Antibiotic Stewardship in LTC What does this mean?

Antibiotic Stewardship in LTC What does this mean? Kieran Moore FCFP,FRCPC, Diane Lu CCFP KFLA Public Health

Disclosure The findings and conclusions represent those of the presenter and may not necessarily represent the official position of Public Health Ontario, KFLA Public Health or of the MOH LTC No funding from Pharmaceutical Companies

Objectives 1. Develop an awareness and understanding of what antibiotic stewardship is. 2. Appreciate the concerns regarding inappropriate antibiotic use. 3. Discuss local project in the development of protocols for antibiotic use in LTC.

Clinical Case ID: 76yo female admitted April 2012 to local community hospital RFA: presumed pneumonia PMH: non-remarkable, healthy SHx: living independently, physically active, engaged in community

Clinical Case Course while hospitalized: Treated with IV antibiotics-respiratory fluoroquinolone for 10 days course in April On proposed day of discharge, contracted symptomatic C. difficile Roommate in semi private room had C. Difficile Treated in-hospital for CDI with multiple courses of Abx from May-August 2012

Clinical Case Discharged home on August 20 th with resolution of CDI Became symptomatic again with diarrhea and retested by family physician for CDI Readmitted on Sept 6 th 2012 for confirmed CDI and died Sept 7 th 2012 Cause of death on death certificate: C. Difficile

Antibiotics We need to use best evidence and guidelines for the treatment of Pneumonia, Urinary Tract Infection or Soft Tissue infection we can do better.

What is Antibiotic Stewardship? Is it important?

Why Do We Need to Improve Antibiotic Use?-PATIENT SAFETY Antibiotics are misused in hospitals and LTC Antibiotic misuse affects both patients and society Improving antibiotic use improves patient outcomes and saves money Improving antibiotic use is a public health imperative

Antibiotic Misuse It has been recognized for several decades that up to 50% of antimicrobial use is inappropriate. IDS/SHEA Guidelines for Antimicrobial Stewardship Programs http://www.journals.uchicago.edu/doi/pdf/10.1086/510393

What is Antibiotic Misuse?D s Diagnosis: Right drug for problem DRUG: Pick best antibiotic based on guideline DOSE: Prescribed at the incorrect dose DURATION: Prescribed for the correct duration Dollars: Use narrow spectrum first

Consequences of Antibiotic Misuse Antibiotic associated infections (C. difficile) Antibiotic resistance Adverse drug effects or drug interactions Increased costs

C Diff Seasonality-IATROGENIC

Antibiotic Associated Infections Antibiotic exposure is the single most important risk factor for the development of Clostridium difficile associated disease (CDAD) Up to 85% of patients with CDAD have antibiotic exposure in the 28 days before infection 1 1. Chang HT et al. Infect Control Hosp Epidemiol 2007; 28: 926 931

CDI Emergence of the NAP-1/BI or epidemic strain of C. difficile has intensified the risks associated with antibiotic exposure. Epidemic strain of C. difficile is associated with increased risk of morbidity and mortality. Epidemic strain is resistant to fluoroquinolone antibiotics, which confers a selective advantage. McDonald, LC et al. NEJM 2005; 353: 2433-41

C Diff Trending US

Valiquette, et al. Clin Infect Dis 2007; 45: S112

What is Antibiotic Stewardship? A program that encourages judicious use of antibiotics Antibiotics are so effective, non-toxic and inexpensive that they are easy to use and so, prone to misuse Stewardship strives to optimize antibiotic therapy Maximize effectiveness Minimize toxicity Reduce selection for resistance Optimize costs Encourage step-down and discontinuation

Examples of ASP TOPS (Towards Optimized Practice) www.topalbertadoctors.org Infectious Disease Society of America (IDSA) Society for Healthcare Epidemiology of America (SHEA) CDC Get Smart: Know when antibiotics work http://www.cdc.gov/getsmart/

Common Infections in LTC UTI Respiratory Skin and soft tissue infections CDiff

Antibiotic Use in LTC Antimicrobials are among the most frequently prescribed pharmaceutical agents in LTC accounting for approximately 40% of all prescribed systemic drugs Point prevalence of systemic antibiotic use is approximately 8% 50-70% likelihood that a resident will receive at least once course of a systemic antimicrobial agent during a 1 year period 22-89% of antibiotic prescription in LTC are inappropriate 1. Nicolle, LE et al. Infect Control Hosp Epidemiol 1996; 17: 119-128. 2. Loeb, M et al. Infect Control Hosp Epidemiol 2001; 22: 120-124

Antibiotic Misuse in LTC Patient Factors Atypical clinical presentation Impaired communication Difficulty obtaining specimens Family concerns System Factors Limited diagnostic resources Limited staff with time constraints Lack of continuity of care Provider Factors Lack of information at time of decision making Limited direct evaluation Lack of knowledge

Development of Protocols for Antibiotic Use in LTC UTI Pneumonia Soft tissue infections CDI Scabies

Pneumonia

Pneumonia Treatment

Pneumonia Management

Soft Tissue Infection

Treatment

Infection Watch Live

Respiratory Seasonal Curve-KFLA

Primary Prevention-AHE Vaccination-Influenza, Pneumococcus Monitor health of community-iwl Sentinel swabs.early detection of viral pathogens Family and HCW immunization, hygiene- SHEAR

SHEAR Approach Surveillance-case definition, thresholds, lab notification Hand Hygiene-rates, contact precautions>48hr Environmental cleaning-checklists, sporocidal, audit, ICRT report Education-staff, patients, families, signage Antibiotic Stewardship-program, audit Risk Factors-Epi triad of Agent, Host, Environment

Summary Antibiotic misuse occurs in all health-care settings Antibiotic misuse has significant consequences for patients and society Appropriate antibiotic use is a Public Health imperative Antibiotic Stewardship is key

Thanks, Contacts Dr Diane Lu Dr. Kieran Moore kmoore@kflapublichealth.ca http://www.cdc.gov/getsmart/ www.topalbertadoctors.org Nursing staff at Rideau Crest

Questions?