ANTIMICROBIAL STEWARDSHIP IN LONG TERM CARE FACILITIES

ANTIMICROBIAL STEWARDSHIP IN LONG TERM CARE FACILITIES ANTIMICROBIAL STEWARDSHIP COLLABORATIVE COLORADO HOSPITAL ASSOCIATION MARCH 23, 2016 Bridget Olson, RPh Infectious Disease Pharmacist, Sharp Coronado Hospital & Villa Long Term Care Facility Raymond Chinn, MD Medical Director of Infection Prevention, Sharp Memorial Hospital

OBJECTIVES: Identify challenges with antimicrobial prescribing in long-term care facilities (LTCFs) Review a practical application of an ASP in LTCFs Demonstrate the impact of reducing antimicrobial use on antimicrobial resistance Benefits of LTCF ASP to associated acute care hospitals

CHALLENGES OF A CHANGING LTCF POPULATION: Presence of more invasive devices and procedures Multiple co-morbidities and advanced age Colonization and infection with multi-drug resistant organisms (MDROs) Missed opportunities to provide the staff of LTCFs with education to better care for their patients Trivedi, K. Approaches to Antimicrobial Stewardship in LTC facilities. IDAC Symposium 2011

BACKGROUND: (my beginning in ASP) 1998 - An Antimicrobial Surveillance Team (AST) was formed at Sharp Cabrillo Hospital in San Diego and included: Pharmacist Infection Control RN Infectious Disease Physician Acute care services were later relocated but the importance of continued AST was recognized when the facility was converted to all LTC. Administration showed great foresight in retaining the ASP for the LTCF

OUR LTCF ISSUES WITH TREATMENT OF INFECTIONS Frequent colonization with multi-drug resistant organisms that can result in infection Incomplete reporting of patient s symptoms to physicians Patient evaluation and diagnosis are difficult Physicians were unsure of best empiric treatment choices LTCF patient sputum culture Antimicrobials are ordered by phone without proper patient assessment Treatment of culture results, with inadequate assessment of patient signs and symptoms of infection Suboptimal follow-up of culture results to de-escalate or to stop antimicrobial agents Consequent overuse of antimicrobial agents resulting in development of antimicrobial resistance Sputum culture with 1 GNR

STRATEGIES FOR OUR 181-BED COMMUNITY HOSPITAL: 59 ACUTE-CARE & 122 LTC BEDS Establish an Antimicrobial Stewardship Program with ID oversight Use modified McGeer Criteria* as a guideline for initiation of antimicrobials in LTCF Develop comprehensive patient assessment forms Establish a LTCF Fever/Suspected Infection Protocol Implement initiatives to reduce C.difficile infections Provide nursing education Ensure physician acceptance *Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 ;33(10):965-977

CONTRIBUTORS TO THE ANTIMICROBIAL STEWARDSHIP PROGRAM Administrative Support ID Pharmacist ID Physician Microbiologist Lead Nursing Educator Infection Preventionist Information systems

MCGEER CRITERIA (OCTOBER 2012 UPDATE BY STONE, ET.AL.) Identification of infection should not be based on a single piece of evidence, but should always consider the clinical presentation in addition to microbiological or radiological information available Goal: to standardize identifying factors for infections in LTCF patients often difficult to assess: Symptoms not expressed or misinterpreted Co-morbidities can obscure signs symptoms of infection Criteria for antibiotic initiation in 4 main categories: UTI Respiratory Infection Skin & soft Tissue Infection Fever of Unknown Origin Nicolle, LE et al. Antimicrobial Use in LTCFs, Infect Control Hosp Epidemiol 2000; 21: 537-545 Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 October; 33(10):965-977

MICROBIOLOGY DATA 2015: RESPIRATORY ORGANISMS CULTURED FROM LTCF PATIENTS Strep Grp G, 8% Others*, 19% H. influenzae, 10% (all B-lactamase positive) S.aureus 11% (MRSA, 72%) Proteus sp., 42% Pseudomonas aeruginosa, 54% (of which 5% MDRO) *Others = Acinetobacter, Chryseobacterium, Corynbacterium, E. cloacae, Klebsiella, Moraxella spp, Mycobacterium, Serratia, grp B Strep, S. pnemo, E. coli 2015, Sharp Coronado Hospital & Villa LTCF (n=109)

DOT per 1000 patient days % susceptibility 25 20 15 10 5 0 100 80 60 40 20 0 DECREASED PIP/TAZO, QUINOLONE, CARBAPENEM, AZTREONAM USE INCREASED PSEUDOMONAS AERUGINOSA (PSA) SUSCEPTIBILITY LTCF Antipseudomonal Usage Trending 2011-2014 (Jan-Jun) 2011 Aztreonam Cefepime Carbapenems Quinolones Pip/tazo 2 2012- no outside admissions x 6 months LTCF Pseudomonal Susceptibility Trending 2011-2015 2011 2012 2013 2014 2012 2013 2014 2015

MCGEER CRITERIA FLOW-CHARTS: RESPIRATORY Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 October; 33(10):965-977

MICROBIOLOGY DATA 2015: URINARY ORGANISMS CULTURED FROM LTCF PATIENTS Pseudomonas aeruginosa, 19% Others*, 17% E. coli, 28% (46% MDRO) E. faecalis**, 16% Providencia stuartii, 5% Proteus mirabilis, 30% Klebsiella pneumoniae, 7% E. faecium**, 2% *Others = Acinetobacter, Citrobacter, Enterobacter, Moraxella, Serratia, Staph, Strep, MRSA **31% of Enterococcus were from urine cultures with > 3 organisms 2015, Sharp Coronado Hospital & Villa LTCF (n=93)

URINARY E.coli SUSCEPTIBILITIES TRENDED While 74% of urine ESBL E.coli isolates are covered by Tobramycin, it covers 90% of all E.coli isolates in the LTCF #isolates 2010 50 2011 49 2012 26 2013 22 2014 10

ASP EFFECTS ON RESISTANCE DECREASED FLUOROQUINOLONE USE INCREASED E.COLI SUSCEPTIBILITY DOT/ 1000 Pt Days 450 400 350 300 250 200 150 100 50 0 Fluoroquinolone Usage Trend 2010 2011 2012 2013 2014 2015 % E.coli susceptibility 60 50 40 30 20 10 0 LTC E.coli susceptibility to Levofloxacin 2010 2011 2012 2013 2014 2015

MCGEER CRITERIA FLOW-CHARTS: URINARY Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 October; 33(10):965-977

LTCF FEVER/SUSPECTED INFECTION PROTOCOL Provides a multi-disciplinary approach Ensures comprehensive patient assessments in a checklist format, based on modified McGeer criteria Involves pharmacists, working with nurses in assessing need for initiation of antimicrobial agents Utilizes computer-based Powerplans to aid in ordering labs, IV fluids, cultures and appropriate IDrecommended empiric therapy

NURSING EDUCATION AND INVOLVEMENT: Nurses play a major role in whether antimicrobials are initiated, based on their assessments and reporting. They are the eyes and ears for the physicians Education of all levels of nursing (RN, LVN, CNA) is essential, both initially and on-going. First slide of Nursing Education PowerPoint

COMPONENTS OF NURSING EDUCATION: Patient assessment Difference between colonization vs. infection Use of empiric vs. targeted antibiotics Why bacterial resistance develops Importance of limiting unnecessary antimicrobials Format for physician calls Strategies to decrease C.difficile infection MRSA screening and usefulness in de-escalation of therapy

PATIENT ASSESSMENT FORMS A comprehensive checklist format, based on the modified McGeer Criteria Symptoms are grouped by association with the 4 basic categories of infection (UTI, respiratory, SSTI and fever of unknown origin) Reviewed by pharmacist who assesses with criteria for antimicrobial use and history of resistant organisms.

3 COMPUTER POWERPLANS FOR ORDERING Protocol order-sets for ease of ordering labs, cultures, fluids and antibiotics:

REDUCTION OF CLOSTRIDIUM DIFFICILE INFECTION (CDI) INITIATIVES 1. Incorporate Antimicrobial Stewardship 2. Change in intensity of GI prophylaxis 3. Initiate probiotic therapy with antimicrobials

ANTIBIOTIC PRESSURE PRIOR TO C.DIFFICILE INFECTIONS Antimicrobials used prior to C.difficile infections 2009-2014 aminoglycosides 4% No abx amox/clavanulate 7% 4% azithromycin 4% other (<2% each) 9% Quinolones 26% carbapenems 11% extended-spectrum PCNs 12% 3rd-4th gen. Cephalosporins 23% Other (<2% each): 1st-gen cephs, linezolid, clindamycin, cefuroxime, doxycycline, & colistin

DOT/1000 patient days 90 80 70 60 50 40 30 DAYS OF ANTIMICROBIAL THERAPY (DOT) TRENDING (PER 1000 PATIENT DAYS) Started LTC Prospective reviews with intervention CORONADO HOSPITAL LTCF JAN 2010-->DEC 2014 2012 LTCF Fever Protocol started Information Systems runs a DOT report to track antimicrobial usage 20 10 No outside admissions x 6 months 0

REDUCTION IN ACID SUPPRESSION: (DUE TO ASSOCIATION WITH CDI) May 2010: Long-term care facility (LTCF) patients on GI prophylaxis with proton pump inhibitors (PPI) were converted to H2 receptor antagonists Physicians noted drop in CDI rates, and began to avoid PPIs in both acute care and LTC 2012: PPIs removed from treatment Powerplans of hospital system

PROBIOTIC THERAPY Probiotics are promoted to help re-establish GI micro-flora after disruption from antimicrobials +/- acid suppression Probiotics recommended for all patients on broad spectrum antimicrobials + 1 additional week 1 Products: Lactobacillus acidophilus and L.casei, L. rhamnosus, (Biok-plus) 2 capsules orally daily OR Liquid probiotic yogurt 1 bottle per FT BID Contraindications: 1) immunosuppressed patients if neutropenic 2) post-pyloric feeding tube (J-tube) administration 3) NPO w/o enteral feedings 1 Johnston BC, Ma SY, Goldenberg JZ, et al. Probiotics for the Prevention of Clostridium difficile-associated Diarrhea. Ann Intern Med. 2012; 157:878-888.

RESULTS: CDI REDUCTION LTCF CDI rate per 10,000 patient days was reduced from 6.1 (average rate 2008-2010) to 1.1 (average rate 2011-2014) Olson, B, et.al. A Multipronged Approach to Decrease the Risk of Clostridium difficile Infection at a Community Hospital and Long- Term Care Facility. J Clin Outcome Manag 2015; 22(9): 398-406

ASP INTERVENTIONS: 30 Goals: Patient Safety, Antibiotic resistance, cost #interventions 25 20 15 10 portion not corrected interventions LTC Care Interventions (94% acceptance) 5 0 Jan-Jun 2015; n=110

MRSA SCREENING Colonization with S aureus precedes most invasive diseases caused by S.aureus MRSA screening- molecular amp (nares) o o upon admission prior to initiation of antibiotics if there is a risk for staph infections: respiratory infections skin & soft tissue infections Results available: MRSA molecular amp: 24 hours vs. cultures : 2-3 days Negative result has a 99% negative predictive value for MRSA pneumonia 1 More rapid de-escalation of vancomycin or other anti-mrsa therapy is possible Fever protocol allows automatic discontinuation of vanco if MRSA nares negative 1 Dangerfield B, et.al. Predictive value of methicillin-resistant Staphylococcus aureus(mrsa) nasal swab PCR assay for MRSA pneumonia. Antimicrob Agents Chemother. 2014;58(2):859-64

ASP EFFECTS ON RESISTANCE DECREASED VANCOMYCIN AND OVERALL ABX USE DECREASING VRE Days of Therapy 160 140 120 100 80 60 40 20 0 40% 30% Vancomycin IV DOT Trending Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012 2013 2014 VRE % of Enterococcus Acute + LTCF 2014 % VRE 20% 10% 0% 2009 2010 2011 2012 2013 2014

BENEFITS OF LTCF ASP TO ASSOCIATED ACUTE CARE HOSPITALS Improves quality of patient care through: Decreased horizontal transfer of resistant organisms (less MDRO, XDRO) Decreased re-admissions Decreased antibiotic expenditures Decreased C.difficile infections New legislation in California requiring LTCF ASP (SB 361, Oct 2015): may allow for increased resources and support for ASPs 1 1 K. Trivedi. Pew Charitable Trusts: Inpatient Antibiotic Stewardship Program Case Studies, 2015

SUMMARY A multi-disciplinary ASP can result in decreasing transmission of multi-drug resistant organisms such as ESBL E.coli, VRE, MDRO Pseudomonas and C.difficile by improving antimicrobial use in a LTCF. With a robust ASP, these benefits can be sustained over time Full engagement and ongoing interdisciplinary cooperation among nursing, physicians and pharmacists is necessary for ASP success. Looking forward, additional studies on the growing population of LTCF patients with their particular susceptibility to infections would be impactful in improving treatment. Resources are available for education

THANK YOU! QUESTIONS? CONTACT INFORMATION: Bridget Olson, ID/ASP Pharmacist Sharp Coronado Hospital Coronado, California Bridget.Olson@sharp.com Please feel free to contact me for copies of forms or education PowerPoints, etc.