1. Antimicrobial Stewardship in Long Term Care
Marianne Pavia, MS, BS, MT(ASCP), CLS,CIC

2. Learning Objectives
Understand the burden of infection in LTC as related to the characteristics of the residents and the capabilities of the facility.
Describe the challenges and patterns of use of antibiotics in a LTCF.
Develop and apply the minimum criteria for initiating antimicrobial therapy in LTC.
Understand the uniqueness of a facility in regard to developing strategies for a stewardship program.
Apply CDC Campaign to prevent antimicrobial resistance among LTC residents.

3. Long Term Care Characteristics
1.7 million residents in LTC
Mean age 80
Decreased:
Immune function
Swallowing/ chewing
Skin integrity
Mobility
Bowel and bladder control
Increased:
Acuity
Medications
Dementia/depression/apathy

4. Burden of Infection in LTC
15,000 LTCFs in United States
Infection prevalence rate 5.3% (single day survey)
Infection incidence rate /1000 resident days
Examples:
UTI
Lower respiratory, including pneumonia
Skin and soft tissue
Gastroenteritis

5. Burden of Infection in LTC
Higher incidence of invasive MRSA
MDRO more severe infections, hospitalizations, risk of death, cost of care
12 month Rhode Island study:
72% inappropriate Ab, according to guidelines
67% longer than recommended duration
Adverse drug event risk
Increased incidence of Cdiff
Gerwitz JH, Field TS, Harrold LR. Incidence and preventability of adverse drugevents among older persons in the ambulatory setting. JAMA 2003;289:1107–11.

6. Challenges with Antimicrobial Use in LTC
Suspected UTIs account for 30-60% of antibiotic use due to diagnostic challenges
Clinical providers are off-site
Assessments communicated by front-line staff
Limited diagnostic testing (laboratory and radiology)
Off-site testing results in delays in specimen receiving, processing and results

7. Patterns of Antimicrobial Use in LTC
47%-80% residents exposed to ≥ one antibiotic course yearly.
Variability due to:
Provider prescribing habits
Types of residents
Types of resident services- i.e. pulmonary team
Estimate of “inappropriate” use of Ab varies upon definition
between 25%-75%

8. Loeb Minimum Criteria (LMC)
Created in 2000, updated in 2005
Minimum criteria of symptoms that should be present before initiating antimicrobial therapy
Developed to:
Decrease inappropriate use of Ab without evidence of infection
Decrease the overuse of newer, broad spectrum Ab
Guide rational assessment of infection
Proposed to improve Ab use
Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomized controlled trial. Loeb M1, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, Zoutman D, Smith S, Liu X, Walter SD.

9. Loeb Minimum Criteria

10. Urine Culture Results Algorithm

11. Intervention LTC with Loeb Minimum Criteria
Sent algorithms to physicians with written explanatory notes
Mounted at nursing stations
Presented 6 case scenarios to staff
Nursing completed log of symptoms
Four week training period

12. LMC

13. Successful Interventions with LMC in LTC
Still new to LTC implementation but:
30% reduction in Ab use and decreased Cdiff in one institution that used ID consultant
20% decrease in Ab that were adherent to guidelines from educational material ( no decrease in control group)
Jump RL, Olds DM, Seifi N, et al. Effective antimicrobial stewardship in a longterm care facility through an infectious disease consultation service: keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012;33(12):1185–92.
Monette J, Miller MA, Monette M, et al. Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities. J Am Geriatr Soc 2007;55:1231–5.

14. Case Study
92 yo female with stage 5 Alzheimers in LTC for severe knee arthritis, which has prevented her for walking for the past year. In addition, she suffers from depression and advanced glaucoma. Staff calls on-call MD noting dark and concentrated urine. Resident is also more confused but afebrile with normal vitals and no catheter in place. Nursing staff asks MD for a urine and he orders UA and culture. Two days later, primary attending is called with urine results not knowing the clinical situation present on ordering. Patient is now stable and no fever or urinary symptoms. UA= mod pyuria and 1+ nitrites Cx- 100 K GNR

15. Case Study Questions
Are there minimal criteria that should be considered prior to initiating antibiotic treatment for suspected UTI in a LTC resident?
Is there a potential for harm when ordering urine tests for LTC residents in the setting on non-specific symptoms?
Is withholding an antibiotic in the presence of nonspecific symptoms the same as failure to treat?
What is the role of the facility’s ICP and medical director in reducing over-diagnosis and treatment of UTI?

16. Surveillance purposes, highly specific for reliable bench marching
Question 1: Are there minimal criteria that should be considered prior to initiating antibiotic treatment for suspected UTI in a LTC resident?
The McGreer Criteria
Surveillance purposes, highly specific for reliable bench marching
Often determined retrospectively following full assessment
Not the standard for initiating antibiotics

18. Question 2. Is there a potential for harm when ordering urine tests for LTC residents in the setting on non-specific symptoms?
Asymptomatic Bacteriuria- prevalence rate of 15%-50% in LTC Positive UA and culture in LTC regardless of presence of UTI Over treating: Adverse drug reactions Increase Cdiff rates Increase in MDROs

19. Question 2. Is there a potential for harm when ordering urine tests for LTC residents in the setting on non-specific symptoms?
Urine tests drive decisions
Intervention is an algorithm to reduce unnecessary testing and treatment
Trials decrease Ab use with no negative outcomes

20. MD expected to take action
Question 3. Is withholding an antibiotic in the presence of nonspecific symptoms the same as failure to treat?
MD expected to take action
Worry about missing an infection, delayed treatment or not meeting the family’s expectation
Observing and monitoring is taking action
“Watchful waiting”- a cornerstone of clinical practice

21. Question 4. What is the role of the facility’s ICP and medical director in reducing over-diagnosis and treatment of UTI?
QAPI target- safety and liability risks, costs and impact resident’s quality of life.
Establish minimum criteria for culturing
Communicate findings from antibiogram
Support tools for reporting change in resident condition (SBAR)
Educate resident and family as well as staff and MD

22. Infectious Disease Society of America (IDSA) Guidelines
2008 updates to Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities
Felt LMC too focused on fever
Fever is absent in more than one-half of LTCF residents with serious infection
Focuses on elderly with multiple chronic co morbidities and functional disabilities
Resources are typically available to evaluate suspected infection
What clinical evaluation should be performed
Infectious Disease Society of America

23. Implementing Antimicrobial Stewardship Interventions
There is no ‘‘one-size-fits-all’’ approach.
Understand what the problem areas are at your institution
Determine what resources are available or may become available
Select stewardship strategies that best address the problems while accounting for the resources
Show off your success (or explain why success was not possible)
Use your success to secure more resources to address more problem areas.

24. Core Elements for Antimicrobial Stewardship Program
Leadership commitment
Accountability for improvement
Need drug expertise
Implementing action through targeted policies and guidelines
Tracking and reporting to staff on prescribing and resistance
Identifying key participants and ASP champions and offer education

25. Prescriptions
Physicians discuss with a stewardship team member before prescribing:
is usage appropriate
may delay initiating therapy
Post-prescription review:
Best hours or once a week

26. St. Mary’s Hospital for Children Antimicrobial Stewardship Program

27. SMH Stewardship Program
Leadership commitment- driven by CEO
Accountability for improvement- QAPI for medicine
Tracking and reporting to staff on prescribing and resistance
Implementing modified LMC/IDSA policies and guidelines for our population:
100 children- 60% trach, 10% vented, 10% short gut w/TPN

28. Cumulative Antibiogram
The primary use is for the selection of appropriate empiric therapy.
The use will result in tools to track antibiotic resistance as well as to assist the physician in making empiric antibiotic selections.
Limited bacteriology cultures ordered
2014 – created MDROs

29. SMH Stewardship Program
Jan 2014:
Organized ASP Committee- Director of Pharmacy, Medical Director, Nursing Leadership, IC
Reviewed Ab use retrospectively monthly
Epic fail
April 2014:
Reorganized, “low hanging fruit”

30. SMH Stewardship Program Conjunctivitis Criteria
Not be due to allergy or trauma to the conjunctiva and one of the following:
Pus from one or both eyes
New or increased conjunctival redness with or without itching or pain
If meets criteria:
Bacterial eye culture
Ab treatment initiated- Fluoroquinolone drops
Ab discontinued in culture is negative

31. SMH Stewardship Program Conjunctivitis
Resident
Eye Cult Date
Results
Growth
Treatment
Ana
8/30/14
9/2/14
Rare CNS, Rare Coryn sp
Tobradex
8/30-9/2
Joseph
8/31/14
9/4/14
Rare Haem influenza
Oflaxacin
8/31-9/07
Jason
9/10/14
Mod CNS
Tobrex
9/5-9/10
Austin
9/12/14
9/16/14
Few Prot mirabilis, rare MSSA
9/12-9/19
Adam
9/18/14
9/21/14
Many Haem influenza
Cipro
9/19-9/26
Stephanie
10/2/14
10/4/14
Many Moraxella catarrhalis
10/2-10/9
Jordan
10/10/14
10/13/14
Few CNS, Few AHS
10/10-10/17
3/7 or 43% - not significant growth. Discontinue Abs

32. SMH Stewardship Program Respiratory Viral Criteria
A case definition as follows:
Fever 100.5ºF above AND least ONE of the following:
Runny nose
Change in sputum
Shortness of breath
Wheezing
New or increased dry cough
Criteria met:
RVP ordered
Ab treatment considered if RVP is negative and symptoms present

33. SMH Stewardship Program Tracheitis
Uncommon infectious cause of acute upper airway obstruction except at SMH
Work in progress:
Need criteria
Many returns from ACF on Abs for “tracheitis” even if RVP is positive
Being treated with Ab that are inappropriate
Stop/question treatment
Tobi nebs

34. Topical Antibacterial Products
Agent
Uses
Comment
Bactraban
mupirocin
impetigo (ointment)
localized minor skin infections (cream)
nasal formulation indicated to eradicate nasal colonization of MRSA
available in ointment, cream, and nasal ointment formulations
relatively expensive
available by prescription
bacitracin
localized minor skin infections
Inexpensive
available OTC

35. SMH Stewardship Program Future Work Needed
Attention to transmission and treatment between LTCFs and ACF serving the same communities
Increased implementation of guidelines for culturing and treatment
Better documentation
CLABSI – de-escalating treatment
Approval for specific antimicrobials

37. Prevent Infection Step 1. Vaccinate- staff and residents
Step 2. Prevent conditions that lead to infection
aspiration, pressure ulcers, dehydration
Step 3. Get the unnecessary devices out
Insert only when essential
Minimize duration and reassess regularly
Use proper insertion and care protocols
Remove when no long necessary

38. Diagnose and Treat Infection Effectively
Step 4. Use established criteria for diagnosis
Target empiric therapy to likely pathogens
Target definitive therapy to known pathogens
Obtain appropriate cultures and interpret results with care
Consider Cdiff in patients with diarrhea and antibiotic exposure
Step 5. Use local resources
Consult infectious disease experts
Know what is going on in your local and regional area
Get previous updates and labs from transfer residents

39. Use Antimicrobials Wisely
Step 6. Know when to say “NO”
Minimize use of broad-spectrum antibiotics
Avoid long-term prophylaxis
Monitor antibiotic use
Step 7. Treat Infection, not colonization or contamination
Re-evaluate the need for Abs after hours
Do not treat asymptomatic bacteriuria
Step 8. Stop antimicrobial treatment
When cultures are negative and infection unlikely
When infection has resolved

40. Prevent Transmission
Step 9. Isolate the pathogen-standard and transmission-based precautions
Step 10. Break the chain of infection
Step 11. Perform hand hygiene
Step 12. Identify residents with MDROs
Identify both new admissions and existing residents with MDROs
Follow standard precautions for MDRO management

41. References
IDSA Guideline: Kevin P. High, Suzanne F. Bradley, Stefan Gravenstein, David R. Mehr, Vincent J. Quagliarello, Chesley Richards, and Thomas T. Yoshikawa Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update by the Infectious Diseases Society of America Clin Infect Dis. (2009) 48 (2): doi: /595683
J Am Geriatr Soc Aug;55(8): Effect of an educational intervention on optimizing antibiotic prescribing in long- term care facilities. Monette J1, Miller MA, Monette M, Laurier C, Boivin JF, Sourial N, Le Cruguel JP, Vandal A, Cotton- Montpetit M.
Jump RL, Olds DM, Seifi N, et al. Effective antimicrobial stewardship in a long term care facility through an infectious disease consultation service: keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012;33(12):1185–92.
Monette J, Miller MA, Monette M, et al. Effect of an educational intervention on optimizing antibiotic prescribing in long- term care facilities. J Am Geriatr Soc 2007;55:1231–5.
Stone ND, Rhee SM. Antimicrobial stewardship in long-term care facilities. Infect Dis Clin North Am, 2014 Jun; 28(2): doi: /j.idc

42. Questions/Comments