Transcript LTC Characteristics - APIC Greater NY Home

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?
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 nonspecific symptoms?
 Urine tests drive decisions
 Intervention is an algorithm to reduce unnecessary
testing and treatment
 Trials decrease Ab use with no negative outcomes
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
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
9/4/14
9/10/14
Mod CNS
Tobrex
9/5-9/10
Austin
9/12/14
9/16/14
Few Prot
mirabilis, rare
MSSA
Oflaxacin
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
Cipro
10/2-10/9
Jordan
10/10/14
10/13/14
Few CNS, Few
AHS
Cipro
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
impetigo (ointment)
available in ointment,
cream, and nasal
ointment formulations
mupirocin
localized minor skin
infections (cream)
relatively expensive
nasal formulation
indicated to
eradicate nasal
colonization of
MRSA
bacitracin
localized minor
skin infections
available by prescription
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
1
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
2
J Am Geriatr Soc. 2007 Aug;55(8):1231-5.Effect of an educational intervention on optimizing antibiotic prescribing in longterm care facilities. Monette J1, Miller MA, Monette M, Laurier C, Boivin JF, Sourial N, Le Cruguel JP, Vandal A, CottonMontpetit M.
3
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.
4
Monette J, Miller MA, Monette M, et al. Effect of an educational intervention on optimizing antibiotic prescribing in longterm care facilities. J Am Geriatr Soc 2007;55:1231–5.
5
Stone ND, Rhee SM. Antimicrobial stewardship in long-term care facilities. Infect Dis Clin North Am, 2014 Jun; 28(2):23746. doi: 10.1016/j.idc.2014.01.001
Questions/Comments