Presentation on theme: "Antimicrobial Stewardship in Long Term Care"— Presentation transcript:
1 Antimicrobial Stewardship in Long Term Care Marianne Pavia, MS, BS, MT(ASCP), CLS,CIC
2 Learning ObjectivesUnderstand 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 LTCMean age 80Decreased:Immune functionSwallowing/ chewingSkin integrityMobilityBowel and bladder controlIncreased:AcuityMedicationsDementia/depression/apathy
4 Burden of Infection in LTC 15,000 LTCFs in United StatesInfection prevalence rate 5.3% (single day survey)Infection incidence rate /1000 resident daysExamples:UTILower respiratory, including pneumoniaSkin and soft tissueGastroenteritis
5 Burden of Infection in LTC Higher incidence of invasive MRSAMDRO more severe infections, hospitalizations, risk of death, cost of care12 month Rhode Island study:72% inappropriate Ab, according to guidelines67% longer than recommended durationAdverse drug event riskIncreased incidence of CdiffGerwitz 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 challengesClinical providers are off-siteAssessments communicated by front-line staffLimited 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 habitsTypes of residentsTypes of resident services- i.e. pulmonary teamEstimate of “inappropriate” use of Ab varies upon definitionbetween 25%-75%
8 Loeb Minimum Criteria (LMC) Created in 2000, updated in 2005Minimum criteria of symptoms that should be present before initiating antimicrobial therapyDeveloped to:Decrease inappropriate use of Ab without evidence of infectionDecrease the overuse of newer, broad spectrum AbGuide rational assessment of infectionProposed to improve Ab useEffect 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.
11 Intervention LTC with Loeb Minimum Criteria Sent algorithms to physicians with written explanatory notesMounted at nursing stationsPresented 6 case scenarios to staffNursing completed log of symptomsFour week training period
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 consultant20% 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 Study92 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 QuestionsAre 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 CriteriaSurveillance purposes, highly specific for reliable bench marchingOften determined retrospectively following full assessmentNot 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 decisionsIntervention is an algorithm to reduce unnecessary testing and treatmentTrials 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 actionWorry about missing an infection, delayed treatment or not meeting the family’s expectationObserving 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 culturingCommunicate findings from antibiogramSupport 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 FacilitiesFelt LMC too focused on feverFever is absent in more than one-half of LTCF residents with serious infectionFocuses on elderly with multiple chronic co morbidities and functional disabilitiesResources are typically available to evaluate suspected infectionWhat clinical evaluation should be performedInfectious 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 institutionDetermine what resources are available or may become availableSelect stewardship strategies that best address the problems while accounting for the resourcesShow 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 commitmentAccountability for improvementNeed drug expertiseImplementing action through targeted policies and guidelinesTracking and reporting to staff on prescribing and resistanceIdentifying key participants and ASP champions and offer education
25 PrescriptionsPhysicians discuss with a stewardship team member before prescribing:is usage appropriatemay delay initiating therapyPost-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 CEOAccountability for improvement- QAPI for medicineTracking and reporting to staff on prescribing and resistanceImplementing 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 ordered2014 – created MDROs
29 SMH Stewardship Program Jan 2014:Organized ASP Committee- Director of Pharmacy, Medical Director, Nursing Leadership, ICReviewed Ab use retrospectively monthlyEpic failApril 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 eyesNew or increased conjunctival redness with or without itching or painIf meets criteria:Bacterial eye cultureAb treatment initiated- Fluoroquinolone dropsAb discontinued in culture is negative
31 SMH Stewardship Program Conjunctivitis ResidentEye Cult DateResultsGrowthTreatmentAna8/30/149/2/14Rare CNS, Rare Coryn spTobradex8/30-9/2Joseph8/31/149/4/14Rare Haem influenzaOflaxacin8/31-9/07Jason9/10/14Mod CNSTobrex9/5-9/10Austin9/12/149/16/14Few Prot mirabilis, rare MSSA9/12-9/19Adam9/18/149/21/14Many Haem influenzaCipro9/19-9/26Stephanie10/2/1410/4/14Many Moraxella catarrhalis10/2-10/9Jordan10/10/1410/13/14Few CNS, Few AHS10/10-10/173/7 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 noseChange in sputumShortness of breathWheezingNew or increased dry coughCriteria met:RVP orderedAb treatment considered if RVP is negative and symptoms present
33 SMH Stewardship Program Tracheitis Uncommon infectious cause of acute upper airway obstruction except at SMHWork in progress:Need criteriaMany returns from ACF on Abs for “tracheitis” even if RVP is positiveBeing treated with Ab that are inappropriateStop/question treatmentTobi nebs
34 Topical Antibacterial Products AgentUsesCommentBactrabanmupirocinimpetigo (ointment)localized minor skin infections (cream)nasal formulation indicated to eradicate nasal colonization of MRSAavailable in ointment, cream, and nasal ointment formulationsrelatively expensiveavailable by prescriptionbacitracinlocalized minor skin infectionsInexpensiveavailable OTC
35 SMH Stewardship Program Future Work Needed Attention to transmission and treatment between LTCFs and ACF serving the same communitiesIncreased implementation of guidelines for culturing and treatmentBetter documentationCLABSI – de-escalating treatmentApproval for specific antimicrobials
37 Prevent Infection Step 1. Vaccinate- staff and residents Step 2. Prevent conditions that lead to infectionaspiration, pressure ulcers, dehydrationStep 3. Get the unnecessary devices outInsert only when essentialMinimize duration and reassess regularlyUse proper insertion and care protocolsRemove when no long necessary
38 Diagnose and Treat Infection Effectively Step 4. Use established criteria for diagnosisTarget empiric therapy to likely pathogensTarget definitive therapy to known pathogensObtain appropriate cultures and interpret results with careConsider Cdiff in patients with diarrhea and antibiotic exposureStep 5. Use local resourcesConsult infectious disease expertsKnow what is going on in your local and regional areaGet previous updates and labs from transfer residents
39 Use Antimicrobials Wisely Step 6. Know when to say “NO”Minimize use of broad-spectrum antibioticsAvoid long-term prophylaxisMonitor antibiotic useStep 7. Treat Infection, not colonization or contaminationRe-evaluate the need for Abs after hoursDo not treat asymptomatic bacteriuriaStep 8. Stop antimicrobial treatmentWhen cultures are negative and infection unlikelyWhen infection has resolved
40 Prevent TransmissionStep 9. Isolate the pathogen-standard and transmission-based precautionsStep 10. Break the chain of infectionStep 11. Perform hand hygieneStep 12. Identify residents with MDROsIdentify both new admissions and existing residents with MDROsFollow standard precautions for MDRO management
41 ReferencesIDSA 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: /595683J 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