Transcript Opening Slides and Overview - Massachusetts Coalition for the

IMPROVING DRUG USE TO ENHANCE
INFECTION PREVENTION: ANTIBIOTIC
STEWARDSHIP AND BEYOND
CDI Prevention Partnership Collaborative
Workshop
May 16, 2012
www.macoalition.org
C. Difficile Prevention Partnership Collaborative
10/11
Team
call
11/11
Kickoff
Workshop
12/11
Coaching
Call
1/12
Leadership
call
Refresher
call
Regional
workshops
4/12
Antibiotic
Stewardshi
p
Call
(overview +
PPI us)
4&5/12
Regional
Antibiotic
Stewardship
Workshops
6/12
Statewide
Learning &
Sharing
Workshop
Hospital / Long Term Care Partnerships
MEASURE / MONITOR
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Upcoming Events


June 22nd C. Difficile Prevention Partnership
Collaborative Learning and Sharing Workshop
Learn additional strategies for C. diff prevention from local and
national experts, and your Massachusetts colleagues
Contact Fiona Roberts
[email protected]
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Contacts
Susanne Salem-Schatz
[email protected]
Fiona Roberts, MA Coalition for
Prevention of Medical Errors
[email protected]
Helen Magliozzi, MA Senior Care
[email protected]
Eileen McHale, Department of
Public Health
[email protected]
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Program Overview
Morning workshop:

Antibiotic Stewardship Overview: Opportunities in long term care

Appropriate diagnosis and treatment of UTI in acute and long term
care

Communication about antibiotic treatment inside and across facilities:
working with with residents/ families, colleagues, and transferring
facilities
ALL programs grant CME / CEUs for physicians, nurses, pharmacists and long
term care administrators
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Faculty Disclosure

Today’s presenters have no financial
interests or relationships to disclose.
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Antibiotic stewardship
and the
opportunities in long term care
Paula Griswold
Massachusetts Coalition
for the
Prevention of Medical Errors
Antibiotics in Long Term Care:
why do we care?
• Antibiotics are among the most commonly
prescribed classes of medications in longterm care facilities
• Up to 70% of residents in long-term care
facilities per year receive an antibiotic
• It is estimated that between $38 million
and $137 million are spent each year on
antibiotics for long-term care residents
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The importance of prudent use of
antibiotics
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Bad Bugs No Drugs
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The burden of infection in long term
care
• 12 studies in North America:
– 1.8-13.5 infections per 1000 resident-care
days
– Rate of death from infection 0.04-0.71 per
1000 resident-care days
Strausbaugh et al. Infection Control and
Hospital Epidemiology 2000, 21(10), p. 674679
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The burden of resistance in long
term care
• Rogers et al:
– Over 3000 LTCFs
– One year (2003)
– Incidence of new infection caused by an
antibiotic-resistant organism was 12.7 per
1000 patients
Rogers et al. Journal of Infection Control 2008,
Volume 36, Issue 7, Pages 472-475
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Antimicrobial Therapy
Appropriate initial
antibiotic while improving
patient outcomes and
healthcare
Unnecessary
Antibiotics, adverse
patient outcomes and
increased cost
A Balancing Act
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Why focus on long term care?
• Many long-term care residents are colonized
with bacteria that live in an on the patient without
causing harm
• Protocols are not readily available or
consistently used to distinguish between
colonization and true infection
• So, patients are regularly treated for infection
when they have none
– 30-50% of elderly long-term care residents have a
positive urine culture in the absence of infection
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Why focus on long term care?
• When patients are transferred from acute
to long-term care, potential for
miscommunication can lead to
inappropriate antibiotic use
• Elderly or debilitated long-term care
residents are at particularly high risk for
complications due to the adverse effects of
antibiotics, including Clostridium difficile
infection
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Common long-term care scenarios
in which antibiotics are not needed
• Positive urine culture in the absence of symptoms
(cloudy or smelly urine should not be considered
symptoms)
• Upper respiratory infection (common cold with or without
fever, bronchitis, sinusitis not meeting clinical criteria for
antibiotics)
• Abnormal chest x-ray without signs/symptoms of
respiratory infection
• Positive wound culture in the absence of cellulitis,
abscess or necrosis
• Diarrhea in the absence of positive C. diff toxin assay
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Long term facilities can*
• Establish multidisciplinary teams to address
antibiotic stewardship and optimal drug use
• Have protocols that outline the appropriate
circumstances for use of antibiotics
• Review antibiotic culture data for trends
suggesting a worsening resistance problem
• Have protocols ensuring that cultures are
checked and antibiotics adjusted according to
culture results
• Establish programs for periodic review of
antibiotic utilization
*Centers for Disease Control
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Long term facility providers should*
• Obtain cultures whenever available when
starting antibiotics, and check results, adjusting
antibiotics appropriately to the narrowest
spectrum agent possible
• Avoid the use of antibiotics for colonization or
viral infections, and keep the duration as short
as possible
• Take care to effectively communicate with the
transferring facility re pending lab results and
plan for antibiotics and follow-up
*Centers for Disease Control
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Nurses Can
• Be familiar with current protocols for testing and
treatment of urinary tract infection
• Educate families and residents that many
respiratory infections are caused by viruses and
do not require antibiotics
• Identify advanced directives for limited treatment
• Follow up with referring facility regarding
pending lab results
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Physicians / NPs can
• Obtain cultures whenever available when starting antibiotics, and
check results, adjusting antibiotics appropriately to the narrowest
spectrum agent possible
• Avoid the use of antibiotics for colonization or viral infections, and
keep the duration as short as possible
• Encourage use of screening tools and protocols to decrease the use
of unnecessary antibiotics.
• Educate fellow clinicians, staff and family members on appropriate
use of antibiotics
• Implement measures to reduce the need for treating with antibiotics
(avoidance of indwelling urinary catheters, maximizing immunization
levels, decubitus ulcers, etc.
• Take care to effectively communicate with the transferring facility re
pending lab results and plan for antibiotics and follow-up
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Pharmacists can
• Get more involved with infection control issues in each facility
serviced, particularly antibiotic treatment of symptomatic versus
asymptomatic UTIs.
• Review antibiotic utilization and, where possible, appropriateness;
identify opportunities for improved prescribing to discuss at quarterly
QI meetings.
• Educate physicians and nursing staff about targeted antibiotic use,
using a narrow spectrum antibiotic based on culture results.
• Prepare updated and easily accessible protocols for certain
antibiotics; monitor vancomycin trough levels and focus on
monitoring for appropriate vancomycin doses, dosing intervals and
duration of therapy
• Avoid simultaneous administration of “heavy metal”
drugs (containing Fe, Ca, Zn, Mg, etc) with Quinolones. Either
temporarily hold or administer these drugs AT LEAST Six (6) hours
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BEFORE or Two (2) hours AFTER the Quinolones.
What facilities can do together
• Develop communication tools to share critical information between
acute and long term facilities when patients are transferred
–
–
–
–
–
–
Culture results
Pending results
Treatments initiated (what, when, indication, stop date)
Precautions
Immunizations
History of C. difficile
• Ensure contact information is provided for follow up on patient
history and pending test results.
• Establish cross-facility teams to address infection prevention
and antibiotic stewardship.
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