1. Rohit M. Jangi, MD Medical Director, Bethany Health Care Center RJANGI@PCHI.PARTNERS.ORG

2.  130 Beds  Average patient age: 89  Average life expectancy: 90 years  Medical Staff: ◦ 1 physician (always accessible by phone) ◦ Evercare nurse practitioners.

3.  Comprehensive approach ◦ to tackle the common and complex problem facing long term care of the elderly.  Critical thinking ◦ By staff at all levels  Prevention first, then treatment

4. Prevention  Oral hygiene  Aspiration precautions  Avoid feeding tubes  Avoid psychotropic drugs Treatment  We do not routinely treat aspiration episodes with antibiotics

5. Prevention  Skilled staff ◦ High CNA retention rate ◦ Residents rarely develop decubitii  Sedative use is minimized  Wound cultures are avoided Treatment  Use narrow spectrum drugs  Don’t use cephalosporins.

6. Prevention  Hydration hygiene,  Only send urine cultures when specific signs and symptoms of UTI are present.  Minimize use of indwelling Foley catheter; most catheters are discontinued on admission  Avoid drugs that promote urinary retention

7. Prevention  All staff is educated in proper clinical assessment, which includes taking history, clinical examination, taking vital signs, and reporting to physician/NPs.  We always do urinalysis along with culture so that no UTI is treated in absence of significant pyuria.  We treat all residence with home made yogurt after course of antibiotic.

8. Treatment  Often patients come in with diagnosis of UTI without evidence. We take them off if no cause.  If resident shows evidence of gram negative sepsis, parenteral broad spectrum antibiotic is chosen only on day by day basis, and switched to narrowest spectrum antibiotic as soon as culture report is available.  Generally we wait to treat for culture is patient is clinically stable, monitoring closely.  Trimethoprim / Sulfa or Nitrofurantoin are drugs of choice as these drugs do not cause C. Difficile.  We treat all residence with home made yogurt after course of antibiotic.

9.  10 UTIs treated in 2013 ◦ Of these only 1 failed meet protocol criteria  Last UTI at Bethany Health Care: August 2013  0 cases ofC. difficile infection in 5 years  0 cases of other MDROs in 5 years