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- Reduce Duration of Antibiotic Treatment for Uncomplicated CAP to 5 Days
Reduce Duration of Antibiotic Treatment for Uncomplicated CAP to 5 Days
Background, Rationale and Suggested Implementation Strategies
- Educate providers about the elimination of HCAP and new broader CAP definition per the 2019 IDSA/ATS CAP guidelines.
- Educate providers on the justification for 5 days of therapy for uncomplicated CAP.
- Review CAP cases identified by HMS to implement high-yield interventions for recurrent problems
- Evaluate and understand differences in provider groups (e.g., Hospitalists, Emergency Medicine providers). Target interventions to specific provider groups as necessary.
- Evaluate existing order sets to ensure antibiotic preferred options, doses, and durations are consistent with institutional pneumonia guidelines.
- Require documentation of dose and indication of antibiotics prescribed in the antibiotic order.
- Encourage documentation of dose, indication, and duration of antibiotics in the progress note.
- Require a 72-hour Antibiotic Time Out, during which total duration should be discussed.
- Focus efforts on discharge prescribing, as HMS data shows that discharge prescriptions account for 80% of inappropriate antibiotic treatment for uncomplicated CAP.
- Require documentation of the total duration of antibiotics in the discharge summary, potentially incorporating an area for antibiotic duration to be filled out in an automated discharge process.
- Incorporate nursing and pharmacy into review of the discharge antibiotic.
- Provide audit and feedback directly to providers regarding the duration of antibiotics they use for patients with uncomplicated CAP.
- Consider incorporating compliance with treatment duration for uncomplicated CAP as part of hospitalists’ performance targets (for compensation).
Resources and Tools
- HMS Document: Treatment Duration for Uncomplicated Community-Acquired Pneumonia: The Evidence in Support of 5 Days. (updated 2/19/2021)
- Review HMS site reports (hard copy distributed at collaborative wide meetings and live reports available daily via the HMS data entry system) for the following:
- Uncomplicated CAP treated with 5 days of antibiotics
- Types of Reports Available via HMS Registry: Hospital Specific, Provider Group Specific (i.e. hospitalist v. emergency room physician), or Provider Specific
- Uncomplicated CAP treated with 5 days of antibiotics
- HMS Guideline:
- CAP Pocket Card
- Consider modifying to poster size for posting in workrooms
- Fact Sheet Emphasizing Focus on Discharge Prescriptions
- Antibiotic Time Out Checklist
- Tiered Antibiotic Use at Discharge Resource
- CDC Poster: Be Antibiotics Aware at Hospital Discharge
- CDC Poster: Use the Shortest Effective Antibiotic Duration
- Antibiotic Use at Discharge Pocket Card (Michigan Medicine)
- “Strive for Five” Hospital Newsletter Example (Corewell Health Farmington Hills)
- Example of email feedback on provider performance for duration of CAP treatment #1 – Top Performer (Trinity Health Ann Arbor)
- Example of email feedback on provider performance for duration of CAP treatment #2 – Prolonged Duration of Antibiotics (Trinity Health Ann Arbor)
- Case Studies: Adult Case – Community Acquired Pneumonia (Presentation for SHEA ASP Training Course, 2021 by Dr. Valerie Vaughn)
- Video Presentation: Diagnostic Error and Antibiotic Use in Patients Hospitalized with Pneumonia Training Video
- Presenter: Valerie Vaughn, MD, MSc
- Session Length: ~24 minutes
- Sepsis Alliance Webinar: The Blind Spot of Antibiotic Stewardship – Antibiotic Overuse at Discharge
- Presenter: Valerie Vaughn, MD, MSc
- CE Information: 1.6 CNE, 1.25 CE for other healthcare professionals
- Session Overview: This presentation will address the current state of antibiotic use at discharge, discuss why providers often overprescribe at discharge, and help improve prescribing and patient outcomes during care transitions.
- Presentation (For HMS Members – Additional authentication may be required):
- Antimicrobial Use Breakout Session – Improving Antimicrobial Use at Discharge at the March 17, 2021 HMS Collaborative Wide Meeting
- Dr. Stephanie Burdick (Medical Director, Clinical Standardization – Corewell Health Grand Rapids) at the November 2, 2022 HMS Collaborative Wide Meeting: Community Acquired Pneumonia – Growing a Culture of Stewardship
- Order set examples from this presentation
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- Henry Ford River District Antimicrobial Stewardship Team at the March 15, 2023 HMS Collaborative Wide Meeting: Journey of a Small Hospital – The CAP Experience
- Slides 14-16 show an example of a Message Center Alert that directs the physician’s ability to quickly identify the antibiotics and number of days the patient has received so far
- Henry Ford River District Antimicrobial Stewardship Team at the March 15, 2023 HMS Collaborative Wide Meeting: Journey of a Small Hospital – The CAP Experience
References
- Avdic E, et al. Impact of an Antimicrobial Stewardship Intervention on Shortening the Duration of Therapy for Community-acquired Pneumonia. Clin Infec Dis 2012.
- Reduced treatment duration of CAP with educational lectures based on survey results, and post-prescription pharmacy review with verbal feedback
- Ciarkowski CE, et al. A Pathway for Community-Acquired Pneumonia with Rapid Conversion to Oral Therapy Improves Health Care Value. Open Forum Infect Dis 2020.
- This study noted a shorter length of IV antibiotic therapy when a clinical decision support-driven CAP pathway was implemented, along with active antimicrobial stewardship review.
- Foolad F, et al. A Multi-center Stewardship Initiative to Decrease Excessive Duration of Antibiotic Therapy for the Treatment of Community Acquired Pneumonia. J Antimicro Chemo 2018
- Treatment duration for CAP was reduced by updating institutional CAP guidelines, providing educational sessions and performing daily audit and feedback on appropriate treatment duration for CAP patients.
- Giesler DL, et al. Reducing Overuse of Antibiotics at Discharge Home: A Single-Center Mixed Methods Pilot Study. Am Journ Inf Con 2022.
- A pharmacist-facilitated antibiotic timeout at time of hospital discharge was feasible and holds promise as a method to improve antibiotic use at discharge.
- Petty LA, et al. Impact of Updated ATS/IDSA CAP Guidelines on Duration of Antibiotics. Open Forum Inf Dis 2022.
- Among patients hospitalized with pneumonia, two thirds received an excess antibiotic duration. Prior to the updated IDSA guidelines, the 5-day treatment rate was improving for HCAP and pCAP – suggesting the 2019 guidelines did not have an added effect on improving antibiotic duration.
- Vaughn V, et al. Antibiotic Stewardship Strategies and Their Association with Antibiotic Overuse After Hospital Discharge: An Analysis of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home Framework. Clin Inf Dis 2022.
- Antibiotics are frequently prescribed and overprescribed at hospital discharge, leading to patient harm. In 2019, a total of 39 hospitals were surveyed for their antibiotic stewardship strategies around discharge for patients with CAP and UTI. The more stewardship strategies reported, the lower a hospital’s antibiotic overuse at discharge.
- Vaughn V, et al. Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized with Pneumonia. Annals of Int Med 2019.
- Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events.
- Vaughn V, et al. A Statewide Collaborative Quality Initiative to Improve Antibiotic Duration and Outcomes in Patients Hospitalized with Uncomplicated Community-Acquired Pneumonia. Clin Inf Dis 2022.
- Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. Across a range of hospitals, Michigan Hospital Medicine Safety Consortium (HMS) participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP.
- Yogo N, et al. Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach. Infect Contol Hosp Epidemio 2017.
- Reduced antibiotic duration prescribed at discharge by developing a guideline for antibiotic selection and treatment duration and performing pharmacy audit and feedback of discharge prescriptions