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NEVADANS FOR ANTIBIOTIC AWARENESS

NEVADANS FOR ANTIBIOTIC AWARENESS. 2004 Partner Conference April 9, 2004 Bill Berliner, MD. THE ANTIBIOTIC RESISTANCE CRISIS. THE ANTIBIOTIC RESISTANCE CRISIS. HISTORY OF BACTERIA HISTORY OF ANTIBIOTICS RESISTANCE THE PROBLEM NOW NEVADANS FOR ANTIBIOTIC AWARENESS.

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NEVADANS FOR ANTIBIOTIC AWARENESS

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  1. NEVADANS FOR ANTIBIOTIC AWARENESS 2004 Partner Conference April 9, 2004 Bill Berliner, MD

  2. THE ANTIBIOTIC RESISTANCE CRISIS

  3. THE ANTIBIOTIC RESISTANCE CRISIS • HISTORY OF BACTERIA • HISTORY OF ANTIBIOTICS • RESISTANCE • THE PROBLEM NOW • NEVADANS FOR ANTIBIOTIC AWARENESS

  4. HISTORY OF BACTERIA BACTERIA HAVE BEEN AROUND LONGER THAN ANY LIVING THING ON EARTH. FOSSIL EVIDENCE DATES BACK 3.5 BILLION YEARS.

  5. HISTORY OF BACTERIA EARTH AS A DAY: 5:00 AM - BACTERIA APPEAR 10:00 PM - DINOSAURS APPEAR 11:59 PM - HUMANS APPEAR

  6. HISTORY OF ANTIBIOTICS 1928 – DR. FLEMING DISCOVERS PENICILLIN FROM BREAD MOLD 1944 – U.S. MILITARY TAKES PENICILLIN TO THE BATTLEFIELD 1945 – BACTERIA WITH RESISTANCE TO PENICILLIN ISOLATED

  7. HISTORY OF ANTIBIOTICS RESISTANCE 1960’s: METHICILLIN INTRODUCED 1991: 29% OF STAPH AUREUS RESISTANT 2001: 62% OF STAPH AUREUS RESISTANT

  8. THE PROBLEM 1991 1999 2000 2001 1991 1999 2000 2001

  9. THE PROBLEM 2000 2001 2000 2001

  10. THE PROBLEM > 50% OF HOSPITAL ACQUIRED BLOODSTREAM INFECTIONS ARE CAUSED BY METHICILLIN-RESISTANT STAPH AUREUS (MRSA) > 70% OF NURSING HOME STAPH INFECTIONS ARE CAUSED BY MRSA

  11. THE PROBLEM “THERE ARE PATIENTS TODAY IN HOSPITALS FOR WHOM THERE ARE NO EFFECTIVE THERAPIES.” Gary Doern Director of Clinical Microbiology University of Iowa

  12. NEVADANS FOR ANTIBIOTIC AWARENESS WHO WE ARE • A STATEWIDE TASK FORCE THAT HAS BEEN IN EXISTENCE SINCE FEBRUARY 2001 • 3 SUBCOMMITTEES • PUBLIC AWARENESS • PROVIDER EDUCATION • INFECTION CONTROL & SURVEILLANCE

  13. Pharmacist-directed pneumococcal vaccine protocol increases number of patients receiving immunization by 1200% MountainView Hospital - Las Vegas, Nevada Warren Wood, Pharm.D.

  14. Program Revised in 1999 MountainView Hospital • Criteria checked by admitting nurse • Over 65 • Hx of COPD,CHF,CAP,Splenectomy, No previous vaccine • If criteria is met, chart is stamped with an optional order for the physician to check off • Once ordered, the patient was to receive the vaccine after consent was signed • Started June 1999

  15. Pneumococcal Vaccine Results after 3 Years# Patients Receiving During Hospitalization Total doses administered for all of 2002 = 91

  16. Federal Register Oct 2002CMS modified guidelines, Standing Orders Removed requirement for specific physician order Allowed Medical Staff Approved protocols, in place of specific orders Approved for Nursing Homes, Clinics, and Hospitals

  17. Pneumococcal Vaccine CriteriaCDC/MMWR 1997 All immunocompromised persons aged >2yr All persons over 5yr Persons age 2-64 with: Cardiovascular or pulmonary disease Diabetes mellitus Kidney disease Alcoholism, chronic liver disease Cerebrospinal fluid leaks Functional or anatomic asplenia Living in special environments or social settings

  18. Pneumococcal VaccineProcess Revision • Proposed Protocol: • Nurse assessment as before, list sent to pharmacy • Move to a Pharmacist-Directed approach: • Past success with IVtoPO conversion • Change in Medicare Regulations • Pharmacist will write order to administer Vaccine next day • Physician and/or Patient has over-ride ability

  19. Pneumococcal Vaccine Process Flowchart

  20. 4th Qtr 2003 MountainView = 88%

  21. Pneumococcal Vaccine Results#Patients Receiving During Hospitalization 1200% Increase over 2002

  22. Medicare National Voluntary Hospital Reporting Initiative4th Qtr MountainView was at 88% Top 2%

  23. Urgent Care Antibiotic Use Eugene Somphone MD Urgent Care Department Chief Southwest Medical Associates

  24. Introduction • Reduction of antibiotic use • Initial assessment of antibiotic use • Provider and patient education • Incentives to reduce inappropriate use • Follow-up studies • Future reduction

  25. Urgent Care History • SMA Urgent Cares 100,000 visits a year • High volume of respiratory infections • High rate of antibiotic prescriptions

  26. Inappropriate Uses • Over one-half of all antibiotics written annually are for respiratory infections • More than 50 million unnecessary prescriptions are written annually • 17 million prescriptions for antibiotics are written for the common cold • Antibiotics are given to 75% of patients with sore throat

  27. Initial Study • Random charts pulled for upper respiratory complaints • Symptoms of cough, sore throat, runny nose, congestion, sinus pain • Percentage of patients prescribed an antibiotic

  28. Results of Initial Study • Overall prescription rate 66.7% • Fulltime providers 53.5% • Per diem providers 78.8% • Range 14-100% • 3 providers prescribed antibiotics 100% of the time!

  29. Methods to Reduce Inappropriate Use • Patient education • Handouts • Posters • Discussion • Provider education • Financial incentives to reduce inappropriate use

  30. Provider Education • URIs are self-limiting • Colored secretions are not predictors of bacterial infection • Bronchitis is viral in nature • Differentiate sinus symptoms from sinus infection • Otitis media is oftentimes self-limiting • Criteria for Strep throat

  31. Financial Incentives • SMA Bonus • Antibiotic use as quality measure • Goal set at less than 45%

  32. Results • After 3 months rate decreased to 34.2% • After 6 months rate decreased to 30.5%

  33. Patient Satisfaction • Overall patient satisfaction rate remains high • Some disgruntled patients • Less resistance from patients

  34. Rocephin • In 2001 Rancho Urgent Care used $70,000 • Provider education and guidelines • In 2002 all 3 SMA Urgent Cares used $40,000

  35. Choice of Antibiotics • Generic vs. Branded • Narrow-spectrum vs. Broad-spectrum

  36. Provider A • Branded antibiotics prescribed in a 6-month period: • Augmentin 2 • Cipro 1 • Floxin 1 • Levaquin 1 • Omnicef 1 • Tequin 29 • Z-pak 9

  37. Provider A • Generic antibiotics prescribed in a 6-month period: • Amoxicillin 185 • Cefaclor 11 • Cephalexin 87 • Doxycycline 34 • Erythromycin 36 • Penicillin 14 • Tetracycline 3

  38. Provider B • Branded antibiotics prescribed in a 6-month period: • Augmentin 6 • Ceftin 2 • Cipro 7 • Levaquin 6 • Tequin 4 • Z-pak 5

  39. Provider B • Generic antibiotics prescribed in a 6-month period: • Amoxicillin 75 • Cephalexin 57 • Doxycycline 19 • Erythromycin 20 • Penicillin 38

  40. Future Reductions • Rapid Strep Testing • AOM: recent recommendations

  41. Stop Antibiotic Resistance In Washoe County! How Can Childcare Providers Help? Joyce Minter, RN, PHN www.co.washoe.nv.us/health/cchs

  42. About one-third of Nevada’s children under the age five are in some form of licensed childcare because their parents work1Source: Washoe County Child Care Health Consulting; Trust Fund for Public Health, RFA 2002-2003

  43. Approximately 10,000 children under age six attend 327 licensed childcare homes and centers in Washoe County1Source: Washoe County Child Care Health Consulting; Trust Fund for Public Health, RFA 2002-2003

  44. Childcare providers play a key role in disseminating information and health education to children and families

  45. Antimicrobial Resistance (AR) outreach was put into the Child Care Health Consulting (CCHC) grant, a Trust Fund for Public Health (TFPH) grant, to do education and evaluation of efforts The CCHC is part of Health Child Care Nevada, which is part of the Health Care America campaign

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