Antibiotic stewardship in long term care Shira Doron, MD Associate Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston, MA Consultant to Massachusetts Partnership Collaborative: Improving Antibiotic Stewardship for UTI
Antibiotics in Long Term Care: why do we care? Antibiotics are among the most commonly prescribed classes of medications in long-term 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 As much as half of antibiotic use in long term care may be inappropriate or unnecessary 2
The importance of prudent use of antibiotics 3
Bad Bugs No Drugs 4
The drug development pipeline for antibacterials 5
The burden of infection in long term care 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. 674-679 6
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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 10
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 18
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 19
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 20
Antibiotic misuse adversely impacts patients Getting an antibiotic increases a patient s chance of becoming colonized or infected with a resistant organism.
Number of patients with VRE Defined daily doses of vancomycin/1000 patient days Association of vancomycin use with resistance (JID 1999;179:163) 250 85 200 80 150 75 100 70 50 65 0 1990 1991 1992 1993 1994 1995 60 Patients with VRE DDD vancomycin
% Imipenem-resistant P. aeruginosa Annual prevalence of imipenem resistance in P. aeruginosa vs. carbapenem use rate 80 70 60 50 40 30 20 10 0 r = 0.41, p =.004 (Pearson correlation coefficient) 0 20 40 60 80 100 Carbapenem Use Rate 45 LTACHs, 2002-03 (59 LTACH years) Gould et al. ICHE 2006;27:923-5
Case An 82-year-old long-term care resident has fever and a productive cough He has no urinary or other symptoms, and a chronic venous stasis ulcer on the lower extremity is unchanged A pan-culture is initiated in which urine is sent for UA and culture, sputum and blood are sent for culture, and the ulcer on the leg is swabbed. 24
A CXR is done and is negative The urinalysis has 3 white blood cells Urine culture is positive for >100,000 CFU of E coli Sputum gram stain has no PMNs, no organisms Sputum grows 1+ Candida albicans Wound culture grows VRE 25
The patient is started on cipro for the E coli in the urine, linezolid for the VRE in the wound, and fluconazole for the Candida in the sputum Two weeks later the patient has diarrhea and C. diff toxin assay is positive 26
The only infection this patient ever had was a viral URI
Colonized or Infected: What is the Difference? People who carry bacteria or fungi without evidence of infection are colonized If an infection develops, it is usually from bacteria or fungi that colonize patients Bacteria or fungi that colonize patients can be transmitted from one patient to another by the hands of healthcare workers There is no need to treat for colonization 28
The Iceberg Effect Infected Colonized 29
What could have been done differently? Understanding the difference between colonization and infection No (or very few) WBCs in a UA= no UTI In the absence of dyspnea, hypoxia and CXR changed, pneumonia is unlikely Candida is an exceedingly rare cause of pneumonia Wounds will grow organisms when culturedinfection can only be determined clinically 30
Case 2 A 72 year old man is sent back to his long-term care facility after a brief stay at an acute care hospital The transfer paperwork shows he is on intravenous vancomycin for bloodstream infection This is continued for 4 weeks, at which point the patient develops a brain bleed When his labs are checked he is found to have severely low platelets, presumably a side effect of the vancomycin The blood culture results had been incomplete at the acute care hospital at the time of transfer. As it turned out, when the organism was finally identified, it was one typically associated with blood culture contamination rather than infection, and the patient should not have received any antibiotics. 31
What could have been done differently? Improve communication and coordination Acute care hospital could have communicated to long-term care facility the plan re duration of antibiotics and the pending lab result A system could be in place for the hospital to follow up on the culture results of a patient longer in their care and communicate with the long term care facility 32
Case 3 A 68 year old long term care resident develops respiratory symptoms, and chest xray is consistent with pneumonia, so he is started on the broad-spectrum antibiotic piperacillintazobactam to cover resistant organisms 2 days later the sputum culture grows Strep pneumoniae The patient responds quickly, so no one narrows the antibiotic, and the patient completes a 10- day course One month later the patient develops urosepsis with Pseudomonas highly resistant to all antibiotics tested including piperacillintazobactam 33
What could have been done differently? Use of a narrower agent rather than a broad-spectrum antibiotic Shorter, appropriate course of treatment Adjust antibiotics based on culture results 34
What can YOU do to prevent the consequences of antibiotic overuse, misuse and abuse? 35
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 36
Long term facility providers should* Obtain cultures whenever possible when starting antibiotics, and check results, adjusting antibiotics appropriately to the narrowest spectrum agent possible Avoid the use of antibiotics for colonization, contamination, 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 37
Nurses Can Be familiar with current protocols for testing and treatment of presumed bacterial infections Educate families and residents that many respiratory infections are caused by viruses and do not require antibiotics Educate families and residents about the appropriate indications for testing for and treating suspected UTIs Identify advanced directives for limited treatment Follow up with referring facility regarding pending lab results 38
Physicians / NPs can 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 ulcer prevention, etc.) 39
Pharmacists can Get involved with infection control issues Review antibiotic utilization and, where possible, appropriateness; identify opportunities for improved prescribing and discuss at 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 monitoring vancomycin trough levels and focusing on monitoring for appropriate vancomycin doses, dosing intervals and duration of therapy avoid administration of divalent cations (Fe, Mg, Ca, Zn) within 6 hours before or 2 hours after fluoroquinolones 40
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. 41
New England Sinai Hospital
The program Worked with leadership, ID consultant, IP, Pharmacy director End date and indication required by pharmacy for all antimicrobials List of the great eight antimicrobials 2 ID physicians, off-site, M-F Log on and generate report: patients on antimicrobials at least 7 days Review electronic medical records Recommendations made by email Clinical pathways
Results: Types of Infections April 2011 July 2012, n=530 Other 20% Colitis 24% Osteomyelitis 9% Bacteremia 7% UTI 14% PNA 26% 44
Results: Types of Recommendations More Information Needed 16% April 2011-July 2012 Other 8% Change Antibiotics 6% Agree with Management 47% Stop Therapy 23% 45
Results: NE Sinai Antimicrobial Usage Year 12 months prior to launch Average monthly DDD/1000 patient days 296 Year 1 285 Year 2 Year 3 252 233 46
Results: NE Sinai Cdiff rates Year 12 months prior to launch Year 3 Cdiff cases per 1000 PD 1.4 0.6 47
Prudent Use of Antibiotics in Long Term Care Residents with Suspected UTI: A Massachusetts collaborative
Two programs November 2012-June 2013 October 2013-June 2014 17 hospitals participated in the first collaborative AND submitted monthly data Of these, 12 continued through the 2 nd collaborative and 13 new facilities joined 49
UTI in the Elderly 2012-2013 11/12 12/12 Kickoff Workshop 12/12 Coaching call 1/13 Clinical topic Webinars 2/13 Sharing and learning call 3/13 Sharing and learning call 4/13 Sharing and learning call 6/13 Closing workshop Hospital / Long Term Care Partnerships SURVEY MEASURE / MONITOR SURVEYS
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Results: rates of urine culture and diagnosis of UTI 55
Results: rates of urine culture and diagnosis of UTI 56
Results: rates of urine culture and diagnosis of UTI 57
Results: Cdiff, UTI, urine culture rates
When it comes to resistance Think globally, act locally 59