[ Music ] >> Hello, good afternoon and welcometo today’s webinar: CDC’s Core Elements of Outpatient AntibioticStewardship, hosted by CDC. CDC’s mission is to protect patientswhenever they receive their medical care. My name is Kelly O’Neill and I’m a HealthCommunications Specialist leading antibiotic stewardship communications for the Divisionof Healthcare Quality Promotion at CDC. This webinar is part of a series of infectioncontrol 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. KatherineFleming Dutra, Medical Officer sorry, just having some slide issues Dr. KatherineFleming Dutra, Medical Officer in the Office of Antibiotic Stewardship in the Divisionof Healthcare Quality Promotion at CDC. She will discuss implementing antibioticstewardship into your outpatient practice. Before we get started there afew housekeeping items to cover. We welcome your questions. Please submit any questions or commentsyou have via the chat window located on the lower left hand side of the webinarscreen anytime during the presentation. Questions will be addressed afterall presentations as time allows.To ask for help, please press the raisedhand button located on the top left hand side of the screen if you need to chat witha meeting chairperson for assistance such as technical difficultiesduring the webinar. To hear the audio please ensure that yourspeakers are turned on with the volume up. The audio for today’s conference shouldbe coming through your computer speakers. In addition, the speaker slides fromtoday’s presentation will be provided to participants in a follow-up email. Thank you. Now it is my pleasure to introduce our speakerfor today, Dr. Katherine Fleming Dutra. >> Thank you and thanks forjoining us this afternoon.As far as today’s objectives, we will reviewthe importance of antibiotic stewardship in outpatient settings, then we will identifyfour core elements of antibiotic stewardship across various outpatient settings and finally,we will discuss evidence based strategies that can be used to implement thecore elements in your practice. So why is antibiotic stewardship so important? It’s because antibiotics reallyare such important medicines. The lifesaving benefits of antibiotics inmedicine and public health are undeniable. Infectious bacterial diseases that were oncedeadly are now treatable substantially reducing deaths compared to the pre antibiotic era.We should also recognize that antibioticsare an important and crucial adjunct to modern medical advances permittingsurgical and medical treatments for a variety of serious illnesses. Antibiotics are critical tools that help maketransplants and cancer chemotherapy possible by allowing us to prevent andtreat bacterial infections. Antibiotics really are miracle drugs and weneed them and we need them to keep working. And that’s why antibiotic resistance is one of the most pressing publichealth threats of our time. CDC estimates that two millionillnesses and 23,000 deaths are caused by antibiotic resistant infectionseach year in the U.S., and antibiotic resistant infectionscost an estimated $20 billion dollars in excess direct healthcare costs annually. To be very clear, the primary modifiable driverof antibiotic resistance is antibiotic use. To illustrate this let’s walk through abrief timeline of the history of antibiotics. On the top you can see the year thateach of these antibiotics were introduced and then we can overlay the date that resistancewas first identified in select species to each of these antibiotics, and what you can see is that resistance is never far behindthe introduction of new antibiotics.Bacteria will inevitably find ways ofresisting antibiotics developed by humans which is why aggressive action is needednow to keep new resistance from developing and to prevent the resistance thatalready exists from spreading. And that’s why we must useantibiotics appropriately. And it isn’t just antibioticresistance that we have to worry about. It’s important to remember that antibioticscan also have other unintended consequences including adverse events. It’s really a matter of patient safety.Antibiotic associated adverse events can rangefrom minor conditions to much more severe. They can cause side effects like rashesand antibiotic associated diarrhea and they can cause allergic reactions includinglife threatening ones like anaphylaxis. And one in a thousand antibiotic prescriptionsleads to an emergency department or ER visit for an adverse event which equatesto 142,000 ER visits per year for antibiotic associated adverse events. And this is especially problematicfor the pediatric population as antibiotics are the most common cause of drug related emergencydepartment visits for children.And there is also emerging evidence oflong term consequences of antibiotic use. Evidence that antibiotics are associatedwith chronic disease including allergic and autoimmune diseases through disruption ofthe microbiota the community of microbes living in and on our body and themicrobiome, the collective genes and gene products of that microbial community. Another serious unintended consequence of antibiotic use are clostridiumdifficile infections. Clostridium difficile or C. diff is a bacterium that can cause very serious diarrhealillness even life threatening illness. Taking antibiotics can put peopleat 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 yearleading to an estimated $1 billion dollars in medical costs, and a more recent estimate putthose 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 antibioticresistance, these are all reasons why it’s so important to use antibioticsonly when they are needed. So with why should we focuson the outpatient setting? Antibiotic stewardship programs aretraditionally in the inpatient setting. This graph shows antibiotic expendituresin the U.S. by treatment setting which totaled $10.7 billion in 2009. Of that $10.7 billion, 62 percent of antibioticexpenditures occurred in the community or outpatient setting followed by 34 percentin hospitals and 5 percent in nursing homes. And remember that most antibiotics used inthe inpatient setting are much more expensive than those used in the outpatient setting. And thus the actual volume of antibiotic use inthe outpatient setting is likely much higher. Based on data from other developedcountries we estimate that 80 to 90 percent of human antibiotic use occurs in the outpatientsetting illustrating why antibiotic stewardship is also critical to combattingantibiotic resistance. It’s clear that we need to improve antibioticuse across the spectrum of healthcare and we can’t leave the outpatientsetting out of those efforts. So do we have room to improve antibioticprescribing in the outpatient setting? We do. Recently CDC estimatedthat at least 30 percent, almost one third of antibioticprescriptions written in the outpatient setting were unnecessarymeaning that no antibiotic was needed at all.And even among the quote necessary 70 percent, there are still more inappropriate antibioticprescribing including inappropriate antibiotic selection meaning that the wrong antibioticmay have been chosen, inappropriate dosing, and inappropriate duration meaningthat the antibiotic was given for too long or too short a time. Total inappropriate antibiotic prescribingincluding unnecessary antibiotic prescribing plus inappropriate selection, dosingand duration is likely much higher. So what is antibiotic stewardship? Antibiotic stewardship is the effortto measure antibiotic prescribing, to improve antibiotic prescribing so thatantibiotics are only prescribed and used when needed, to minimize misdiagnoses ordelayed diagnoses leading to the underuse of antibiotics, to ensure that the right drug, dose and duration are selectedwhen an antibiotic is needed. And antibiotic stewardship isfundamentally about patient safety and delivering high quality healthcare. Antibiotics are wonderful medicines. They are lifesaving, but like allmedicines they have risks and benefits and to keep our patientssafe, we want to make sure that we are using antibiotics appropriately. In 2014 and 15, CDC released the Core Elementsof Hospital Antibiotic Stewardship Program and the Core Elements of AntibioticStewardship for Nursing Homes respectively. These core elements do not include theoutpatient setting and we heard from or stakeholders that therewas a need for core elements for outpatient antibiotic stewardship basedon the outpatient stewardship literature, based on what works in the outpatient settingand that’s tailored for outpatient settings.So we heard you and now we have the CoreElements of Outpatient Antibiotic Stewardship which were published in the Morbidity andMortality Weekly Report or MMWR: Recommendations and Reports last week on November 11th andthese core elements provide a framework for improving antibiotic prescribing byoutpatient clinicians and within facilities that routinely provide outpatientantibiotic treatment. So who are the Core Elements of OutpatientAntibiotic Stewardship intended for? They have a broad target audience and areintended for any outpatient clinician, clinic or health system that is interestedin improving antibiotic prescribing and use. These may include: primary care cliniciansand clinics, outpatient specialty and subspecialty clinicians and clinics,emergency department, retail health clinicians, dentists, urgent care clinicians, nursepractitioners and physician assistants working in outpatient settings, and healthcaresystems that have outpatient facilities. So where do you start? What are the initial steps to implementingoutpatient antibiotic stewardship? First, it’s important to identify within yourpractice or clinic what are the opportunities for improvement by identifying the highpriority conditions for intervention. So high priority conditions are thoseconditions within your practice or facility for which clinicians are commonly deviatingfrom best practices for prescribing antibiotics.So some examples of the typesof conditions that often lead to inappropriate antibiotic prescribing are: Conditions for which antibioticsare overprescribed such as acute bronchitis a condition forwhich antibiotics are not recommended but are often prescribed;conditions which are overdiagnosed for example streptococcal pharyngitiswhich is sometimes diagnosed in the absence of confirmatory tests such as arapid strep test or a throat culture; conditions for which the wrong dose,duration or agent is selected such as when clinicians diagnose acute bacterialsinusitis and prescribe azithromycin rather than amoxicillin or amoxicillin/clavulanicacid as recommended by national clinical practice guidelines;conditions for which watchful waiting or delayed prescribing is underused such as foracute otitis media in children and conditions for which antibiotics are underused or theneed for timely antibiotics isn’t recognized, for example sexually transmitted diseases inwhich misdiagnoses might lead to undertreatment or in sepsis in which timelytreatment with antibiotics is critical.Next it’s important to identify barriersthat lead to deviation from best practices. So barriers to prescribing antibioticsappropriately might include clinician knowledge gaps about best practices in clinicalpractice guidelines but deficits in clinician knowledge areseldom the only barrier to prescribing antibioticsappropriately in the outpatient setting. Other barriers to appropriateprescribing include clinician perception of patient expectations for antibiotics,perceived pressure to see patients quickly, clinician concerns about decreasedpatient satisfaction with clinical visits when antibiotics are not prescribed. Effective antibiotic stewardshipinterventions need to help clinician address and overcome barriers toappropriate prescribing. And in order to do so it’s importantto understand what those barriers are.And finally establish standards for prescribing. Standards for antibiotic prescribing can bebased on national clinical practice guidelines by national healthcare professional societiessuch as the American Academy of Pediatrics, the American College of Physicians or the Infectious DiseasesSociety of America to name a few. Or if applicable can be based on facility orsystem specific clinical practice guidelines. Establishing standards is reallythe foundation of deciding what is and what is not appropriate antibioticprescribing and clinicians need to know what they are supposed to beprescribing to be able to make improvements. So what are the four core elementsof outpatient antibiotic prescribing? First is commitment which means todemonstrate dedication to and accountability for optimizing antibioticprescribing and patient safety. Next is action for policy and practice toimplement at least one policy or practice to improve antibiotic prescribing, assesswhether it’s working and modify as needed.After that is tracking and reporting which meansto monitor antibiotic prescribing practices and offer regular feedback to clinicians orhave clinicians assess their own antibiotic use. And finally is education and expertise toprovide educational resources to clinicians and patients on antibioticprescribing and ensure access to needed expertise on antibiotic prescribing. So next I’m going to go through each element indetail and for each I’ll describe the element and then highlight interventions aimedat clinicians including those in small or solo practice and then interventions aimedat clinic or health system leadership levels.We organize the document in this way in order tomake it easier for clinicians in small practices to find those interventions thatare pertinent to their setting. And for the leadership of biggerorganizations to find those interventions that may need the infrastructure of alarger clinic or system to accomplish. In order to meet each core element onlyone suggested intervention needs to be done from either the clinician list orthe organizational leadership list. And as I talk about each list Iwill talk about the interventions under the clinician sectionor the organization section.With that being said, we hope that cliniciansand health systems will strive to implement many of the interventions over time from bothlists whichever makes the most sense for your practice. So first, commitment again meansdemonstrating dedication to and accountability for optimizing antibioticprescribing and patient safety. So first, I’ll focus on what clinicians can do. Individual clinicians can writeand display public commitments in support of antibiotic stewardship. This sounds perhaps a bit corny but it’sactually an evidence based intervention to improve antibiotic prescribing. So using public commitments is a novel approachto changing prescriber behavior that relies on principles of behavioral science. In a study published in JAMAInternal Medicine in 2014, Mika and colleagues used a very simpleintervention, putting a poster in the exam room with clinicians’ pictures and commitmentsto use antibiotics appropriately. But they did this intervention in a scientifically rigorousway, a randomized control trial. They used a principle of behavioralscience, the clinicians like all people want to be consistent with theirprevious commitments. The poster had the clinician’s picture on it andthe commitment to use antibiotics appropriately and they called this a behavioralnudge to make the right choice.They didn’t require that theantibiotics were used appropriately, but the poster reminded clinicians of theircommitment to use antibiotics appropriately at exactly the right time, at thetime of the patient encounter. And the poster contained a letter on it andto highlight part of what it said it ended with this quote, “As your doctors we promiseto treat your illness in the best way possible. We are also dedicated toavoid prescribing antibiotics when they are likely to do more harm than good.” And the amazing thing is that thisworked, it actually worked really well. In the poster group, therewas a 20 percent reduction in inappropriate antibiotic prescribing foracute respiratory infections compared to control and it was statistically significant. And this is a fairly impressive effect size for improving antibioticprescribing and at a minimal cost. So the study highlights the importance ofrecognizing that prescribing is a behavior and insights from behavioral science are likelyto help us change the behavior for the better. And so I hope you’ll see this importancein the remaining core elements.And we aren’t the only ones thatthink this is a great intervention. The authors of the poster commitmentstudy have assisted states and clinicians across the country to implementtheir own version of this commitment to appropriate antibiotic prescribing includingthe Illinois Department of Public Health and Superior Health Plan in Texas incollaboration with the Texas Health and Human Services Commission andDepartment of State Health Services, and the New York State Department of Healthwhich is providing commitment posters and encouraging clinicians tosign their Get Smart guarantee. To read more about these three examples pleasevisit our safe healthcare blog post listed at the link. And we at CDC would really like tosee every clinic use this simple, low cost and effective intervention and CDCalso worked with the authors of this study to make the commitment poster to make acommitment poster that’s now available on CDC’s website for download andclinicians can add their signature and pictures and post it in their clinics. So we hope that you’ll all make the commitmentto use antibiotics appropriately by starting with a commitment poster either by usingone of the ones available in your state, making one yourself or byusing the one from CDC.And in doing so you will fulfill the first coreelement of outpatient antibiotic stewardship. At the organizational level inaddition to the commitment poster, leadership can also identify a single leaderto direct antibiotic stewardship activities within a facility, they can includeantibiotic stewardship related duties and position descriptionsor job evaluation criteria which will help ensure staff members havesufficient time and resources to devote to stewardship, and they can communicate with all clinic staff membersto set patient expectations. Patient visits for acute illnesses might ormight not result in an antibiotic prescription and all staff members can improve antibioticprescribing by using consistent messages when communicating with patientsabout the indications for antibiotics.Action means implementing at least one policyor practice to improve antibiotic prescribing, assess whether it’s working,and modify as needed. So we have included a lot ofexamples of actions but again, I want to stress that the core elementsare about implementing at least one, so don’t feel like you needto start with all of these. As with all quality improvementinitiatives it’s best to implement these elementsin a step-wise fashion.Implement an action, assess whether it’sworking and then modify it if needed. Individual clinicians can implementat least one of the following actions: use evidence based diagnostic criteria andtreatment recommendations based on national or local clinical practice guidelines. And clinicians can also use delayed prescribingpractices or watchful waiting when appropriate. Delayed prescribing can be used forpatients with conditions that usually resolve without treatment but who can benefit fromantibiotics if the conditions do not improve. Examples of conditions for which nationalclinical practice guidelines support the use of delayed prescribing or watchful waitinginclude acute uncomplicated sinusitis or mild acute otitis media in children.And we at CDC know that itcan be challenging to keep up with the national clinicalpractice guidelines from all of the various professional societiesso on our website we have consolidated and summarized the treatmentrecommendations for adults and children for common outpatient sections aswell as provided the references and links to the national guidelines. So please check out this site foran easy summary of these guidelines. For the organizational leadership actions mayalso include providing communication skills training for clinicians, requiring explicitwritten justification in the medical record for non recommended antibiotic prescribing,providing support for clinical decisions and using call centers, nursehotlines or pharmacist consultations as triage systems to prevent unnecessary visits. More information about all of theseinterventions including the references for which the supporting evidencefor the supporting evidence for these interventions are containedin the core elements document. But I want to take a minute to highlight one ofthese actions, communication skills training. So communication training is actually aneffective antibiotic stewardship intervention. Studies using enhanced communication traininghave reduced inappropriate antibiotic prescribing for respiratory infectionswhile maintaining patient satisfaction.And the communication traininghas reviewed a number of goals for each visit includingunderstanding the patient’s expectation, explaining why antibioticswill or will not help, providing symptomatic treatment recommendationsso that the patient can feel better, discussing when the patient should returnor call back if the patient is not better. And the effect of these trainingswas sustainable over time. In one study, improvements in antibioticprescribing persisted three and a half years after the communication training occurred. So based on the evidence, trainingclinicians to communicate effectively about antibiotic prescribing is animportant stewardship intervention. So we hope that you will train your clinicianshow to approach these very common visits so that they can prescribe antibioticsappropriately and maintain patient satisfaction.Next is tracking and reporting clinicianantibiotic prescribing, also called audit and feedback which means to monitorantibiotic prescribing practices and offer regular feedback to clinicians. For individual clinicians, this will likely meanself-evaluating their own antibiotic prescribing practices to make sure they align withupdated evidence based recommendations and clinical practice guidelines. And one way to do this is to participatein continuing medical education and quality improvement activitiesthat incorporate tracking and improving antibiotic prescribingpractices into these activities. These activities may be available throughprofessional societies and may be used to meet licensure or othereducational requirements. At the organizational levelthis means implementing at least one antibiotic prescribingtracking or reporting system. It can also mean assessing and sharingperformance of quality measures and establish reduction goals addressingappropriate antibiotic prescribing.So for example, three current healthcareeffectiveness data and information sets or HEDIS measures that areoften tracked by health plans and payers include quality measuresaddressing appropriate antibiotic prescribing. These are appropriate testings for children withpharyngitis, appropriate treatment for children with upper respiratory infections, i.e.avoidance of antibiotics and avoidance of antibiotic treatment andadults with acute bronchitis. So organizations can report clinicianperformance on these measures, track the clinician as part ofa tracking and reporting system. So what should you track andreport in your outpatient facility? Outpatient clinicians and clinic or healthsystem leaders can select outcomes to track and report on the basis ofidentified opportunities for improvement in their practice or clinics. We really meant this documentto be flexible so it can apply to a variety of outpatient settings. Systems can track high priorityconditions identified as opportunities to improve clinician adherence to bestpractices and clinical practice guidelines.So for example, acute bronchitisis a common condition for which antibiotics are not recommendedin national clinical practice guidelines, yet antibiotics are commonly prescribed. Therefore, leaders might choose toprovide feedback on the percentage of acute bronchitis visits in which a clinicianprescribed an antibiotic and include comparisons to their peers prescribingpercentages for acute bronchitis. Systems can also track thepercentage of all visits for which an individual clinicianprescribed antibiotics meaning the number of all antibiotics prescribed for all diagnosesby that clinician divided by the total number of visits for all diagnoses by that clinician.And also certain healthcare systems might beable to track and report the complications of antibiotic use, events like adverse drugevents and Clostridium difficile infections and they can also track antibioticresistance trends among common outpatient bacterial pathogens. However, it’s important to note thatat the individual or clinic level, smaller sample sizes might make thesemeasures based on adverse events and antibiotic resistance less reliable. So it’s important to understand that effectivefeedback interventions have included comparisons of clinician’s performancewith that of their peers. Examples of studies that usepeer comparisons include a study that sent regular reports comparingantibiotic selection patterns of clinicians with their colleagues mean performance. This led to improvements in use ofguideline recommended antibiotic agents for common outpatient conditionsincluding acute bacterial sinusitis.Another study compared clinician’spercentage of inappropriate prescribing for acute respiratory conditionsto top performers in their practice and top performers meant clinicians whoare performing in the top 10 percent or had the least amount of antibioticprescriptions for acute respiratory infections that did not warrant antibioticssuch as colds and bronchitis. In this study the top performers had zeroor no unnecessary antibiotic prescriptions for acute respiratory infectionsthat didn’t warrant antibiotics.And this peer comparison intervention led todecreased inappropriate antibiotic prescribing for acute respiratory infections thatshould not be treated with antibiotics, again like colds and acute bronchitis. Another study conducted in the National HealthService in England looked at the percentage of all visits leading to antibiotic prescriptionand notified clinicians who prescribed more than more antibiotics than80 percent of their peers.They sent a letter to those cliniciansfrom the Chief Medical Officer of the National Health Service that said,”quote the great majority, 80 percent, of practices in your area prescribed fewerantibiotics per head than yours” end quote. This intervention led to decreased overallantibiotic prescribing and to cost savings. From these studies we can see how important peercomparisons are to include in effective tracking and reporting system and we hope thatyou will include peer comparisons in your tracking and reporting systems. And finally, education and expertise which meansto provide educational resources to clinicians and to patients on antibiotic prescribingand ensure access to needed expertise on optimizing antibiotic prescribing.Clinicians can educate theirpatients and their patients’ families about appropriate antibiotic use. To do so they can use effectivecommunication strategies to educate patients about when antibiotics are and are not needed. They can educate about the potential harmsof antibiotic treatment including both common and serious side effects of antibiotics, C.difficile infection and antibiotic resistance and they can provide patient educationmaterials that include information on appropriate antibiotic use,potential adverse drug events and available resources regardingsymptomatic relief for common infections. So I want to again highlightthe issue of communication. In this sense educating patientsthrough effective communication. We talked about how communication trainingcan be an action for policy and practice. Clinicians themselves can then useeffective communication strategies as a way to fulfill the educationand expertise core element and we very purposely highlighted the importanceof communication in two different places as a way to fulfill the core elementsbecause it is an evidence based strategy to improve antibiotic prescribing.And it really gets back to understandingthe barriers that prevent clinicians from prescribing antibiotics appropriatelyand helping clinicians address those barriers. We know that clinicians cite patientdemands for antibiotics and concerns about patient satisfaction as areason they prescribe inappropriately. It turns out patients rarelyovertly request antibiotics and clinicians aren’t actually very good atdetermining which patients want antibiotics, but if the clinician thinksthe patient wants antibiotics, they are more likely to prescribe antibiotics.So there is an element of miscommunicationbetween clinicians and patients that is contributing to inappropriateantibiotic prescribing and this is where effectively communicating with patientsand educating patients can really help. And patients really can be satisfiedwithout antibiotics even if they expect them if the clinician can effectivelycommunicate with them. So a couple of communication techniqueshave been shown to be effective. First, combining explanations of whyantibiotics are and are not needed or why antibiotics are notneeded with recommendations for managing symptoms have beenassociated with increases in satisfaction and by this we mean educating the patientwhy they don’t need antibiotics especially discussing what they see onphysical exams or in the evaluation that shows that antibiotics are not needed.And then also providing those recommendationsof what they can do to feel better. And then providing recommendations of whento seek medical care if the patient worsens or doesn’t improve also called acontingency plan, has been associated with increased satisfaction for patients whoexpected but did not receive antibiotics. And by this we mean giving specificmessages 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 cliniciansprovide quality care to patients, use antibiotics appropriately andmaintain patient satisfaction. And that’s why we hope clinicians willuse effective communication strategies to educate their patients about whenantibiotics are and are not needed.At the organizational level outpatient clinics and healthcare system leaderscan provide education to clinicians and ensure access to expertise. When approaching educationalinterventions, it’s critical to understand that in the outpatient sitting inappropriateantibiotic prescribing is rarely due to knowledge gaps alone. Educational strategies need to be groundedin helping clinicians address the barriers that lead to prescribingantibiotics inappropriately. So education can include providing face to face educational trainingalso called academic detailing, providing continuing educationactivities for clinicians and relevant continuing educationactivities include those that address appropriate antibiotic prescribing, adverse drug events and communicationstrategies. And also by ensuring timelyaccess to persons with expertise. So what do we mean by this? Expertise in optimizing antibioticprescribing may come from pharmacists who can help clinicians optimizeantibiotic dosing and selection and advise clinicians onmedication interactions. In hospitals pharmacists with infectiousdisease training have been effective and important members ofantibiotic stewardship programs. Access to expertise might also mean havingaccess to a dentist to manage dental conditions that need procedures ratherthan antibiotics or to a surgeon or to an infectious disease physician.The expertise needed will likelydiffer among outpatient facilities and can be determined by each facility. So where can you find informationto educate patients and providers? There are many great resources fromprofessional societies, from healthcare systems, from many places, but I hope you’ll go toour website for some of those resources. We are the Get Smart: Know When AntibioticsWork program and our campaign focuses on increasing awareness aboutantibiotic resistance and the importance of appropriate antibiotic use amonghealthcare providers and the general public. Our website has lots of information, resourcesfor patients and healthcare professionals, partners and information about GetSmart About Antibiotics Week too. So please check it out and we hope you find ituseful and you’re welcome to use or materials and we hope you will as partof your educational program.This year we have some new materialsfor Get Smart About Antibiotics Week. We try to update and add materials every year. So for example, we have patient focusedinformation this year that’s new on delayed prescribing and watchful waitingthat you can share with your patients, we have a new fact sheet on ear infections, howthey’re treated and also includes information on preventing ear infections and onwatchful waiting for ear infections. And for more resources, please visit orwebsite for the core elements which has links to the document, to checklistsabout implementing the core elements and other resources that can helpyou implement the core elements.And we will continue to build this websiteout as more resources become available. And also feel free to check out thisMedscape video on the Core Elements of Outpatient Antibiotic Stewardship as well. And finally, the importance of antibioticstewardship has risen to national prominence and actually international prominence. President Obama has issued a presidentialproclamation declaring this week Get Smart About Antibiotics Week and I encourageyou to go look at the link here. So in summary, antibiotic resistanceis a major public health threat and antibiotic stewardship is oneof the most important strategies to combat antibiotic resistanceand to keep our patients safe. The Core Elements of OutpatientAntibiotic Stewardship provides a framework for improving outpatient antibiotic prescribing. And to remind you the core elements include thefollowing: Commitment, demonstrate dedication to and accountability for optimizingantibiotic prescribing and patient safety; action for policy and practice, toimplement at least one policy or practice to improve antibiotic prescribing, assesswhether it’s working and modify as needed; tracking and reporting, monitor antibioticprescribing practices and offer regular feedback to clinicians or have clinicians assess theirown antibiotic use; education and expertise, provide educational resources to cliniciansand patients on antibiotic prescribing and ensure the needed expertiseon antibiotic prescribing.So we can all be antibiotic stewards and we hope that you will all implement the coreelements in your outpatient practice. And so of course this was the work onmany people and I want to make sure to thank my coauthors including MemoSanchez, Becky Roberts and Lauri Hicks. And I also want to thankthose who gave us feedback on this document including John Finkelstein,Jeff Gerber, Adam Hersh, David Hyum, Jeff Linder, Larissa May, DanMerenstein, Katie Suda and Rachel Zetts. To our awesome communications team whoprovided 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 logisticstoday 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 websiteand I’m happy to take questions now and if you have questionsthat come up in the future, please feel free to emailus at getsmart@cdc.gov. >> Great. Thank you, Dr. Fleming Dutra for yourtime 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 questionstoday and don’t forget if you have a question, please add it to the chat boxon the lower left hand side. One of our first questions is: Most physiciansI work with prefer to prescribe the antibiotic without doing any lab testingto confirm diagnosis. Could a complete blood count or culture beutilized prior to prescribing antibiotics? >> Thank you for that question.So I think it depends uponthe clinical situation. Certainly if you’re concerned about sepsis,blood cultures, cultures of other sites on the body complete blood count and manyother lab tests are very important prior to prescribing antibiotics. Other conditions don’t require a CBC prior to prescribing antibioticssuch as strep pharyngitis. If the rapid strep test is positivethere’s not a need in many circumstances for a backup culture, there’snot a need for blood work. So it really depends upon the clinicalsituation and for those types of things, again, we encourage you to follow your national thenational clinical practice guidelines or local or facility specific clinicalpractice guidelines. >> Okay. Thank you. So the next question is: Please differentiatebetween microbiome and microbiota. Is this a concept that’s neededto be taught to patients/clients? >> Great. Thank you for that question. So the definition as I understand it althoughI’m not the expert on microbiota and microbiome but the definition as I understand it isthat the microbiota are really the community of microbes living in and on the body thatinclude bacteria but it also includes viruses and other microorganisms and themicrobiome really means the collective genes and gene products of that microbial community, so obviously these are veryintertwined concepts.So this is in regard to the second part of thequestion, this is a complicated thing to explain to patients but I think it is an important one. We are just really starting to understand theimportance of the microbiota and the microbiome to the development of the immune system, toeverything that we do, to the functioning of our bodies, to protecting usand patients need to understand that antibiotics may have long termconsequences and that disruption of the microbiota is not necessarily a goodthing and that that’s one of the reasons that we want to use antibioticsonly when they’re needed. >> Great, thank you. So next question: Can you addresshow immunizations can be part of this list of initiatives? >> Great question. Immunizations are a very important partof combatting antibiotic resistance and using antibiotics appropriately. Really one of the things that we can do toprevent the inappropriate antibiotic use is to prevent the infection in the first place.And so for example, the pneumococcal conjugatevaccine is a great example of a vaccine that has prevented many infectionsin children and adults and helped reduce antibiotic resistance bypreventing these infections and the spread of these infections and additionallyinfluenza vaccine is another vaccine that can really improve antibiotic use. If patients don’t get sick with influenza, theydon’t present for care and they are less likely to get an antibiotic unnecessarily. They are also less likely to get a secondarybacterial infection associated with influenza. So vaccinations are a veryimportant part of keeping us healthy and combatting antibiotic resistance. >> Great. Thank you. Next question: Is antibiotic stewardshippart of the standard curriculum in medical schools throughoutthe country that you’re aware of? >> I’m going to actually let Dr.LauriHicks who is the Director of the Office of Antibiotic Stewardship answer some ofthese questions so she’ll take that one. >> So this is Lauri Hicks and I wouldlike to let you know and for those of you who are not aware that there is a medical schoolcurriculum that is actually available online. It’s through Wake Forest University andwas developed in collaboration with folks from the Infectious Disease Department of Wake Forest University andCDC reviewed the curriculum.It is not a requirement, however, wecertainly are encouraging medical schools to incorporate this curriculum or their owncontent related to improving antibiotic use if there is availability intheir curriculum to do so. >> And actually one more question,Lauri, for you while we have you. Someone had a question about, unlikeinpatient and long term care stewardship, outpatient stewardship has astronger patient stakeholder effect. Will there be some form of outreach to thepublic at large to increase public awareness by CDC through various public media? >> So I’d like to just state that actuallyone of the major goals of Get Smart About Antibiotics Week whichis actually this week and as Katherine mentioned this week the14th through the 20th and our goal is to reach the general public as well as providersand all of our partners to improve knowledge around antibiotic resistanceas well as antibiotic use.In addition to that CDC has alongstanding campaign the Get Smart: Know When Antibiotics Work campaignand Katherine suggested that you look at our campaign website to access resourcesfor patients and undoubtedly we have to address all facets of the prescribing problem and that includes addressing thepatient demand aspect of it as well. >> Great. Thank you, Lauri. Let’s see for our next question: Is thereany sort of benchmarking data available or is there a reporting system or tool available to clinicians facilities totrack and report such data? >> So there is there are a couple ofdifferent data systems that we use here at CDC to track national antibiotic prescribingpractices in the outpatient setting.We do look at proprietary data that isdispensing data from U.S. pharmacies that really gives us a complete pictureof the amount and types of antibiotics that are being dispensedin the outpatient setting. That being said, it doesn’t come withindications or diagnoses so it’s somewhat hard to assess appropriatenessbut we can see in that data that there is substantial geographic variationthat really suggests inappropriate use of antibiotics in certain parts of the country. Additionally, there are some national surveysthat are run by CDC for which we can look at appropriateness of antibioticprescribing in the outpatient setting.These surveys look at doctors’ offices andemergency departments and we recently used that survey to estimate that 30 percentof outpatient antibiotic prescriptions in those settings were unnecessary. And then we encourage health systems and clinicsto look at your own data and your own EMRs to look and assess appropriateness ofantibiotic prescribing and then also to use the HEDIS measures and other qualitymeasures available through the CMS MIPS program and other programs like that to trackperformance on the measures that are associated with appropriate antibiotic prescribing andthat can be leveraged by clinicians, clinics, health systems to look at their owndata and to measure improvement. >> Great. Thank you. So two questions related to pharmacists next. Would a pharmacist be an acceptable leader foroutpatient stewardship in the facility setting? >> Absolutely, I think that whatwe’re looking for is a leader in the outpatient facility setting whois understands outpatient stewardship, that understands outpatientmedicine and is excited about this and if a pharmacist is available, Ithink they would be an outstanding leader for that activity in outpatient settings.They’ve been outstanding leaders andcontributors to inpatient stewardship so we would love to see pharmacistsstep into that role if that’s something availablein your clinic or practice. >> And then a follow-up questionto that: Are there initiatives to have retail pharmacies be proactive inantibiotic stewardship that you’re aware of? >> That’s a great question. So the Get Smart program has long reached out to pharmacists both clinicalpharmacists and retail pharmacists. Pharmacists certainly they often seethe patient before they ever come in for care to a doctor or another provider. They can help recommend symptomatic treatmentsto patients presenting in retail pharmacies, they can also help educate patients whenthey receive an antibiotic prescription about adverse events, about takingthe antibiotic correctly and disposing of any leftover antibiotics as well.So we think retail pharmacists are a veryimportant part of outpatient stewardship. >> Wonderful. The next question: Are you developing acurriculum for enhanced communications training or are there other resources out there tohelp clinicians with communication training? >> Great. That is a great question. There are a couple of resources out there for communications trainingand communications skills. We hope to have those postedon our website linked from our website they are notour resources but some good ones that we’ll have linked on our website soon. There was a recent skills training that wasfunded by the Robert Wood Johnson Foundation from Cognito that worked on communication skillsand you can actually play the role of provider or patient in a conversation about antibiotics.Also the New York State Department ofHealth put out a video this week talking about communication around this very issueand it was really well done and we’re excited to be able to provide those resourcesas 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 apatient, how would you overcome this barrier to taking the time to educate patientsabout why antibiotics aren’t needed? >> That’s a great question andclinicians do cite concerns for time as a reason they prescribeantibiotics inappropriately. They sometimes think it’s easier to prescribethe antibiotic and not fully explain things. But patients really want communicationwhether or not they get an antibiotic. That’s what they, you know, they really wantfrom their clinicians and it doesn’t take that long to to give them that message and Iwould argue and I think many people would argue that that’s part of good patient care regardlessof the treatment plan that you’re providing.So there are ways to give those messages inshort and succinct ways that don’t add much time to the visit but also help maintain satisfactionand we have many materials on our website that can help clinicianswith those types of education and that they can also provide patients. >> And this is Lauri and I would justadd to that that one of the resources that Katherine was alluding to on our websiteis a prescription pad for symptomatic therapy and it may just be that the provider isrecommending a humidifier for example lozenges for a sore throat but it provides somethingfor the patient to do and the patient feels like they have some instructions forsteps that they can take to feel better.>> Great. Thank you. So our next question: How useful areantibiograms in guiding the primary physicians on which antibiotics to useand should local data be used. >> That’s a great question. Thank you for that. So antibiograms can be very helpful in helping physicians determine whatthe appropriate antibiotic selection for a particular diagnoses are. So for example, for urinary tractinfections it’s very important to know what the local resistancepatterns for urinary pathogens are. One important piece of gettingthe correct antibiogram and having that antibiogram be useful isto make sure that it’s pertinent to your setting and, you know, that it’s local.So if you’re in a primary careoffice you don’t want to be looking at the hospital’s ICU antibiogram but reallylooking at outpatient primary care antibiograms, but they can there are critical pieces informing appropriate antibiotic selection and many of the national clinical practiceguidelines recommend consulting your local antibiograms. >> Great. Thank you. Next question: So regarding tracking andrecording, who is the appropriate person to manage this and how much timeand resources need to be allocated to properly implement a trackingand reporting system? >> So that is a great question.I think there are multiple people thatcould potentially be managing this. It can be the medical director of theclinic, it can be a nurse administrator, other administrator, it could be a pharmacist. If it’s within a health system it could occurmuch more centrally within that health system. It could actually be the clinician thatis doing it within their own practice. It certainly is probably, itcertainly could take a lot of time if there’s not an automated way to do thatin the electronic record but then we hope that for those clinics wherethat might be more difficult that you could potentially utilize the HEDISmeasures or other quality measures to start that piece of tracking and reporting as well. And it could also be done manuallywith, you know, for certain diagnoses or for a certain number of charts per day. >> Let’s see, so we probablyhave time for about one or two more questions beforewe just need to wrap up. So here’s another question. Do you anticipate an increase in resourcerequirement 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 initiativesthere certainly is an investment of time and resources that are needed. We hope that this document is flexible, we hopethat it provides a range of different options that some of which are relatively easysuch as the commitment poster to things that require a bit more infrastructure. But we hope that it provides a range ofoptions that fit many different settings. But again this is really about patientsafety and about high quality healthcare and antibiotic resistance is one of the mostpressing public health threats of our time and outpatient antibiotic use is the majority ofantibiotic use in humans in the United States.And so we really need to focus on this to keep these important lifesavingmedicines working for our patients. >> Great. Thank you. Here’s another question. Do you think antibiotic stewardship willbecome a core measure in the outpatient setting as it has in the inpatient setting? >> This is Lauri Hicks and I would saythat we are seeing increasing interest in incorporating I wouldincorporating stewardship into policies that would help encourage itsimplementation in outpatient settings. And I just want to include a couple of examples,for example, we have been having discussions with the joint commission aboutopportunities to incorporate the core elements into joint commission requirementsfor outpatient settings. We’ve also been talking to payers like CMS aswell as private payers about the opportunity to incorporate antibiotic stewardship, outpatient antibiotic stewardshipinitiatives into their activities. So I think you should anticipate that thiswill be of increasing interest to both payers, policymakers and even some ofour state health departments and I would say state policymakersare 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 systemswho 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 thata number of people are holding on to antibiotics at home or sharing antibiotics or doing thethings that we hope that they would never do. So certainly pharmacists are a greatresource for discarding all left over medications including left over antibioticsand so we would encourage both clinicians when they prescribe antibiotics, pharmacistswhen they dispense antibiotics and, you know, public health is, you know, and we have someof this information on our website as well to encourage patients to discardany left over antibiotics.Not to share them, not to save them fornext time and never take an antibiotic that was not prescribed for them. >> Wonderful. Thank you everyone for chattingin all your questions today. That’s all the time we havefor answering these inquiries. But please stay tuned for a follow-up email thatwill include the slides from today’s webinar. So we’ll be sending out the slidesfollowing this presentation. And then one final plug for Get Smart Week. We just wanted to remind everyone it is GetSmart Week and you still have a couple ways that you can be involved with the week includingon Friday we have a global Twitter chat from 11 a.m. to 1 p.m. Eastern usingthe hash tag antibiotic resistance. And then definitely checkout our Safe Healthcare Blog for a couple blogs this weekrelated to stewardship and then we also have somenew data sets available on our Antibiotic Resistance Patient SafetyAtlas and outpatient antibiotic prescriptions and also the percentage of antibioticstewardship programs in hospitals and then we’ve also included a linkhere 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 andpass the post test activity at 75 percent and complete the webinar evaluation. So when you close out of this webinara post meeting web page will pop up that will have detailed instructions forcompleting the CE post test and evaluation, so please be sure to fill that out. And for those on the phone who currentlyaren’t logged into Ready Talk online, in order to obtain the CE credit pleasego to http://www.cdc.gov/tceonline and then enter in the access code for thiswebinar which is WC1115. And just to say that one moretime the access code is WC1115.And then a follow-up email will also be sentout this afternoon with detailed instructions on completing the CE post test and evaluation. And with that we’d like to thank you Dr. FlemingDutra for talking with us today and for all of you for your time and also Dr. Lauri Hicksfor helping answer some of your great questions. And that is all we have foryou today, so thank you. Oh and again, the website to accessthe post test is http://www.cdc.gov/tceonline and the access code is WC1115. Thank you..
