dicon.medicine.duke.edudason.medicine.duke.edu

CAN DE-ESCALATION BE MEASURED WITHOUT CHART REVIEW? A PROPOSED ELECTRONIC DEFINITIONR E B E K AH W. M O E H R I N G , M D , M P H 1 ; X I N R U R E N , P H D 2; D E V E R I C K J . A N D E R S O N , M D , M P H 1; A N G E L I N A D AV I S , P H A R M D 1; A P R I L D Y E R , P H A R M D 1; Y U L I YA L O K H N Y G I N A , P H D 2; L A U R I A . H I C K S , D O 3; A R J U N S R I N I VA S A N , M D 3; E L I Z A B E T H D O D D S A S H L E Y, P H A R M D , M H S 1

1D U K E C E N T E R F O R A N T I M I C R O B I A L S T E W A R D S H I P A N D I N F E C T I O N P R E V E N T I O N , D U R H A M , N C , U S A

2D U K E B I O S TAT I S T I C S C O R E , D U R H A M , N C , U S A

3C E N T E R S F O R D I S E A S E C O N T R O L A N D P R E V E N T I O N , AT L A N TA , G A , U S A

Disclosures Funding: Centers for Disease Control and Prevention FoundationThe source of this information is the Patient Tools for Antibiotic Stewardship Programs, a joint project made possible by a partnership between the CDC Foundation and Merck & Co., Inc.

Rationale: De-escalation EventsDe-escalation is a core principle of Antimicrobial Stewardship.Target/narrow antibiotic therapies after more data returnsStop therapy when infection has been ruled outTracking de-escalations may:Demonstrate impact of AS activities Identify where AS interventions are needed

EmpiricBroad-spectrum

TargetedNarrow-spectrum

Tim

e

Aim: Create an objective definition for de-escalation based on electronic dataDe-escalation should be considered for any infection treated empirically More broad than pneumonia and ICU1,3,4

De-escalation occurs after a few days of empiric therapy Subset to a hospital population that is eligible2

Instead of only “spectrum,”1 we will also consider “protected” agents Agents we have interest in conserving from AS perspective (e.g. risk of toxicity, safety,

development of resistance, cost)

1. Madaras Kelly ICHE 2014 2. Braykov/Morgan Lancet ID 20143. Yamana JHI 20164. Tabah CID 2015

MethodsSetting: 5 Pilot Hospitals from Duke Health System and the Duke Antimicrobial Stewardship Outreach Network (DASON)Data: electronic medication administration records (eMAR) and demographic dataRetrospective, descriptive, among:HospitalsUnits Infectious syndrome (based on ICD-10 diagnosis for admission)

Calendar year 2016

Inclusion/Exclusion CriteriaInpatient units, excluding behavioral health and procedural unitsAge>=18Anti-bacterial only, excluded inhaled/topical antifungal, antiviral agentsLength of stay 3 days or greater since first calendar day of antibiotic exposure on an inpatient unit (Day 1)Did not die prior to Day 5Minimum time on antibiotics 2 or more days

No:Pediatrics

OutpatientsShort stays

Dead people1x doses

Inhaled agents

Antibiotic RankNarrow spectrum Broad spectrum Extended spectrum,

including MDRO and Pseudomonas

Restricted

1 2 3 41st- and 2nd-generation cephalosporinsAmoxicillin TMP/SMX Nafcillin, OxacillinMetronidazoleDoxycyclineNitrofurantoinPenicillin

CeftriaxoneAzithromycinClarithromycinAmoxicillin/clavulanateAmpicillin/sulbactamClindamycin

Antipseudomonal penicillinsFluoroquinolonesAminoglycosidesVancomycinCefepime, CeftazidimeErtapenemAztreonam

Antipseudomonal carbapenemColistinTigecyclineLinezolid, TedizolidDaptomycinCeftarolineCeftazidime/avibactamCeftolozane/tazobactam

Calculate both N Antibiotics and Rank Term DefinitionAntibiotic Rank

Highest individual agent rank for all agents given on the same calendar day.

N antibiotics

Number of different antibiotic agents administered in a calendar day.

Calendar Day

Agent 1 VancoAgent 2 Pip/TazoAgent 3 AzithroRank 3N Antibiotics 3

Define 2 time pointsTerm DefinitionDay 1 First day of antibiotic exposure on an inpatient unit during hospitalization,

using a calendar day definition (12am to 1159pm)

Day D Day of discharge or day 5 of antibiotic exposure, whichever comes first.

8/24 8/25 8/26 8/27 8/28 8/29 8/30Abx started in MICU

Transfer to Gen Med

Discharged

Day 1 Day 5

Day D is 3, 4, or 5

Direction of Change: Day 1 vs. Day D

N AntibioticsLower Same Higher

Rank

Lower De-esc De-esc Unchanged

Same De-esc Unchanged EscHigher Unchanged Esc Esc

9 combos, 3 outcomes

Results39,226 admissions among 5 hospitals

De-escalation: 36%Escalation: 13%Unchanged: 51%

N AntibioticsLower Same Higher

Rank

Lower 10551 (27) 1269 (3) 146 (<1)

Same 2318 (6) 19703 (50) 3048 (8)Higher 110 (<1) 732 (2) 1349 (3)

De-escalation varied among Hospitals

De-escalation:Median 37%, range 31-39%, p<0.001

39% 38% 37% 33% 31%

51% 49% 52% 52% 53%

11% 13% 11% 15% 16%

0%

20%

40%

60%

80%

100%

Hospital

De-escalation Unchanged Escalation

ICU vs. non-ICUICUs had both higher escalation and de-escalation when compared to non-ICU wards, p<0.001

0%

5%

10%

15%

20%

25%

0% 20% 40% 60% 80%

Esc

alat

ion

%

De-escalation %

De-escalation % and Escalation % among Units

Non-ICU ICU

N De-escalation Escalation

ICU 5319 2264 (43%) 831 (16%)

Non-ICU 33907 11874 (35%) 4298 (13%)

Syndromes (ICD-10)N (%) De-escalation Escalation

>1 Infection Diagnosis Code 16874 (43%) 35% 17%

No Infection Diagnosis Code 7476 (19%) 40% 7%

GI Tract 19%Intra-abdominal 23%

ENT/URI 28%SSTI 28%

UTI 43%Pneumonia 44%

LimitationsPilot study sample of 5 hospitals in Southeastern United StatesDid not measure appropriateness or eligibility for de-escalation Prophylaxis MDRO infection

Rankings may not align with an individual ASP practice (e.g. restricted agents)Only evaluated first antibiotic course per admissionICD-10 codes for infection diagnosis?

ConclusionsWe developed an objective definition for de-escalation based on electronic data.De-escalation occurred in ~1 in 3 admissions; similar to other estimates in the literature.2,5

Variability among hospitals, units, and syndromes.De-escalation could be used as a process metric to demonstrate ASP impact on antibiotic decisions.De-escalation may help identify areas for intervention if paired with benchmarking and risk-adjustment methods.

EmpiricBroad-spectrum

TargetedNarrow-spectrum

Tim

e

AcknowledgementsCo-authorsCDC FoundationASP staff at Study Sites: Duke University Hospital (Dev Anderson, Christina Sarubbi, Rebekah Wrenn, Jason Jackson) Duke Regional Hospital (John Boreyko, Ted Hendershot) Piedmont Fayette Hospital (Janice Davis, Angela Swayne) Piedmont Newnan Hospital (David Copeland, John Marsalis) Southeastern Regional Medical Center (April Dyer, Eric Locklear)

DASON Clinical and Data Teams

References1. Madaras-Kelly et al. Infect Control Hosp Epid. 2014 September; 35(9): 1103–1113.2. Braykov and Morgan et al. Lancet Infect Dis 2014; 14: 1220–27.

3. Yamana et al. Journal of Infection (2016) 73, 314e325.

4. Tahbah et al. Clin Infect Disease 2016;62(8):1009–17.5. Madaras-Kelly et al. J Antimicrob Chemother 2016; 71: 539–546.

Extra Slides

Example: De-escalation

8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo

Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir

Example: De-escalation

8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo

Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir

3 3 2 2 2 2 22 2 1 2 2 2 2

RankN Abx

Example: De-escalation

8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo

Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir

3 3 2 2 2 2 22 2 1 2 2 2 2

RankN Abx

Day 1 Day 5

8/24 8/25 8/26 8/27 8/28 8/29 8/30VancoPip/Tazo Pip/Tazo

Ceftriaxone CeftriaxoneMetro Metro Metro MetroCefdinir Cefdinir Cefdinir Cefdinir

3 3 2 2 2 2 22 2 1 2 2 2 2

RankN Abx

Day 1 Day 5

N Antibiotics

Lower Same Higher

Rank

Lower De-esc De-esc Unchanged

Same De-esc Unchanged Esc

Higher Unchanged Esc Esc

Rank: LowerN Abx: Same

Other Unit type estimatesN units De-escalation Escalation Unchanged

Med/Surg Wards 7 35% 13% 52%

Surgical Wards 7 33% 12% 55%

Medical Wards 16 35% 13% 52%

Hem/Onc Wards 3 33% 13% 54%