FINAL OUTCOMES REPORT
Clinical Commentary: Multidrug Resistant Bacteria – An Ongoing Global Healthcare Challenge
Merck Grant ID: AAN151207035508 Executive Summary (Level 1-2)
Reach • 5,874 Participants and 4,991 Certificates • Pharmacist Participants - 4,469 • Pharmacist Completers with Certificate - 3,809 • MDs, PAs, RNs, & NPs Participants - 1,405 • MDs, PAs, RNs, & NPs Completers with Certificate - 1,182 • 62% of participants were pharmacists
Satisfaction • 93% of clinicians would recommend this activity to a colleague • 98% of learners did not perceive any bias • 91% of learners rated educational content as good/excellent
Learning Objectives • 98% of participants strongly agree/agree that they are better able to meet the learning objectives after completing the activity
Impact • 93% of learners stated that the activity increased or validated their competence in practice • 68% of learners will change their practice based on this activity; 35% plan to change the management and/or treatment of my patients • 47% of learners will seek to address potential barriers to patient access to therapies
Icon made by FreePik from www.flaticon.com Executive Summary (Level 3-4)
Knowledge • Participants demonstrated increased awareness of differences in the definitions of multi-drug resistance • Participants demonstrated increased knowledge of the mechanism of vancomycin-resistant enterococci
Competence • Participants demonstrated improved competence in the selection of therapy for a theoretical case patient • Learners reported increased confidence across several areas, including application of local antibiograms and selection of therapy
Performance and Patient Outcomes • Clinician learners reported an intent to obtain a culture and refer to their local antibiogram; however, only one-third reported this intent to change • Of pharmacist learners, 51% plan to collaborate with colleagues to discuss best practices and approaches to dosing and duration of therapy • These members of the multidisciplinary team plan to implement changes that may optimize antimicrobial therapy and reduce the development of resistance
Icon made by FreePik from www.flaticon.com Future Educational Opportunities
Clinician learners are most interested in education on infection control while pharmacist learners are most interested Future Educational in antibiotic stewardship Opportunities
Learners would like more knowledge on the clinical application of new antimicrobials
Consider case-based activities as learners demonstrated increased competence with newer therapies based on the faculty discussion on selection of therapy for diverse patients
Icon made by FreePik from www.flaticon.com
Program Overview
Overview: This online clinical commentary reviewed the impact of extended-spectrum beta-lactamase (ESBL) and carbapenemase-producing bacteria and presented comparative data on current and emerging therapies to develop strategies for initial therapy and optimal outcomes.
Intended Audience: This activity intended to educate physicians, nurses, pharmacists, and other clinicians involved in the treatment of multidrug resistant infections.
Activity Date: June 30, 2016 Expiration Date: June 30, 2017
Power-Pak C.E. ™ (Pharmacists) - http://www.powerpak.com/course/preamble/113153 freeCME (MDs, PAs, RNs, & NPs) - https://learning.freecme.com/a/21674PAgzkgE
Credit: 1.0 AMA PRA Category 1 Credit™ (Physicians), 1.0 CPE contact hour (Pharmacists) and 0.1 IACET contact hour (Nurses)
Sponsored By: The Academy for Continued Healthcare Learning (ACHL)
Funding: Supported by an educational grant from Merck Faculty
James Lewis, PharmD Clinical Pharmacist Antimicrobial Management Team Department of Pharmacy Services Oregon Health & Science University Portland, OR
Carlene A. Muto, MD, MS Associate Professor Department of Medicine, Infectious Diseases University of Virginia Charlottesville, VA Participation
Participants: 5874 Clinician Type Certificates: 4991
Physician 7% 8% 10% 7% Physician 4% Assistant 2% Nurse
Nurse Practitioner Pharmacist
62% Pharmacist Tech Participation (Cont.)
Pharmacy Specialty 1%
14% Academia/Pharmacy School Health Systems Long Term Care/Nursing Home 44% Managed Care Company Pharmacuetical Manufacturer Pharmacy Benefit Manager 31% Psychiatric Hospital Retail Other
1% 1% 2% 2% 4%
*other includes ambulatory care, changing setting, compounding, cardio practice, development inst., info tech pharmacist, med education, mail order, drug wholesale distributor Participation (Cont.)
Clinician Breakdown
4% 3% 3% Family Practice 4% 12% Uknown Other 7% 9% Internal Medicine 8% Emergency Medicine Pediatrics General Practice 50% Surgery Primary Care
*Other includes cardiologists, podiatrists, dermatologists, psychiatrists, gastroenterologists, radiologists, hospitalists etc. Learning Objectives
Please rate the following objectives to indicate if you Analysis of are better able to: Respondents Rating Scale: 4=Strongly Agree 1=Strongly Disagree Demonstrate an understanding of the molecular epidemiology of 3.41 antibiotic resistance in bacterial pathogens Summarize the salient features and critical differences amongst 3.40 available antibiotics and those in development for use against multidrug resistant gram-negative bacteria Describe strategies to optimize initial antimicrobial therapy to ensure 3.42 effectiveness of antibiotics and reduce the development of resistance Discuss the interventions with the potential to reduce inappropriate 3.42 use of antibiotics and improve outcomes in patients with resistant bacterial infections
Learners Strongly Agree/Agree that all learning objectives were met, with an average rating of N=4,974 3.41/4.0 Faculty
Faculty Evaluation Analysis of Respondents 5 = Excellent, 1 = Poor James Lewis, PharmD Carlene A. Muto, MD, MS
Ability to effectively convey 4.32 4.34 the subject matter Ability to deliver an objective 4.34 4.35 and balanced presentation Ability to present scientifically 4.33 4.34 rigorous information Expertise on the subject matter 4.37 4.38
The faculty were highly rated across all areas, with an average rating of 4.35/5.0.
N=4,974 Satisfaction
Overall Evaluation Analysis of Respondents 5=Excellent, 1=Poor
Quality of educational content 4.30 Usefulness of educational material 4.29 Effectiveness of teaching method used 4.23 Appropriateness and effectiveness of active learning 4.27 strategies (questions, cases, discussion, etc)
Usefulness of educational material and active learning strategies were able to support learning with 4.29 and 4.27 out of 5.0 rating respectively.
Quality of educational content was highly rated at 4.30 out of 5.0
N=4,974 Objectivity & Bias
Perception of Bias Objectivity & Balance 98% 100% 100%
80% 80%
60% 60% 49% 40% 40% 40%
20% 20% 10% 2% 1% 0% 0% Yes No
N=4,989 N=4,956
Activity was viewed as objective, balanced, and non-biased. Levels 3-4: Pretest vs. Posttest Summary
Below is a summary of participant responses, based on questions answered at pre-activity and immediately following the activity. 96% 91% 100% 86% 86%85% 86% 81% 72% 47% 48% 50% 31% 31% 38% 23% 22% 28%
0% Q1 Q2 Q3 Q4
Pharmacists Pre n=7,638 Pharmacists Post n=3,809 MDs, PAs, RNs, & NPs Pre n=1,356 MDs, PAs, RNs, & NPs Post n=1,206
Question Topic % Change % Change MD, Pharmacist PA, RN, NP Defining multi-drug resistant Q1 bacteria 274% 227% Q2 Mechanisms of resistance 210% 177% Q3 Selection of therapy 124% 207% Q4 Novel therapies 94% 69% Levels 3-4: Pretest vs. Posttest
1. Definitions of multi-drug resistant bacteria:
A. Have been standardized by United States and European organizations B. Vary across hospitals MDs, PAs, RNs, & NPs Pre n=1,356
C. Apply to pathogens that are resistant to one 100% Post n=1,206 or more classes of antimicrobials 72% 58% D. Are consistent across pathogens 75% 50% 22% 16% 25% 10% 11% 4% 0% ABCD Pharmacists Pre n=7,638 Post n=3,809 100% 86% Correct responses increased in both groups of 75% 62% learners after participation in the activity, but 50% pharmacists displayed greater improvement. 23% The baseline results from this question are 12% 25% 9% indicative of the inconsistencies in defining 4% 3% 1% 0% multi-drug resistance across institutions. ABCD Increased awareness of the challenges discussed by the faculty may prompt learners to examine how their respective institution defines multi-drug resistance. Levels 3-4: Pretest vs. Posttest
2. What is the mechanism of resistance of vancomycin-resistant enterococci?
A. Change in binding site B. Upregulated efflux pumps C. Enzymatic degradation MDs, PAs, RNs, & NPs Pre n=1,356 D. Outer membrane porin changes Post n=1,206 100% 86% 75%
50% 31% 24% 32% 25% 13% 5% 5% 4% 0% ABCD
Pharmacists Pre n=7,638 Both groups of learners had low performance Post n=3,809 on this question around mechanisms of 100% 86% resistance on the pre-test. However, by the 75% end of the activity, knowledge across both 50% 31% groups of learners increased with 29% 20% 20% 25% participants providing correct responses 80% 1% 1% 1% (or greater) of the time. 0% ABCD Levels 3-4: Pretest vs. Posttest
3. A 67-year old woman with a history of smoking is admitted from the ED for rapidly progressing pneumonia. Despite therapy, she exhibits worsening signs and is transferred to the ICU. P. aeruginosa is isolated from sputum specimens. What therapy would you select for her? MDs, PAs, RNs, & NPs Pre n=1,356 A. A carbapenem Post n=1,206 100% B. Ceftolozane-tazobactam 86% C. Piperacillin-tazobactam 75% D. A quinolone 50% 39% 28% 25% 16% 17% 4% 6% 4% 0% ABCD
Both groups of learners demonstrated increased Pharmacists Pre n=7,638 competence in the selection of therapy for this Post n=3,809 theoretical patient. Selection of therapy at 100% 85% baseline varied greatly in both sets of learners, 75% with approximately one-third selecting the newer, yet off-label, approach of using ceftolozane- 50% 38% 32% 18% tazobactam. The percentage selecting 25% 10% 12% piperacillin-tazobactam increased to 3% 2% 0% approximately 85%, likely based on the faculty ABCD discussion. Levels 3-4: Pretest vs. Posttest
4. Ceftolozane, the new cephalosporin in the combination of ceftolozane- tazobactam, is distinguished from other cephalosporins by its activity against which of the following?
A. Acinetobacter baumannii MDs, PAs, RNs, & NPs B. Klebsiella pneumoniae carbapenemase 100% Pre n=1,356 C. New Delhi metallo-β-lactamase–producing 81% Post n=1,206 Enterobacteriaceae 75% 48% D. Pseudomonas aeruginosa 50% 25% 25% 14% 13%12% 3% 4% 0% ABCD
Pharmacists
100% Pre n=7,638 91% The percentage of clinician and pharmacist Post n=3,809 75% learners demonstrating increased knowledge of 47% ceftolozane-tazobactam increased after 50% 28% participation in the activity. The increase was 25% 12% 13% greater in pharmacists. This increased 1% 4% 4% 0% knowledge may translate into clinical decisions ABCD when selecting therapy. Confidence: Local Antibiogram Knowledge
How confident are you in your knowledge of the local antibiogram in your institution?
A. Very confident MDs, PAs, RNs, & NPs Pre n=1,356 B. Somewhat confident 100% Post n=1,180 C. Minimally confident 75% 56% D. Not at all confident 50% 44% 29% 23% 25% 13% 16% 14% 5% 0% ABCD Pharmacists Prior to participating in the activity, 100% Pre n=7,661 confidence in their knowledge of local Post n=2,557 75% antibiograms was reported by slightly more 55% than one-half of all learners. After viewing 50% 42% 31% 27% the faculty discussion on the use of 25% 12% 14% 15% antibiograms to selection therapy, 79% and 4% 0% 82% of clinician and pharmacist learners, ABCD respectively, reported being “very” or “somewhat” confident in their knowledge. Confidence: Selection of Therapy
How confident are you in your ability to select therapy for your patients with multi-drug resistant infections? MDs, PAs, RNs, & NPs A. Very confident 100% Pre n=1,356 B. Somewhat confident Post n=1,180 75% 59% C. Minimally confident 50% 44% 30% D. Not at all confident 23% 25% 12% 14% 14% 4% 0% ABCD
Approximately 55% of clinicians and pharmacists Pharmacists reported being “very” or “somewhat” confident in their ability to select therapy for 100% Pre n=7,661 their patients with multi-drug resistant 75% Post n=2,557 58% infections at the beginning of the activity. 50% 44% After the activity, confidence levels improved 32% 27% in both target audiences with 82% and 85% 25% 11% 12% 13% 3% reporting confidence. The faculty case-based 0% discussions on selection of therapy for diverse ABCD patients likely contributed to this improvement in confidence. Confidence: Antimicrobial Therapy Dosing
How confident are you in your ability to determine the appropriate dose and duration of antimicrobial therapy to gain the best outcome and minimize bacterial resistance?
MDs, PAs, RNs, & NPs A. Very confident Pre n=1,356 B. Somewhat confident 100% Post n=1,180 75% C. Minimally confident 58% 50% 44% D. Not at all confident 30% 23% 25% 12% 15% 14% 4% 0% ABCD Pharmacists
100% Pre n=7,661 Post n=2,557 Slightly more than one-half of pharmacists and 75% 57% clinicians reported being “very” or “somewhat” 45% 50% confident in their ability to determine 29% 30% appropriate dosage and duration of 25% 12% 11% 13% 3% antimicrobial therapy prior to participating in 0% the activity. This self-reported confidence ABCD increased in the clinician (81%) and pharmacist (86%) groups after the activity. Again, the case- based portion of this activity may have influenced this improvement. Level 4: How Will You Change Your Practice? (MDs, PAs, RNs, & NPs) Which of the following strategies do you currently employ to improve outcomes in patients with multidrug resistant infection (check all that apply)?
A. Get a culture B. Refer to my hospital/institution A 29% antibiogram to determine the B 21% susceptibility C. Continue or change prescribed C 19% antimicrobial based on results of culture D. Gain infectious disease and/or pharmacy D 17% input E 14% E. Determine appropriate dose and duration of therapy to gain best outcome and FreeCME minimize bacterial resistance
Obtaining a culture and referring to their local antibiogram are the most common approaches employed by these clinicians. However, less than one- third of participants employ these important aspects to improve patient outcomes in patients with multidrug resistant infection. These data underscore the importance of this activity and warrant additional educational endeavors.
N=2,514 Level 4: How Will You Change Your Practice? (MDs, PAs, RNs, & NPs) I plan to make changes to my practice based on this activity, by incorporating the following new strategies:
A. Increase my knowledge of institutional A 46% resistance patterns to assist in the choice of empiric treatment B 24% B. Determine appropriate dose and duration of therapy to gain best outcome and C 25% minimize bacterial resistance C. Consult infectious disease and/or D 5% pharmacy on cases involving difficult to treat multidrug resistant pathogens FreeCME D. Other
Clinician learners indicated that they intend to change their practice after participating in this activity. 46% reported plans to increase their knowledge of institutional resistance patterns to aid in choosing empiric treatment. This is in contrast to the low number of learners who reported referring to their local data before participation.
Additionally, one-quarter intend to determine the appropriate dose and duration of therapy and consult infectious disease or pharmacy experts on difficult to treat multidrug resistant pathogens for better outcomes
N=1,180 Level 4: How Will You Change Your Practice?
(Pharmacists ONLY) I plan to make changes to my practice based on this activity, by incorporating the following new strategies:
A. Collaborate with my clinician colleagues to share best practices to determine A appropriate dose and duration of therapy to 51% gain best outcomes while minimizing bacterial resistance B 37% B. Consult infectious disease/control colleagues on cases involving difficult to treat multidrug resistant pathogens to ensure appropriate C 12% antimicrobial stewardship and optimal outcomes C. Other Power-Pak Pharmacists also report that they intend to change their practice after participation in the activity. 51% plan to collaborate with colleagues to discuss best practices and approaches to dosing and duration of therapy and 37% intend to consult their colleagues on difficult to treat multidrug resistant cases.
Taken together, the clinician and pharmacist data indicate that these important members of the multidisciplinary team plan to implement changes that may optimize antimicrobial therapy and reduce the development of resistance.
N=3,381 Levels 3-5: Impact of Activity
Please rate the projected impact of this activity on your knowledge, competence, performance and patient outcomes?
Yes No Change No This activity increased my knowledge 80% 14% 6%
This activity increased my competence 75% 18% 7% This activity will improve my performance 69% 23% 8%
This activity will improve my patient outcomes 66% 25% 9% This activity was highly effective, with 66% indicating it will impact patient outcomes.
Common themes from participants with respect to knowledge, competence, and performance Knowledge • Beneficial in healthcare documentation for recognition of errors and discrepancies for flagging and risk management • Learned about new combination antibiotics used for cUTI and pyelonephritis • Use of newer agents and new antibiotics • Better understanding of resistance Competence • Awareness of complications within hospital care and some updates on MDR organisms and tx modalities • Recognize the mechanisms of resistance & use of appropriate empiric and sensitivity-based antibiotics • Better prepared to answer physician questions Performance • Gave me a framework for rational clinical decision making in choosing, dosing, and determining length of treatment with antibiotics • This will help me to identify patients who may need admittance to the hospital. I will also perform more cultures as a result in order to maximize efficacy and minimize resistance. • Better prepared to make recommendations and appropriate antibiotic selection for multidrug-resistant organisms
N=4,953; a listing of participant comments is included in the appendix Patient Impact
Number of patients affected by these changes each month: 6% 6% 0 26%
1-10 14%
11-20
21-50
>50
48%
Changes will impact up to 52,725 patients each month. This assumes data in chart above is representative of all participants (5,874), who indicated their patient outcomes would be effected as a result of this activity (66%). Perceived Clinical Barriers
Please indicate any barriers you perceive in implementing these changes.
7% Cost 8% 5% Reimbursement/insurance issues 6% 48% of pharmacists and 46% of clinicians indicated that they will Lack of opportunity (patients) 9% 8% attempt to address these barriers to 11% Lack of experience 12% implement changes. 2% Lack of resources (equipment) 4% Of the learners that intend to 10% Lack of time to assess/counsel patients 6% address barriers to practice, identified strategies include: seek Lack of administrative support 8% 8% resources and support, monitor 7% Lack of consensus or professional… 9% recurrences, and discuss with colleagues and administration on No barriers 21% 15% effective recommendations. 11% Patient compliance issues 22% 8% Other, please specify 3% Pharmacist MDs, PAs, RNs, & NPs
N=5,559 Select all that apply How Barriers Will Be Addressed (open-ended comments)
• Improve communication and awareness of problem associated with bacterial resistance with patient and hospital • Continue to educate myself regarding evolving practice standards • Have time to assess/counsel patients, consensus or professional guidelines and administrative support • Integrate patient education and intervention • Utilizing resources, such as ID specialist and pharmacy for guidance when needed • Share the information in the activity with our infectious disease doctor to help implement new policy • Make sure that the patient really understands the importance and use the method of teach back • Educating the patient about the importance of complying with treatment protocols
*Please see appendix for comprehensive learner comments Future Education Considerations
What topic areas would you like to see in future activities?
18% A. Antimicrobial stewardship A 30% B. Infection control 30% B 19% C. Use of new antimicrobials 24% C 23% D. Dosing and duration of antimicrobials 18% D 20% E. Clinical trial efficacy and safety data 9% E 5% F. Other F 1%3%
MDs, PAs, RNs, & NPs Pharmacist
Among pharmacists, the top two categories for future education were antimicrobial stewardship and the use of new antimicrobials. Clinicians viewed infection control as an area they would most like to see also followed by the use of new antimicrobials. These differences are in line with the roles of pharmacists and other providers in reducing multi-drug resistance.
N=5,385 . For questions, please contact: Rich Keenan VP, Education Development Academy for Continued Healthcare Learning (ACHL) E: [email protected] P: 773-714-0705 ext. 215 C: 610-742-0749 Appendix
. See Attached PDF Comments APPENDIX
PowerPak (Pharmacists)
4. Did you perceive any bias or commercialism towards any product or drug in this activity? If yes, please explain:
Muti drug No mention of use of antibiotics in food supply as source for growing MDR pathogens Too much talk about two new combo antibx...makes u wonder Lecture sponsored by Merck, new drug Ceftolozane; Tazobactam made by Merck Mildly obvious it was oriented to ceftolazane, but not annoyingly so Some preference toward Zerbaxa
7. Please rate the projected impact of this activity on your knowledge, competence, performance and patients’ outcomes in the treatment of multidrug resistant infection:
This activity increased my knowledge. If yes, please describe:
Use of newer agents Better understand resistance Learned about new combination antibiotics used for cUTI, pyelonephritis Learned about a new antibiotic Would like to do more research and learn more Newer agents New antibiotics
8. This activity increased my competence. If yes, please describe:
Better prepared to answer physician questions
9. This activity will improve my performance. If yes, please describe:
Better prepared to make recommendations I plan on reading more about MDR's and finding a job to use my knowledge Increased awareness and confidence Selecting appropriate antibiotics for multidrug‐resistant organisms
10. This activity will improve my patient outcomes. If yes, please describe:
Hopefully patients will be on correct antibiotics for correct duration of time Better understanding of diagnostics
12. (Pharmacists ONLY) I plan to make changes to my practice based on this activity, by incorporating the following new strategies: Other, please specify:
Continue to promote stewardship program in our facility Validated my practice Technician Question /return prescription in data review with inappropriate dose /duration Discussion for IC, rate of infusion, Become familiarized with my institution's antibiogram Compound pharmacy strengthening antibiotic stewardship program i work with homeopathics so this was will not help my practice but improve my knowledge as a pharmacist retail community rph, not involved with treatment decisions formulary consult with clinicians to share best practices community pharmacy you don't have much input into drug selection for MDR infections but I can watch more closely for patients getting repeat/under dose speak to pharmacist in my area of practice, I do not treat or have direct patient contact Be able to address best practice strategies with colleagues pharmacy technician i plan to make changes in cleaning and awareness Collaborate with my physicians not working Not currently in practice increase my education administrative role vs clinical strict formulary as a retail pharmacist I will verify rx on antibiotics therapy accordingly and counsel pt and dr. Collaborate with prescribers Better knowledge as I work in industry I do not choose therapies updating competence my hospital does not have multidisciplinary approach I am employed at a community pharmacy I don't see patients. But we approve IV antibiotics and sometimes orals. monitor abx usage Assist with evidence based order sets I am in retail pharmacy and i have limited susceptibility information not applicable, not a hospital pharmacist, but topic of interest for discussion to pts in community setting not part of the determination of therapies implemented. not in practice-regulatory This is already part of current practice
Please identify how you will change your practice as a result of participating in this activity. Please identify how you will change your practice as a result of participating in this activity (select all that apply).
Other, please specify:
we usually don't do IV antibiotics in my practice inform patients on community acquired drug resistance better assess the choices of antibiotics prescribed by providers for outpatient usage not valid for community practice More involvement of infectious dx pharmacist seek more tools to guide my recommendations better recommendations upon providers request Cannot be implemented in my practice setting Look at the hospital's antibiogram which was newly created Better prepared to make appropriate recommendations very informative take into consideration use of nonformulary medications if appropriate for member's infection improved knowledge I am not directly involved in the decision making of antibiotic therapy. I do not practice in direct patient care watching for repeat therapy and underdosing providers call Consult ID more Since it is difficult subject, a lot of factors involved, maybe gain some knowledge and understand having understanding of the appropriate selection of the right antibiotic cannot see this affecting my current job speak to pharmacist ID stewardship practices these recommendations at my site in my area of practice, I do not treat or have direct patient contact. This lesson is a start to becoming more knowledgeable about MDR therapies more informed to discuss with my clinical RPh Read more of the current literature and also know my antibiogram better Pick up the phone more often to call prescribers who are choosing the wrong antibiotic retail practice limited to consultation with clinicians and patients I will assist Pharmacist in gathering information Change in assisting pharmacists increase my personal education further discuss with others my need for more knowledge in the area when needed administrative role vs clinical formulary restriction will make a change if needed More willing to convey concerns about antibiotic selection ensure appropriate therapy is prescribed updated my knowledge regarding resistance Better knowledge for working industry I do not choose therapies better understanding on compounding Speak with other clinicians press for rapid diagnostic equipment Insurance Formularies. No Change I am not currently working with clinicians in proving consultation of infection diseases I need more training ‐ still not confident question providers about cultures and antibiograms need to research more inquire with colleagues/physicians more will be more aware As a tech ‐ maintain strict adherence to pharmacy protocol for MDR bacteria. I am a cpht and will do what my RPH asks
15. Please indicate any barriers you perceive in implementing these changes. Other, please specify:
formulary Physician education I believe all of the above apply to our institution and in most of the institution in my country (Nigeria) and we have a lot of barriers finance formulary Clinical research work clinical inertia from physicians (especially some older physicians) Physician resistance Formulary and availability of new labs tests believe it or not, too many id docs that don’t accept these current strategies IV compounding pharmacy practice pharmacy tech not allowed old physicians who are resistant to change prescriber education Endemic culture of antimicrobial overuse at my institution formulary restrictions back ordered drugs done by clinical pharmacist multiple barriers‐‐pt compliance, med staff compliance, institutional barriers, etc. hospital formulary lack of ID specialist Physician specific formulary restrictions Lack of physician education on antibiotic stewardship initiatives possible drug shortages retail approval our ID RPH left and we are in process of replacing our ID RPH lack of being in this area on a regular basis I CAN'T PRESCRIBE OR DIAGNOSE formulary restrictions physicians/other providers formulary Unfortunately with FTE constraints there is never enough time for antibiotic stewardship! physician support Lack of physician support little or no input on antibiotic selection Retail environment doesn't allow for intervention time constraints time constrain, inadequate staff provider resistance lack of multidisciplinary approach Lack of Influence on providers lack of physician openness Formulary restrictions Formularies Strict formulary lack of prescriber knowledge/buy in Resistance from doctors to change in prescribing habits Formulary/availability of medications
16. Will you attempt to address these barriers in order to implement changes in your competence, performance, and/or patients’ outcomes? If yes, how? If no, why not?
With our infectious disease pharmacist We evaluate all of aminoglycosides daily and ABX therapy in ICU. When time permits more resources are directed toward ABX . Try to learn more
19. What topic areas would you like to see in future activities? Other, please specify.
All of the above and also polypharmacy in antimicrobial treatment, treatment of infection in pediatrics Use of antimicrobials in pediatrics All of the above (5) Good Manufacturing Practice CERT PHARM TECH provider call Law Antimicrobial use in elderly population Disease diagnosis and treatment Human side effects to pet flea prevention Medical safety CLL ‐NEW TREATMENTS Treatment of multidrug resistant bacteria Antibiotics and proper use. Gram negative vs. Gram positive out patient Medication safety Infection control on cancer pts Poison Ivy Infectious drug therapy after discharge
FreeCME (MDs, PAs, RNs, & NPs)
Did you perceive any bias or commercialism towards any product or drug in this activity? If yes, please explain:
Pro‐new drug, basic options not covered How many drugs are on the market fitting the limits of the discussion? Ceftaroline Supported by big pharma
7. Please elaborate how the activity impacted your knowledge, competence, performance and patients outcomes in the treatment of multidrug resistant infection
better understanding it help me change my practice a lot to explain.. but certainly I’ve learned a lot better understanding of new antibiotic choices Use infection control techniques to reduce spread of infection To better be able to elevate their issue and prescribe the appropriate treatment increase diverse knowledge ICU patients, VAP I now have a broad idea of multidrug resistant infection I am confident know how to treat multidrug resistant patients They were very effective in educating us about MDR bacteria involving most of the problem organisms we currently see. Better understanding of mechanisms and medication can apply to my work Not currently treating these types of infections Increased my awareness of variances between hospitals recognize the mechanisms of resistance & use of appropriate empiric and sensitivity‐based antibiotics knowledge based on epidemiology of AB resistance has increased, allowing me to recommend proper medications I have more knowledge. I do not prescribe so it won't impact my patient outcome, but I will be a more effective teacher and support for my patients and families be more aware Awareness of complications w/in‐hospital care and some updates on MDR organisms and tx modalities. Definite enhancement in bacterial mechanism of resistance and antibiotic choice. Strategies given are great New Knowledge Always good to hear about coming antibiotics and review good practices in selection. knowledge to deal with drug resistance This knowledge is beneficial in healthcare documentation for recognition of errors and discrepancies for flagging and risk management very helpful better and newer treatments to utilize Increase education Less treatment failures I have learned about ceftolozone short duration therapy for comm acquired infection Effective shorter duration antibiotic therapy helps prevent/delay development of drug resistant organisms changed my thoughts the antimicrobials that I often use inappropriately moderately improve patient outcome in the practice Good to hear the mechanisms of resistance ‐ binding site changes, destruction of antibiotics. Would have helped if the Docs talked more slowly and /or had the antibiotics written out and maybe a graph of what antibiotic to use with specific infection. I am a med surg nurse Amazing info less utilization Remember cultures! Improves knowledge and skills to improve outcomes in patients with multidrug‐resistant infection. minimize the wrong treatment with antibiotic Better choice in therapy selection. The faculty were obviously very knowledgeable, but there were too few slides summarizing important information, and they spoke in a very "jargon‐y" way, which was difficult for someone who does not spend much time in the hospital to follow. I learned a little about MDR infections, but it could have been so much better. coordination Resistance and how microbes are changing Exposed me to new information on antibiotic treatment. Precisely and explained well Discussion of the newer antibiotic combinations particularly was most helpful. extensive education material for me learn about multidrug resistant infection clearer view of some resistant pathogens This has made me more aware of appropriate treatment regimens for specific pathogens and also made me aware of new and upcoming drugs. Although I do not currently work in a setting where I am prescribing antibiotics, I believe this will make me a better health care provider all around. To match antimicrobial to microbe quinolone still valid 2nd choice will think harder before ordering the stronger abx, increased knowledge of changes in resistance treatment It updates what I previously knew of the multidrug resistant infection and it has given me the confidence to treat its occurrence when it happens it was educational This was well done and highly informative improve medications Patterns of multidrug resistance Select appropriate antimicrobial therapy Taking into consideration certain comorbidities Better appreciation of antibiotic resistance and choice of medications and likely discussion with Infectious Disease specialists when not certain what to use gave me a framework for rational clinical decision making in choosing, dosing, and determining length of treatment with antibiotics New information Although I am not a prescriber, my understanding of problem has increased. Work with neutropenic pts and have a greater appreciation of the dosing patterns good discussion of resistant strains Better understanding of how happened and what to do more cultures, less empiric therapy more aware The seminar has made good emphasis on adherence to treatment. Good review. Very useful more understanding reaffirmed and made up to date my knowledge and competence to ensure optimal patient outcomes resistance GOOD NEW KNOWLEGE Newer treatment options and regimens. Learned more about multi drug resistance helpful Really helped my understanding of resistance I don't directly treat patients Excellent. wish you had equivalent presentation for clinics vs hospitalized patients use of new antibiotic Mechanism of susceptibility More information base in terms of treatment The activity involves many drugs How VRE causes resistance This activity increased my knowledge to be keen in choosing the antibiotic to be given better understanding of newer and Older agents As a holistic psychiatrist this will help with understanding what is happening to my patient and to advocate for better hygiene and use of immune system bolsters increased understanding of treatment updated knowledge base TREATMENT VARIANCE IN SITUATIONS THAT ENHANCE DRUG RESISTANCE better understanding of this resistance progression It added to it Improved knowledge¨ I am not practicing presently Gave me good information on some drugs I don't typically prescribe more aware of handling MDR pathogens I learned about VRE better understanding on how to decrease spread of the bacteria’s I was out of the loop regarding new therapies info to prescribe Better understanding Rx Obtaining cultures Utilizing hospital specific protocols Spreading awareness improved knowledge Focus in output versus inpatient therapy how to treat LEARNED MORE about the behavior of resistant organism Medication concise summary of salient information I do not treat in this military clinic‐we send out. But I will understand their treatment better Expended spectrum of resistances and causes I can spread the education of antibiotic resistance to friends, family, and patients update knowledge The activity helps me to be a better source for my students This was informative. I learned new information, and some information I already knew were reinforced Learned the different approaches of doctors in tx of multi resistant bacteria New update with resistance and new medication and combination txmts Better understanding of resistant bacteria better awareness Awareness gave me more insight into cef/tazobactam Allowed me to understand how and why this is more information gained will be translated into action for better results in patients it let me know when to refer to specialist Better educated in drug resistance It was nice to see how they broke apart the case studies to better understand what was going on Change rx Better knowledge regarding resistance This activity increased my knowledge Although I work in an outpatient setting, this will help me to identify patient who may need admittance to the hospital. I will also perform more cultures as a result in order to maximize efficacy and minimize resistance. I also did not know there is an Antibiogram option to evaluate bacterial infections within our clinic, this is something that may be useful to me Increased knowledge Great overview understanding application of abx therapy more awareness Don't do inept work anymore but increased my knowledge This activity teach me on how to upgrade my knowledge about antibiotics and multidrug resistant infection after this session i gain a lot of knowledge and information which i can share it and use in our patient I do not write for abx tx. Choosing antibiotic therapy more careful gave me understanding od trend Will discuss with colleagues more readily able to choose appropriate abx develop treatment plan Better understand resistance Be familiar with hospital/ outpatient and community microbii & related Antimicrobiome , use narrow spectrum, effective antibiotic, check safety profile of treatments
12. I plan to make changes to my practice based on this activity, by incorporating the following strategies. Other – please specify:
I have no direct patient interaction. Continue what we are doing ‐ consulting will be more knowledgeable consultant Become more aware of the pathogens that are causing the greatest problem in my area Actually I have been doing all that these doctors had been saying, but it was hard to get the physicians to practice this type of good medicine. I really wish that every doctor would listen to this presentation! Assist the physician by ensuring that isolation precautions are being adhered to and that I am verifying dosing and reporting any patient changes and critical labs in a timely manner Patient education to best hygiene and wellness practice I'm presently not practicing. I only practice out‐patient more awareness of antibiotics Always get a culture! learn about which bugs most commonly effect my neonates Unable to apply as I don't handle patient with such problems Awareness
13. Please identify how you will change your practice as a result of participating in this activity. Please identify how you will change your practice as a result of participating in this activity (select all that apply). Other – please specify:
working with physician to make sure we get sputum specimen on arrival and care for patient Just keep doing what I have been doing Review further NEJM article and IDSA guidelines will attempt to find additional educational activities relating to infections control/epidemiology Refer, but also more thoroughly discuss course with ID refer to I.D. any resistant cases use cultures more have discussion with hospital residents to educate them as well Increase awareness among staff and offer more knowledgeable consultation to other providers, when sought
15. Please indicate any barriers you perceive in implementing these changes. Other, please specify:
Lack of physicians doing what they are supposed to formulary drug formularies
16. Will you attempt to address these barriers in order to implement changes in your competence, performance, and/or patients’ outcomes? If yes, how? If no, why not?
yes, by applying it to our healthcare setting follow protocol seek resources and support Implemented changes Encourage all my patients who are not covered by their employers to obtain insurance early Work with ID Will discuss with physician on a patient to patient basis. improve communication and awareness of problem associated with bacterial resistance with patient and hospital improve care appeal to insurance companies documentation Review new information Continue to practice with best practices techniques. Time will be the teacher. Judicious use of antibiotics local, state, and federal levels will follow guidelines Study in‐services Out of my control round with colleagues monitor recurrences Study the new antibiotics and recommendations work with physicians who prescribe and treat patient Proper patient education give more information to patient Education conversation Continue to educate myself regarding evolving practice standards meetings Consult more talking with primary care provider discuss it with patients Work with infectious disease specialists first off attempt to have the physicians listen to this presentation Second make sure that every time we have an infection there is a culture!!! Pharmacy consults and political intervention future practice may change education doing more research No patients By having a team approach more investigation Co pay cards Application of the information in this CME Consult with my colleagues Discussions with practice committees It's pointless to fight administration Communicate more w/ administration By imparting health teachings to my client Provide guidance to supervising physicians in‐service meetings talking Complain to the drug reps antibiogram Moral hazard‐‐who cares how much money we spend, since "someone else" is paying? The #1 problem with healthcare today is moral hazard. It's everywhere. More proactively deescalate antibiotics Teaching other health professionals Unsure, it's a big problem Medicare doesn't cover anything I do Have time to assess/counsel patients, consensus or professional guidelines and administrative support discussion with lab, increase education, prescribe less antibiotics in clinic unless warranted education ID consult integrate patient education and intervention with time available education I will choose the right antibiotics sooner PATIENT EDUCATION BY KEEPING ABREAST OF INSTITUTIONALCHANGES AND BEING AN ACTIVE PARTICPANT better educate colleges Follow hospital protocols and consult w ID I'm working on returning to practice in the near future on an out‐patient basis By addressing my concerns with administration patient education Patient education KEEP ORDERING CULTURES AND INVOLVE PHARMACISTS Try to establish guidelines education on pathogen Utilizing resources, such as ID specialist and pharmacy for guidance when needed Discussion with the Lab and Pharmacy Reading work hard at it Discussion discuss accessibility with administration better education of the patient Meetings Protocols Standards of care Push harder for appropriate medication as medically necessary, based on newest evidence counseling use hospital antibiogram Further study and education. Better communication of rationale. pursue further education Education of partners in group By educating junior staff keep up on currents better communication by continuing to learn difficult to bring about changes in small set up it will involve looking at cultures ordered by multiple providers for trend analysis share the information in the activity with our infectious disease doctor to help implement new policy refer to I.D. and get C and S if possible/ join committees make sure that the patient really understands the importance and use the method of teach back therapeutic options Patient appeals Education for patients i will search and read more about this Need managerial approval information and use of appropriate abx Discuss good compliance to patients. advocating to the patients insurances More vocal work w/ pharmacy and infectious disease on creating cost effective recommendations watch local resistance trends These barriers involve 3rd parties that we have no control over. Patients can however be counselled for improved adherence/compliance yes coz this will help a lot in treating our patient Through careful attention to detail Educating the patient about the importance of complying with treatment protocols educating improve patient outcomes Seek input from administration It's a big problem in the hospitals
19. What topic areas would you like to see in future activities? Other, please specify.
Pharmacology Anthrax Cardiac surgery New antibiotics. Out patient & ER treatment protocols VS In‐Pt. hospital antibiotic use Neonatal aspects Arthritis
20. General comments:
thank you Thanks very nice activity Good job nice job Thank you Would like to see program about antibiotic resistance for sinusitis and std's The doctors spoke quickly. It would have been helpful to have more charts Excellent program We need newer antibiotics to deal with drug resistance especially Urinary Tract Infection very good excellent fewer acronyms and use the full name of drugs Would have helped if the Docs talked more slowly and /or had the antibiotics written out and maybe a graph of what antibiotic to use with specific infection. I am a med surg RN. I passed the test on the second attempt. Very good material Great job. very good CME activity overall it was educational True experts in their fields. Extraordinarily interesting presentation Thank you. Excellent presentation nice presentation Great program, thank you Job well done GOOD NEW KNOWLEDGE As an Alternative Health Practitioner excellent CME A VERY GOOD PROGRAM I am a nurse not a prescribing professional. I will however use the knowledge gained. Thanks for such useful info. Excellent Great discussion. I feel that discussions are helpful but the inclusion of frequent visual materials summarizing important concepts is very helpful. As this program relied much more on discussion than on visual presentation I found it less effective for my learning. very good Very nice presentation with relevant information very informative Excellent Wish there was an RN on the panel. This activity is probably very worthwhile for individuals who already have expertise in the topic. very good Thank you for having program Good talk, covered all aspects Loved the interaction of both doctors. They were not "dry" to listen to. Thank You good review Good presentation Very knowledgeable speakers all is clear thank you thanks