infections
cost an estimated $20 billion dollars in excess direct healthcare costs annually. To be very clear, the primary modifiable driver
of antibiotic resistance is antibiotic use. To illustrate this let’s walk through a
brief timeline of the history of antibiotics. On the top you can see the year that
each of these antibiotics were introduced and then we can overlay the date that resistance
was first identified in select species to each of these antibiotics, and what you can see is that resistance is never far behind
the introduction of new antibiotics. Bacteria will inevitably find ways of
resisting antibiotics developed by humans which is why aggressive action is needed
now to keep new resistance from developing and to prevent the resistance that
already exists from spreading. And that’s why we must use
antibiotics appropriately. And it isn’t just antibiotic
resistance that we have to worry about. It’s important to remember that antibiotics
can also have other unintended consequences including adverse events. It’s really a matter of patient safety. Antibiotic associated adverse events can range
from minor conditions to much more severe. They can cause side effects like rashes
and antibiotic associated diarrhea and they can cause allergic reactions including
life threatening ones like anaphylaxis. And one in a thousand antibiotic prescriptions
leads to an emergency department or ER visit for an adverse event which equates
to 142,000 ER visits per year for antibiotic associated adverse events. And this is especially problematic
for the pediatric population as antibiotics are the most common cause of drug related emergency
department visits for children. And there is also emerging evidence of
long term consequences of antibiotic use. Evidence that antibiotics are associated
with chronic disease including allergic and autoimmune diseases through disruption of
the microbiota the community of microbes living in and on our body and the
microbiome, the collective genes and gene products of that microbial community. Another serious unintended consequence of antibiotic use are clostridium
difficile infections. Clostridium difficile or C. diff is a bacterium that can cause very serious diarrheal
illness even life threatening illness. Taking antibiotics can put people
at risk for C. difficile infection. In 2013 the CDC estimated that C.
difficile caused at least 250,000 infections and 14,000 deaths in the U.S. each year
leading to an estimated $1 billion dollars in medical costs, and a more recent estimate put
those numbers even higher at 453,000 infections and 15,000 deaths annually in the U.S.,
and the risk of C. difficile infections and adverse events and the risk of antibiotic
resistance, these are all reasons why it’s so important to use antibiotics
only when they are needed. So with why should we focus
on the outpatient setting? Antibiotic stewardship programs are
traditionally in the inpatient setting. This graph shows antibiotic expenditures
in the U.S. by treatment setting which totaled $10.7 billion in 2009. Of that $10.7 billion, 62 percent of antibiotic
expenditures occurred in the community or outpatient setting followed by 34 percent
in hospitals and 5 percent in nursing homes. And remember that most antibiotics used in
the inpatient setting are much more expensive than those used in the outpatient setting. And thus the actual volume of antibiotic use in
the outpatient setting is likely much higher. Based on data from other developed
countries we estimate that 80 to 90 percent of human antibiotic use occurs in the outpatient
setting illustrating why antibiotic stewardship is also critical to combatting
antibiotic resistance. It’s clear that we need to improve antibiotic
use across the spectrum of healthcare and we can’t leave the outpatient
setting out of those efforts. So do we have room to improve antibiotic
prescribing in the outpatient setting? We do. Recently CDC estimated
that at least 30 percent, almost one third of antibiotic
prescriptions written in the outpatient setting were unnecessary
meaning that no antibiotic was needed at all. And even among the quote necessary 70 percent, there are still more inappropriate antibiotic
prescribing including inappropriate antibiotic selection meaning that the wrong antibiotic
may have been chosen, inappropriate dosing, and inappropriate duration meaning
that the antibiotic was given for too long or too short a time. Total inappropriate antibiotic prescribing
including unnecessary antibiotic prescribing plus inappropriate selection, dosing
and duration is likely much higher. So what is antibiotic stewardship? Antibiotic stewardship is the effort
to measure antibiotic prescribing, to improve antibiotic prescribing so that
antibiotics are only prescribed and used when needed, to minimize misdiagnoses or
delayed diagnoses leading to the underuse of antibiotics, to ensure that the right drug, dose and duration are selected
when an antibiotic is needed. And antibiotic stewardship is
fundamentally about patient safety and delivering high quality healthcare. Antibiotics are wonderful medicines. They are lifesaving, but like all
medicines they have risks and benefits and to keep our patients
safe, we want to make sure that we are using antibiotics appropriately. In 2014 and 15, CDC released the Core Elements
of Hospital Antibiotic Stewardship Program and the Core Elements of Antibiotic
Stewardship for Nursing Homes respectively. These core elements do not include the
outpatient setting and we heard from or stakeholders that there
was a need for core elements for outpatient antibiotic stewardship based
on the outpatient stewardship literature, based on what works in the outpatient setting
and that’s tailored for outpatient settings. So we heard you and now we have the Core
Elements of Outpatient Antibiotic Stewardship which were published in the Morbidity and
Mortality Weekly Report or MMWR: Recommendations and Reports last week on November 11th and
these core elements provide a framework for improving antibiotic prescribing by
outpatient clinicians and within facilities that routinely provide outpatient
antibiotic treatment. So who are the Core Elements of Outpatient
Antibiotic Stewardship intended for? They have a broad target audience and are
intended for any outpatient clinician, clinic or health system that is interested
in improving antibiotic prescribing and use. These may include: primary care clinicians
and clinics, outpatient specialty and subspecialty clinicians and clinics,
emergency department, retail health clinicians, dentists, urgent care clinicians, nurse
practitioners and physician assistants working in outpatient settings, and healthcare
systems that have outpatient facilities. So where do you start? What are the initial steps to implementing
outpatient antibiotic stewardship? First, it’s important to identify within your
practice or clinic what are the opportunities for improvement by identifying the high
priority conditions for intervention. So high priority conditions are those
conditions within your practice or facility for which clinicians are commonly deviating
from best practices for prescribing antibiotics. So some examples of the types
of conditions that often lead to inappropriate antibiotic prescribing are: Conditions for which antibiotics
are overprescribed such as acute bronchitis a condition for
which antibiotics are not recommended but are often prescribed;
conditions which are overdiagnosed for example streptococcal pharyngitis
which is sometimes diagnosed in the absence of confirmatory tests such as a
rapid strep test or a throat culture; conditions for which the wrong dose,
duration or agent is selected such as when clinicians diagnose acute bacterial
sinusitis and prescribe azithromycin rather than amoxicillin or amoxicillin/clavulanic
acid as recommended by national clinical practice guidelines;
conditions for which watchful waiting or delayed prescribing is underused such as for
acute otitis media in children and conditions for which antibiotics are underused or the
need for timely antibiotics isn’t recognized, for example sexually transmitted diseases in
which misdiagnoses might lead to undertreatment or in sepsis in which timely
treatment with antibiotics is critical. Next it’s important to identify barriers
that lead to deviation from best practices. So barriers to prescribing antibiotics
appropriately might include clinician knowledge gaps about best practices in clinical
practice guidelines but deficits in clinician knowledge are
seldom the only barrier to prescribing antibiotics
appropriately in the outpatient setting. Other barriers to appropriate
prescribing include clinician perception of patient expectations for antibiotics,
perceived pressure to see patients quickly, clinician concerns about decreased
patient satisfaction with clinical visits when antibiotics are not prescribed. Effective antibiotic stewardship
interventions need to help clinician address and overcome barriers to
appropriate prescribing. And in order to do so it’s important
to understand what those barriers are. And finally establish standards for prescribing. Standards for antibiotic prescribing can be
based on national clinical practice guidelines by national healthcare professional societies
such as the American Academy of Pediatrics, the American College of Physicians or the Infectious Diseases
Society of America to name a few. Or if applicable can be based on facility or
system specific clinical practice guidelines. Establishing standards is really
the foundation of deciding what is and what is not appropriate antibiotic
prescribing and clinicians need to know what they are supposed to be
prescribing to be able to make improvements. So what are the four core elements
of outpatient antibiotic prescribing? First is commitment which means to
demonstrate dedication to and accountability for optimizing antibiotic
prescribing and patient safety. Next is action for policy and practice to
implement at least one policy or practice to improve antibiotic prescribing, assess
whether it’s working and modify as needed. After that is tracking and reporting which means
to monitor antibiotic prescribing practices and offer regular feedback to clinicians or
have clinicians assess their own antibiotic use. And finally is education and expertise to
provide educational resources to clinicians and patients on antibiotic
prescribing and ensure access to needed expertise on antibiotic prescribing. So next I’m going to go through each element in
detail and for each I’ll describe the element and then highlight interventions aimed
at clinicians including those in small or solo practice and then interventions aimed
at clinic or health system leadership levels. We organize the document in this way in order to
make it easier for clinicians in small practices to find those interventions that
are pertinent to their setting. And for the leadership of bigger
organizations to find those interventions that may need the infrastructure of a
larger clinic or system to accomplish. In order to meet each core element only
one suggested intervention needs to be done from either the clinician list or
the organizational leadership list. And as I talk about each list I
will talk about the interventions under the clinician section
or the organization section. With that being said, we hope that clinicians
and health systems will strive to implement many of the interventions over time from both
lists whichever makes the most sense for your practice. So first, commitment again means
demonstrating dedication to and accountability for optimizing antibiotic
prescribing and patient safety. So first, I’ll focus on what clinicians can do. Individual clinicians can write
and display public commitments in support of antibiotic stewardship. This sounds perhaps a bit corny but it’s
actually an evidence based intervention to improve antibiotic prescribing. So using public commitments is a novel approach
to changing prescriber behavior that relies on principles of behavioral science. In a study published in JAMA
Internal Medicine in 2014, Mika and colleagues used a very simple
intervention, putting a poster in the exam room with clinicians’ pictures and commitments
to use antibiotics appropriately. But they did this intervention in a scientifically rigorous
way, a randomized control trial. They used a principle of behavioral
science, the clinicians like all people want to be consistent with their
previous commitments. The poster had the clinician’s picture on it and
the commitment to use antibiotics appropriately and they called this a behavioral
nudge to make the right choice. They didn’t require that the
antibiotics were used appropriately, but the poster reminded clinicians of their
commitment to use antibiotics appropriately at exactly the right time, at the
time of the patient encounter. And the poster contained a letter on it and
to highlight part of what it said it ended with this quote, “As your doctors we promise
to treat your illness in the best way possible. We are also dedicated to
avoid prescribing antibiotics when they are likely to do more harm than good.” And the amazing thing is that this
worked, it actually worked really well. In the poster group, there
was a 20 percent reduction in inappropriate antibiotic prescribing for
acute respiratory infections compared to control and it was statistically significant. And this is a fairly impressive effect size for improving antibiotic
prescribing and at a minimal cost. So the study highlights the importance of
recognizing that prescribing is a behavior and insights from behavioral science are likely
to help us change the behavior for the better. And so I hope you’ll see this importance
in the remaining core elements. And we aren’t the only ones that
think this is a great intervention. The authors of the poster commitment
study have assisted states and clinicians across the country to implement
their own version of this commitment to appropriate antibiotic prescribing including
the Illinois Department of Public Health and Superior Health Plan in Texas in
collaboration with the Texas Health and Human Services Commission and
Department of State Health Services, and the New York State Department of Health
which is providing commitment posters and encouraging clinicians to
sign their Get Smart guarantee. To read more about these three examples please
visit our safe healthcare blog post listed at the link. And we at CDC would really like to
see every clinic use this simple, low cost and effective intervention and CDC
also worked with the authors of this study to make the commitment poster to make a
commitment poster that’s now available on CDC’s website for download and
clinicians can add their signature and pictures and post it in their clinics. So we hope that you’ll all make the commitment
to use antibiotics appropriately by starting with a commitment poster either by using
one of the ones available in your state, making one yourself or by
using the one from CDC. And in doing so you will fulfill the first core
element of outpatient antibiotic stewardship. At the organizational level in
addition to the commitment poster, leadership can also identify a single leader
to direct antibiotic stewardship activities within a facility, they can include
antibiotic stewardship related duties and position descriptions
or job evaluation criteria which will help ensure staff members have
sufficient time and resources to devote to stewardship, and they can communicate with all clinic staff members
to set patient expectations. Patient visits for acute illnesses might or
might not result in an antibiotic prescription and all staff members can improve antibiotic
prescribing by using consistent messages when communicating with patients
about the indications for antibiotics. Action means implementing at least one policy
or practice to improve antibiotic prescribing, assess whether it’s working,
and modify as needed. So we have included a lot of
examples of actions but again, I want to stress that the core elements
are about implementing at least one, so don’t feel like you need
to start with all of these. As with all quality improvement
initiatives it’s best to implement these elements
in a step-wise fashion. Implement an action, assess whether it’s
working and then modify it if needed. Individual clinicians can implement
at least one of the following actions: use evidence based diagnostic criteria and
treatment recommendations based on national or local clinical practice guidelines. And clinicians can also use delayed prescribing
practices or watchful waiting when appropriate. Delayed prescribing can be used for
patients with conditions that usually resolve without treatment but who can benefit from
antibiotics if the conditions do not improve. Examples of conditions for which national
clinical practice guidelines support the use of delayed prescribing or watchful waiting
include acute uncomplicated sinusitis or mild acute otitis media in children. And we at CDC know that it
can be challenging to keep up with the national clinical
practice guidelines from all of the various professional societies
so on our website we have consolidated and summarized the treatment
recommendations for adults and children for common outpatient sections as
well as provided the references and links to the national guidelines. So please check out this site for
an easy summary of these guidelines. For the organizational leadership actions may
also include providing communication skills training for clinicians, requiring explicit
written justification in the medical record for non recommended antibiotic prescribing,
providing support for clinical decisions and using call centers, nurse
hotlines or pharmacist consultations as triage systems to prevent unnecessary visits. More information about all of these
interventions including the references for which the supporting evidence
for the supporting evidence for these interventions are contained
in the core elements document. But I want to take a minute to highlight one of
these actions, communication skills training. So communication training is actually an
effective antibiotic stewardship intervention. Studies using enhanced communication training
have reduced inappropriate antibiotic prescribing for respiratory infections
while maintaining patient satisfaction. And the communication training
has reviewed a number of goals for each visit including
understanding the patient’s expectation, explaining why antibiotics
will or will not help, providing symptomatic treatment recommendations
so that the patient can feel better, discussing when the patient should return
or call back if the patient is not better. And the effect of these trainings
was sustainable over time. In one study, improvements in antibiotic
prescribing persisted three and a half years after the communication training occurred. So based on the evidence, training
clinicians to communicate effectively about antibiotic prescribing is an
important stewardship intervention. So we hope that you will train your clinicians
how to approach these very common visits so that they can prescribe antibiotics
appropriately and maintain patient satisfaction. Next is tracking and reporting clinician
antibiotic prescribing, also called audit and feedback which means to monitor
antibiotic prescribing practices and offer regular feedback to clinicians. For individual clinicians, this will likely mean
self-evaluating their own antibiotic prescribing practices to make sure they align with
updated evidence based recommendations and clinical practice guidelines. And one way to do this is to participate
in continuing medical education and quality improvement activities
that incorporate tracking and improving antibiotic prescribing
practices into these activities. These activities may be available through
professional societies and may be used to meet licensure or other
educational requirements. At the organizational level
this means implementing at least one antibiotic prescribing
tracking or reporting system. It can also mean assessing and sharing
performance of quality measures and establish reduction goals addressing
appropriate antibiotic prescribing. So for example, three current healthcare
effectiveness data and information sets or HEDIS measures that are
often tracked by health plans and payers include quality measures
addressing appropriate antibiotic prescribing. These are appropriate testings for children with
pharyngitis, appropriate treatment for children with upper respiratory infections, i.e.
avoidance of antibiotics and avoidance of antibiotic treatment and
adults with acute bronchitis. So organizations can report clinician
performance on these measures, track the clinician as part of
a tracking and reporting system. So what should you track and
report in your outpatient facility? Outpatient clinicians and clinic or health
system leaders can select outcomes to track and report on the basis of
identified opportunities for improvement in their practice or clinics. We really meant this document
to be flexible so it can apply to a variety of outpatient settings. Systems can track high priority
conditions identified as opportunities to improve clinician adherence to best
practices and clinical practice guidelines. So for example, acute bronchitis
is a common condition for which antibiotics are not recommended
in national clinical practice guidelines, yet antibiotics are commonly prescribed. Therefore, leaders might choose to
provide feedback on the percentage of acute bronchitis visits in which a clinician
prescribed an antibiotic and include comparisons to their peers prescribing
percentages for acute bronchitis. Systems can also track the
percentage of all visits for which an individual clinician
prescribed antibiotics meaning the number of all antibiotics prescribed for all diagnoses
by that clinician divided by the total number of visits for all diagnoses by that clinician. And also certain healthcare systems might be
able to track and report the complications of antibiotic use, events like adverse drug
events and Clostridium difficile infections and they can also track antibiotic
resistance trends among common outpatient bacterial pathogens. However, it’s important to note that
at the individual or clinic level, smaller sample sizes might make these
measures based on adverse events and antibiotic resistance less reliable. So it’s important to understand that effective
feedback interventions have included comparisons of clinician’s performance
with that of their peers. Examples of studies that use
peer comparisons include a study that sent regular reports comparing
antibiotic selection patterns of clinicians with their colleagues mean performance. This led to improvements in use of
guideline recommended antibiotic agents for common outpatient conditions
including acute bacterial sinusitis. Another study compared clinician’s
percentage of inappropriate prescribing for acute respiratory conditions
to top performers in their practice and top performers meant clinicians who
are performing in the top 10 percent or had the least amount of antibiotic
prescriptions for acute respiratory infections that did not warrant antibiotics
such as colds and bronchitis. In this study the top performers had zero
or no unnecessary antibiotic prescriptions for acute respiratory infections
that didn’t warrant antibiotics. And this peer comparison intervention led to
decreased inappropriate antibiotic prescribing for acute respiratory infections that
should not be treated with antibiotics, again like colds and acute bronchitis. Another study conducted in the National Health
Service in England looked at the percentage of all visits leading to antibiotic prescription
and notified clinicians who prescribed more than more antibiotics than
80 percent of their peers. They sent a letter to those clinicians
from the Chief Medical Officer of the National Health Service that said,
“quote the great majority, 80 percent, of practices in your area prescribed fewer
antibiotics per head than yours” end quote. This intervention led to decreased overall
antibiotic prescribing and to cost savings. From these studies we can see how important peer
comparisons are to include in effective tracking and reporting system and we hope that
you will include peer comparisons in your tracking and reporting systems. And finally, education and expertise which means
to provide educational resources to clinicians and to patients on antibiotic prescribing
and ensure access to needed expertise on optimizing antibiotic prescribing. Clinicians can educate their
patients and their patients’ families about appropriate antibiotic use. To do so they can use effective
communication strategies to educate patients about when antibiotics are and are not needed. They can educate about the potential harms
of antibiotic treatment including both common and serious side effects of antibiotics, C.
difficile infection and antibiotic resistance and they can provide patient education
materials that include information on appropriate antibiotic use,
potential adverse drug events and available resources regarding
symptomatic relief for common infections. So I want to again highlight
the issue of communication. In this sense educating patients
through effective communication. We talked about how communication training
can be an action for policy and practice. Clinicians themselves can then use
effective communication strategies as a way to fulfill the education
and expertise core element and we very purposely highlighted the importance
of communication in two different places as a way to fulfill the core elements
because it is an evidence based strategy to improve antibiotic prescribing. And it really gets back to understanding
the barriers that prevent clinicians from prescribing antibiotics appropriately
and helping clinicians address those barriers. We know that clinicians cite patient
demands for antibiotics and concerns about patient satisfaction as a
reason they prescribe inappropriately. It turns out patients rarely
overtly request antibiotics and clinicians aren’t actually very good at
determining which patients want antibiotics, but if the clinician thinks
the patient wants antibiotics, they are more likely to prescribe antibiotics. So there is an element of miscommunication
between clinicians and patients that is contributing to inappropriate
antibiotic prescribing and this is where effectively communicating with patients
and educating patients can really help. And patients really can be satisfied
without antibiotics even if they expect them if the clinician can effectively
communicate with them. So a couple of communication techniques
have been shown to be effective. First, combining explanations of why
antibiotics are and are not needed or why antibiotics are not
needed with recommendations for managing symptoms have been
associated with increases in satisfaction and by this we mean educating the patient
why they don’t need antibiotics especially discussing what they see on
physical exams or in the evaluation that shows that antibiotics are not needed. And then also providing those recommendations
of what they can do to feel better. And then providing recommendations of when
to seek medical care if the patient worsens or doesn’t improve also called a
contingency plan, has been associated with increased satisfaction for patients who
expected but did not receive antibiotics. And by this we mean giving specific
messages such as if you develop a fever or you’re not better in a week,
call and come back and see me. So communication can help clinicians
provide quality care to patients, use antibiotics appropriately and
maintain patient satisfaction. And that’s why we hope clinicians will
use effective communication strategies to educate their patients about when
antibiotics are and are not needed. At the organizational level outpatient clinics and healthcare system leaders
can provide education to clinicians and ensure access to expertise. When approaching educational
interventions, it’s critical to understand that in the outpatient sitting inappropriate
antibiotic prescribing is rarely due to knowledge gaps alone. Educational strategies need to be grounded
in helping clinicians address the barriers that lead to prescribing
antibiotics inappropriately. So education can include providing face to face educational training
also called academic detailing, providing continuing education
activities for clinicians and relevant continuing education
activities include those that address appropriate antibiotic prescribing, adverse drug events and communication
strategies. And also by ensuring timely
access to persons with expertise. So what do we mean by this? Expertise in optimizing antibiotic
prescribing may come from pharmacists who can help clinicians optimize
antibiotic dosing and selection and advise clinicians on
medication interactions. In hospitals pharmacists with infectious
disease training have been effective and important members of
antibiotic stewardship programs. Access to expertise might also mean having
access to a dentist to manage dental conditions that need procedures rather
than antibiotics or to a surgeon or to an infectious disease physician. The expertise needed will likely
differ among outpatient facilities and can be determined by each facility. So where can you find information
to educate patients and providers? There are many great resources from
professional societies, from healthcare systems, from many places, but I hope you’ll go to
our website for some of those resources. We are the Get Smart: Know When Antibiotics
Work program and our campaign focuses on increasing awareness about
antibiotic resistance and the importance of appropriate antibiotic use among
healthcare providers and the general public. Our website has lots of information, resources
for patients and healthcare professionals, partners and information about Get
Smart About Antibiotics Week too. So please check it out and we hope you find it
useful and you’re welcome to use or materials and we hope you will as part
of your educational program. This year we have some new materials
for Get Smart About Antibiotics Week. We try to update and add materials every year. So for example, we have patient focused
information this year that’s new on delayed prescribing and watchful waiting
that you can share with your patients, we have a new fact sheet on ear infections, how
they’re treated and also includes information on preventing ear infections and on
watchful waiting for ear infections. And for more resources, please visit or
website for the core elements which has links to the document, to checklists
about implementing the core elements and other resources that can help
you implement the core elements. And we will continue to build this website
out as more resources become available. And also feel free to check out this
Medscape video on the Core Elements of Outpatient Antibiotic Stewardship as well. And finally, the importance of antibiotic
stewardship has risen to national prominence and actually international prominence. President Obama has issued a presidential
proclamation declaring this week Get Smart About Antibiotics Week and I encourage
you to go look at the link here. So in summary, antibiotic resistance
is a major public health threat and antibiotic stewardship is one
of the most important strategies to combat antibiotic resistance
and to keep our patients safe. The Core Elements of Outpatient
Antibiotic Stewardship provides a framework for improving outpatient antibiotic prescribing. And to remind you the core elements include the
following: Commitment, demonstrate dedication to and accountability for optimizing
antibiotic prescribing and patient safety; action for policy and practice, to
implement at least one policy or practice to improve antibiotic prescribing, assess
whether it’s working and modify as needed; tracking and reporting, monitor antibiotic
prescribing practices and offer regular feedback to clinicians or have clinicians assess their
own antibiotic use; education and expertise, provide educational resources to clinicians
and patients on antibiotic prescribing and ensure the needed expertise
on antibiotic prescribing. So we can all be antibiotic stewards and we hope that you will all implement the core
elements in your outpatient practice. And so of course this was the work on
many people and I want to make sure to thank my coauthors including Memo
Sanchez, Becky Roberts and Lauri Hicks. And I also want to thank
those who gave us feedback on this document including John Finkelstein,
Jeff Gerber, Adam Hersh, David Hyum, Jeff Linder, Larissa May, Dan
Merenstein, Katie Suda and Rachel Zetts. To our awesome communications team who
provided feedback and tons of support and many of the accompanying materials Kelly O’Neill,
Austyn Dukes, Rachel Robb and Meredith Reagan. Thanks to Jacque for organizing the logistics
today and thank you to all of you for listening and for all of the great work that you’re doing. I encourage you to visit our website
and I’m happy to take questions now and if you have questions
that come up in the future, please feel free to email
us at [email protected]>>Great. Thank you, Dr. Fleming Dutra for your
time today in explaining this important topic and we’ve received quite a few questions,
so we will do our best to answer as many as possible in the next few minutes. Thank you for chatting in your questions
today and don’t forget if you have a question, please add it to the chat box
on the lower left hand side. One of our first questions is: Most physicians
I work with prefer to prescribe the antibiotic without doing any lab testing
to confirm diagnosis. Could a complete blood count or culture be
utilized prior to prescribing antibiotics?>>Thank you for that question. So I think it depends upon
the clinical situation. Certainly if you’re concerned about sepsis,
blood cultures, cultures of other sites on the body complete blood count and many
other lab tests are very important prior to prescribing antibiotics. Other conditions don’t require a CBC prior to prescribing antibiotics
such as strep pharyngitis. If the rapid strep test is positive
there’s not a need in many circumstances for a backup culture, there’s
not a need for blood work. So it really depends upon the clinical
situation and for those types of things, again, we encourage you to follow your national the
national clinical practice guidelines or local or facility specific clinical
practice guidelines.>>Okay. Thank you. So the next question is: Please differentiate
between microbiome and microbiota. Is this a concept that’s needed
to be taught to patients/clients?>>Great. Thank you for that question. So the definition as I understand it although
I’m not the expert on microbiota and microbiome but the definition as I understand it is
that the microbiota are really the community of microbes living in and on the body that
include bacteria but it also includes viruses and other microorganisms and the
microbiome really means the collective genes and gene products of that microbial community, so obviously these are very
intertwined concepts. So this is in regard to the second part of the
question, this is a complicated thing to explain to patients but I think it is an important one. We are just really starting to understand the
importance of the microbiota and the microbiome to the development of the immune system, to
everything that we do, to the functioning of our bodies, to protecting us
and patients need to understand that antibiotics may have long term
consequences and that disruption of the microbiota is not necessarily a good
thing and that that’s one of the reasons that we want to use antibiotics
only when they’re needed.>>Great, thank you. So next question: Can you address
how immunizations can be part of this list of initiatives?>>Great question. Immunizations are a very important part
of combatting antibiotic resistance and using antibiotics appropriately. Really one of the things that we can do to
prevent the inappropriate antibiotic use is to prevent the infection in the first place. And so for example, the pneumococcal conjugate
vaccine is a great example of a vaccine that has prevented many infections
in children and adults and helped reduce antibiotic resistance by
preventing these infections and the spread of these infections and additionally
influenza vaccine is another vaccine that can really improve antibiotic use. If patients don’t get sick with influenza, they
don’t present for care and they are less likely to get an antibiotic unnecessarily. They are also less likely to get a secondary
bacterial infection associated with influenza. So vaccinations are a very
important part of keeping us healthy and combatting antibiotic resistance.>>Great. Thank you. Next question: Is antibiotic stewardship
part of the standard curriculum in medical schools throughout
the country that you’re aware of?>>I’m going to actually let Dr. Lauri
Hicks who is the Director of the Office of Antibiotic Stewardship answer some of
these questions so she’ll take that one.>>So this is Lauri Hicks and I would
like to let you know and for those of you who are not aware that there is a medical school
curriculum that is actually available online. It’s through Wake Forest University and
was developed in collaboration with folks from the Infectious Disease Department of Wake Forest University and
CDC reviewed the curriculum. It is not a requirement, however, we
certainly are encouraging medical schools to incorporate this curriculum or their own
content related to improving antibiotic use if there is availability in
their curriculum to do so.>>And actually one more question,
Lauri, for you while we have you. Someone had a question about, unlike
inpatient and long term care stewardship, outpatient stewardship has a
stronger patient stakeholder effect. Will there be some form of outreach to the
public at large to increase public awareness by CDC through various public media?>>So I’d like to just state that actually
one of the major goals of Get Smart About Antibiotics Week which
is actually this week and as Katherine mentioned this week the
14th through the 20th and our goal is to reach the general public as well as providers
and all of our partners to improve knowledge around antibiotic resistance
as well as antibiotic use. In addition to that CDC has a
longstanding campaign the Get Smart: Know When Antibiotics Work campaign
and Katherine suggested that you look at our campaign website to access resources
for patients and undoubtedly we have to address all facets of the prescribing problem and that includes addressing the
patient demand aspect of it as well.>>Great. Thank you, Lauri. Let’s see for our next question: Is there
any sort of benchmarking data available or is there a reporting system or tool available to clinicians facilities to
track and report such data?>>So there is there are a couple of
different data systems that we use here at CDC to track national antibiotic prescribing
practices in the outpatient setting. We do look at proprietary data that is
dispensing data from U.S. pharmacies that really gives us a complete picture
of the amount and types of antibiotics that are being dispensed
in the outpatient setting. That being said, it doesn’t come with
indications or diagnoses so it’s somewhat hard to assess appropriateness
but we can see in that data that there is substantial geographic variation
that really suggests inappropriate use of antibiotics in certain parts of the country. Additionally, there are some national surveys
that are run by CDC for which we can look at appropriateness of antibiotic
prescribing in the outpatient setting. These surveys look at doctors’ offices and
emergency departments and we recently used that survey to estimate that 30 percent
of outpatient antibiotic prescriptions in those settings were unnecessary. And then we encourage health systems and clinics
to look at your own data and your own EMRs to look and assess appropriateness of
antibiotic prescribing and then also to use the HEDIS measures and other quality
measures available through the CMS MIPS program and other programs like that to track
performance on the measures that are associated with appropriate antibiotic prescribing and
that can be leveraged by clinicians, clinics, health systems to look at their own
data and to measure improvement.>>Great. Thank you. So two questions related to pharmacists next. Would a pharmacist be an acceptable leader for
outpatient stewardship in the facility setting?>>Absolutely, I think that what
we’re looking for is a leader in the outpatient facility setting who
is understands outpatient stewardship, that understands outpatient
medicine and is excited about this and if a pharmacist is available, I
think they would be an outstanding leader for that activity in outpatient settings. They’ve been outstanding leaders and
contributors to inpatient stewardship so we would love to see pharmacists
step into that role if that’s something available
in your clinic or practice.>>And then a follow-up question
to that: Are there initiatives to have retail pharmacies be proactive in
antibiotic stewardship that you’re aware of?>>That’s a great question. So the Get Smart program has long reached out to pharmacists both clinical
pharmacists and retail pharmacists. Pharmacists certainly they often see
the patient before they ever come in for care to a doctor or another provider. They can help recommend symptomatic treatments
to patients presenting in retail pharmacies, they can also help educate patients when
they receive an antibiotic prescription about adverse events, about taking
the antibiotic correctly and disposing of any leftover antibiotics as well. So we think retail pharmacists are a very
important part of outpatient stewardship.>>Wonderful. The next question: Are you developing a
curriculum for enhanced communications training or are there other resources out there to
help clinicians with communication training?>>Great. That is a great question. There are a couple of resources out there for communications training
and communications skills. We hope to have those posted
on our website linked from our website they are not
our resources but some good ones that we’ll have linked on our website soon. There was a recent skills training that was
funded by the Robert Wood Johnson Foundation from Cognito that worked on communication skills
and you can actually play the role of provider or patient in a conversation about antibiotics. Also the New York State Department of
Health put out a video this week talking about communication around this very issue
and it was really well done and we’re excited to be able to provide those resources
as well from our website hopefully soon.>>Wonderful. Thank you. And then a follow-up to this one:
Since clinicians are often limited with how much time they can spend with a
patient, how would you overcome this barrier to taking the time to educate patients
about why antibiotics aren’t needed?>>That’s a great question and
clinicians do cite concerns for time as a reason they prescribe
antibiotics inappropriately. They sometimes think it’s easier to prescribe
the antibiotic and not fully explain things. But patients really want communication
whether or not they get an antibiotic. That’s what they, you know, they really want
from their clinicians and it doesn’t take that long to to give them that message and I
would argue and I think many people would argue that that’s part of good patient care regardless
of the treatment plan that you’re providing. So there are ways to give those messages in
short and succinct ways that don’t add much time to the visit but also help maintain satisfaction
and we have many materials on our website that can help clinicians
with those types of education and that they can also provide patients.>>And this is Lauri and I would just
add to that that one of the resources that Katherine was alluding to on our website
is a prescription pad for symptomatic therapy and it may just be that the provider is
recommending a humidifier for example lozenges for a sore throat but it provides something
for the patient to do and the patient feels like they have some instructions for
steps that they can take to feel better.>>Great. Thank you. So our next question: How useful are
antibiograms in guiding the primary physicians on which antibiotics to use
and should local data be used.>>That’s a great question. Thank you for that. So antibiograms can be very helpful in helping physicians determine what
the appropriate antibiotic selection for a particular diagnoses are. So for example, for urinary tract
infections it’s very important to know what the local resistance
patterns for urinary pathogens are. One important piece of getting
the correct antibiogram and having that antibiogram be useful is
to make sure that it’s pertinent to your setting and, you know, that it’s local. So if you’re in a primary care
office you don’t want to be looking at the hospital’s ICU antibiogram but really
looking at outpatient primary care antibiograms, but they can there are critical pieces in
forming appropriate antibiotic selection and many of the national clinical practice
guidelines recommend consulting your local antibiograms.>>Great. Thank you. Next question: So regarding tracking and
recording, who is the appropriate person to manage this and how much time
and resources need to be allocated to properly implement a tracking
and reporting system?>>So that is a great question. I think there are multiple people that
could potentially be managing this. It can be the medical director of the
clinic, it can be a nurse administrator, other administrator, it could be a pharmacist. If it’s within a health system it could occur
much more centrally within that health system. It could actually be the clinician that
is doing it within their own practice. It certainly is probably, it
certainly could take a lot of time if there’s not an automated way to do that
in the electronic record but then we hope that for those clinics where
that might be more difficult that you could potentially utilize the HEDIS
measures or other quality measures to start that piece of tracking and reporting as well. And it could also be done manually
with, you know, for certain diagnoses or for a certain number of charts per day.>>Let’s see, so we probably
have time for about one or two more questions before
we just need to wrap up. So here’s another question. Do you anticipate an increase in resource
requirement at the outpatient facility level for implementing policies,
actions, education and monitoring? If so how is this plan to be managed?>>I think that’s a great question. I think that, you know, certainly with all quality improvement initiatives
there certainly is an investment of time and resources that are needed. We hope that this document is flexible, we hope
that it provides a range of different options that some of which are relatively easy
such as the commitment poster to things that require a bit more infrastructure. But we hope that it provides a range of
options that fit many different settings. But again this is really about patient
safety and about high quality healthcare and antibiotic resistance is one of the most
pressing public health threats of our time and outpatient antibiotic use is the majority of
antibiotic use in humans in the United States. And so we really need to focus on this to keep these important lifesaving
medicines working for our patients.>>Great. Thank you. Here’s another question. Do you think antibiotic stewardship will
become a core measure in the outpatient setting as it has in the inpatient setting?>>This is Lauri Hicks and I would say
that we are seeing increasing interest in incorporating I would
incorporating stewardship into policies that would help encourage its
implementation in outpatient settings. And I just want to include a couple of examples,
for example, we have been having discussions with the joint commission about
opportunities to incorporate the core elements into joint commission requirements
for outpatient settings. We’ve also been talking to payers like CMS as
well as private payers about the opportunity to incorporate antibiotic stewardship, outpatient antibiotic stewardship
initiatives into their activities. So I think you should anticipate that this
will be of increasing interest to both payers, policymakers and even some of
our state health departments and I would say state policymakers
are encouraging stewardship activities in all healthcare settings.>>Great. Thank you, Lauri. I think we have time for one more question. So let’s see if we have one here. Here’s one final question, okay Katherine. Are there any public education tools or systems
who are holding on to unused partially used or old antibiotic prescriptions at home?>>Thank you for that great question. There is actually a recent study that shows that
a number of people are holding on to antibiotics at home or sharing antibiotics or doing the
things that we hope that they would never do. So certainly pharmacists are a great
resource for discarding all left over medications including left over antibiotics
and so we would encourage both clinicians when they prescribe antibiotics, pharmacists
when they dispense antibiotics and, you know, public health is, you know, and we have some
of this information on our website as well to encourage patients to discard
any left over antibiotics. Not to share them, not to save them for
next time and never take an antibiotic that was not prescribed for them.>>Wonderful. Thank you everyone for chatting
in all your questions today. That’s all the time we have
for answering these inquiries. But please stay tuned for a follow-up email that
will include the slides from today’s webinar. So we’ll be sending out the slides
following this presentation. And then one final plug for Get Smart Week. We just wanted to remind everyone it is Get
Smart Week and you still have a couple ways that you can be involved with the week including
on Friday we have a global Twitter chat from 11 a.m. to 1 p.m. Eastern using
the hash tag antibiotic resistance. And then definitely check
out our Safe Healthcare Blog for a couple blogs this week
related to stewardship and then we also have some
new data sets available on our Antibiotic Resistance Patient Safety
Atlas and outpatient antibiotic prescriptions and also the percentage of antibiotic
stewardship programs in hospitals and then we’ve also included a link
here where you can check out all of our Get Smart Week promotional materials. And lastly before we finish up today,
to receive continuing education credit for this webinar you must complete and
pass the post test activity at 75 percent and complete the webinar evaluation. So when you close out of this webinar
a post meeting web page will pop up that will have detailed instructions for
completing the CE post test and evaluation, so please be sure to fill that out. And for those on the phone who currently
aren’t logged into Ready Talk online, in order to obtain the CE credit please
go to www.cdc.gov/tceonline and then enter in the access code for this
webinar which is WC1115. And just to say that one more
time the access code is WC1115. And then a follow-up email will also be sent
out this afternoon with detailed instructions on completing the CE post test and evaluation. And with that we’d like to thank you Dr. Fleming
Dutra for talking with us today and for all of you for your time and also Dr. Lauri Hicks
for helping answer some of your great questions. And that is all we have for
you today, so thank you. Oh and again, the website to access
the post test is www.cdc.gov/tceonline and the access code is WC1115. Thank you.

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