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

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.

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

Burden of Infection in LTC 15,000 LTCFs in United States Infection prevalence rate 5.3% (single day survey) Infection incidence rate 3.6-5.2/1000 resident days Examples: UTI Lower respiratory, including pneumonia Skin and soft tissue Gastroenteritis

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.

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

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%

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.

Loeb Minimum Criteria

Urine Culture Results Algorithm

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

LMC

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.

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

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?

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

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

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

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

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

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

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.

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

Prescriptions Physicians discuss with a stewardship team member before prescribing: is usage appropriate may delay initiating therapy Post-prescription review: Best 48-72 hours or once a week

St. Mary’s Hospital for Children Antimicrobial Stewardship Program

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

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

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”

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

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

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

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

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

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

http://www.kliinikum.ee/infektsioonikontrolliteenistus/doc/oppematerjalid/longterm.pdf

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

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

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 48-72 hours Do not treat asymptomatic bacteriuria Step 8. Stop antimicrobial treatment When cultures are negative and infection unlikely When infection has resolved

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

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): 149-171 doi:10.1086/595683 J Am Geriatr Soc. 2007 Aug;55(8):1231-5.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):237- 46. doi: 10.1016/j.idc.2014.01.001

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