The Journal of the Arkansas Medical Society Med Journal March 2020 Final 2 - Page 13

AFMC: A CLOSER LOOK AT QUALIT Y greater AS success. Collaborative par- ticipants learned from one another’s success and failures, and what could be useful in their practice settings. Following the first AS collabora- tive, Arkansas hospitals meeting all seven of the CDC’s hospital AS core elements increased from 43% in 2015 to 63% by 2016. Improvement continued in meeting all hospital AS core elements during the second AS collaborative, increasing from 67% in 2017 to 79% in 2018. 3 Based on the 2019 pre- and post-assessment results of 57 facilities that participated in the second AS collaborative, 72% reported gaining needed education and planned to implement some aspect of what they learned. The same percentage of participants reported implementation of at least one intervention to improve AS within their facilities. IMPROVING ANTIBIOTIC USAGE 1. Limit antibiotic duration by reassessing patient’s improvement at 72 hours for evidenced-based duration of therapy. Pharmacists can collaborate with physicians to determine if these lengths of therapy can be considered based on clinical improvement: • Skin and soft tissue infections: 5 days 4,5 • Urinary tract infections: 5-7 days 4,5 • Community-acquired pneumonia: 5 days 4-6 2.Verify penicillin allergy. Although 10% of the population reports a penicillin allergy, less than 1% has a true allergy. Pharmacists can assist physicians to determine if a be- ta-lactam antibiotic is appropriate 4,7 by assessing patients’ allergy history and previous antibiotic usage. 3. Avoid treatment of asymptomatic bacteriuria (ASB). A urine culture positive with or without pyuria alone does not indicate a urinary tract infection (UTI) and could be ASB if no symptoms are present. 4,8-9 Pharmacists can discourage unnecessary urine cultures when no UTI symptoms are present, and unnecessary antibiotic usage when ASB is determined. • 100% of patients with a chronic uri- nary catheter will grow an organism from a urine culture with or without a UTI. 4,9 • A change in urine cloudiness or odor alone does not indicate a UTI. 4,8-9 • Delirium should be interpreted with caution since delirium alone has a low specificity for UTI. 4,9 4. Avoid duplicative anaerobic cover- age. Unnecessary duplicate anaero- bic coverage is usually encountered when one of the following combi- nations is ordered unless Metroni- dazole is needed for treatment of Clostridioides difficile: Piperacillin/ tazobactam + Metronidazole, Mero- penem + Metronidazole, Ertape- nem + Metronidazole, Ampicillin/ sulbactam + Metronidazole, Amox- icillin/clavulanate + Metronidazole, etc. When Clindamycin is utilized instead of Metronidazole for an- aerobic coverage in one of these combinations, it is also considered inappropriate unless Clindamycin is added to reduce toxin production in necrotizing infections. Pharma- cists can inform physicians when unnecessary duplicate coverage is prescribed. 4 5. Re-assess antibiotic therapy including anti-Methicillin-resistant Staphyloccocus aureus (MRSA) antibiotics. Pharmacists can alert physicians when new culture infor- mation is available to de-escalate antibiotics. An important consider- ation for de-escalating anti-MRSA coverage is based on negative cultures with clinical improvement, negative MRSA nasal screen in patients with community-acquired pneumonia, etc. 4,6,10 Reasons to continue anti-MRSA antibiotics may exist when certain types of infec- tion require a longer duration of therapy or cultures are not available. Physicians should be encouraged by the involvement of Arkansas phar- macists who have furthered their AS education. Pharmacists can assist in improving patient care and outcomes, education, patient and ASP interven- tions, and leadership skills to fulfill AS requirements. s Dr. Crader is associate professor of pharmacy practice at UAMS and co-leads St. Bernard’s AS program. REFERENCES 1. Clinical Infectious Diseases 2007; 44:159–77. 2. CDC: “What’s New in the Core Elements of Hospital ASPs, 2019”, Arjun Srinivasan, MD. 3. CDC. Antibiotic Resistance and Patient Safety Portal. Hospitals Meeting All Seven Core Elements: 2014-18. https://arpsp.cdc. gov/profile/geography/5. 4. CDC. 5 Ways Antibiotics Can Be Antibiotics Aware. https://www.cdc.gov/antibiotic-use/ community/pdfs/Hospital-Pharmacist- Poster-508.pdf. 5. Clinical Infectious Diseases 2019;69(9): 1476–9. 6. Am J Respir Crit Care Med 2019;200(7): e45– e67. 7. CDC. Is It Really a Penicillin Allergy? https:// www.cdc.gov/antibiotic-use/community/ pdfs/penicillin-factsheet.pdf. 8. Clinical Infectious Diseases 2010; 50:625-663. 9. Clinical Infectious Diseases 2019; 68(10): e83-75. 10. Clinical Infectious Diseases 2018; 67(1):1–7. AFMC WORKS COLLABORATIVELY WITH PROVIDERS, COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO PROMOTE THE QUALITY OF CARE IN ARKANSAS THROUGH EDUCATION AND EVALUATION. FOR MORE INFORMATION ABOUT AFMC QUALITY IMPROVEMENT PROJECTS, CALL 1-877-375-5700 OR VISIT AFMC.ORG. MARCH 2020 Volume 116 • Number 9 MARCH 2020 • 205