Antibiotic Stewardship Program

Antibiotic Stewardship Program KISS PRINCIPLE: KEEP IT SIMPLE AND SUSCEPTIBLE PRESENTED BY: WILLIAM G. DAY, DPH, PD, RPH, FASCP Start an Antimicrobial Stewardship Program: Identify Champions and Gather a Team Conduct a Readiness Assessment Plan for Implementation Introduce new Policies and Procedures to Staff 2018 DON Boot Camp 1

Identify Champions and Gather a Team Choose members to serve on the Choose members to serve on the antimicrobial stewardship program team. Depending on the size of the nursing home, the team may be very small (two or three members) or large (five or six members). At a minimum, the antimicrobial stewardship program team should include several individuals with different responsibilities in the nursing home, such as charge nurses, the director of nursing, the assistant director of nursing, the medical director, the infection preventionist, and possibly an information technology staff member (if the home uses electronic health records). 2018 DON Boot Camp 2

Choose Members cont. If possible, include outside consultants such as a consultant pharmacist, prescribing clinician, and/or resident or family representative. Staff may already consult with these individuals and developing new relationships may not be required to start a program. Including nursing home leadership will help the program receive adequate support and attention, and improve the likelihood that it will succeed. Familiarize the team with antimicrobial stewardship. It is likely that many staff may be new to antimicrobial stewardship. The team must learn about antimicrobial stewardship and understand why it is important. There are many online resources that team members can review. 2018 DON Boot Camp 3

The Centers for Disease Control and Prevention (CDC) Web site is a good place to start and includes links to many relevant resources, including the following: CDC s Core Elements of Antibiotic Stewardship in Nursing Homes CDC's About Antimicrobial Resistance: A Brief Overview CDC's Antibiotic/Antimicrobial Resistance: References and Resources CDC s Antibiotic Resistance Threats in the United States (2013) Resistance: 2018 DON Boot Camp 4

Appoint two champions to promote the importance of an antimicrobial stewardship program in the nursing home. These individuals should lead the effort and be responsible for program outcomes. Two champions are recommended to increase the chance that the antimicrobial stewardship program always has a leader through periods of staff change. These champions should have the following qualities: A basic knowledge of antibiotics An interest in playing a leadership role in the nursing home The respect of his or her peers An understanding of how to be a good team player An understanding of the importance of improving antibiotic use in nursing homes Assign initial roles and responsibilities Assign roles and responsibilities within the team for initial tasks like scheduling meetings and conducting the readiness assessment, as well as long-term tasks like monitoring the program. Suggested roles include: Champions: develop agendas and policies, lead training, provide leadership and support Stewardship staff: Help develop training, review use of tools, remind staff to use tools, help solve problems with implementation Monitoring staff: Abstract data for monitoring, develop findings and communicate them 2018 DON Boot Camp 5

Example of Roles and Responsibilities Chart Example of Roles and Responsibilities Chart Name Title Roles, Responsibilities, and Tasks Phone & Email Example Assistant Co-champion and infection Director control lead. 000-000-0000, name@organization. of Nursing Co-develop agendas. Lead trainings. Monitor the new intervention. Draft policies and procedures; obtain necessary review and approval for new policies and procedures. Help develop staff training. Review whether materials are used. Develop findings related to monitoring the new intervention. net Conduct a Readiness Assessment This tool can be used to assess readiness for an antimicrobial stewardship program in general as well as to assess readiness for specific interventions. Use this tool to Determine whether the nursing home has the right staff Determine whether the nursing home has the necessary resources Identify areas to focus on before implementation 2018 DON Boot Camp 6

If there are only a few yes responses and many no answers, the antimicrobial stewardship program team may want to start with one of the tools that targets the common uses of antibiotics in nursing homes the treatment of urinary tract, lower respiratory, or skin and soft tissue infections or the toolkit for working with a lab to improve prescribing. The team could also consider how to address the no answers. For example, how could the nursing home develop the resources and staff needed for a specific intervention? If there are a higher number of yes responses, the nursing home may be ready to implement complex toolkits like the Comprehensive Antibiogram toolkit. Is the Nursing Home Ready? Yes No Is key leadership supportive of this effort? Support by leadership (i.e., the board and/or administrator, director of nursing, or medical director) is critical to change. Is the medical director actively involved in quality improvement and/or infection control? Is the nursing home financially stable? Is the nursing home s ownership and/or management stable (i.e., no changes anticipated over the next six months)? Is the nursing home in good standing with the State Survey Agency (e.g., not identified as a Special Focus Facility, not under State receivership, has not had admissions frozen)? Are there at least two staff who can serve as program champions and commit to leading the activity? Program champions could include (but are not limited to) the director of nursing, assistant director of nursing, charge nurse(s), infection prevention consultant/practitioner, and the medical director or other prescribing clinician. It is critical that at least two, if not more, staff are willing to lead the effort and champion it. Is there time to train staff? Implementation will require training for nursing staff and possibly prescribing clinicians, depending on the toolkit. Initial training for nurses and prescribing clinicians may take approximately 30 minutes to 2 hours. Are there sufficient resources (e.g., time, funds) to cover such training? Are there sufficient funds to make copies of materials for nurses, prescribing clinicians, and, as appropriate, residents and family members? Are there resources for implementing mechanisms to sustain the effort (e.g., staff who can train new nurses as they are hired and include the topic in the annual education program)? The key to sustaining any new activity is ensuring everyone is knowledgeable about it. 2018 DON Boot Camp 7

Plan for Implementation: Agenda for ABS Planning Amount Agenda Topic of Time 1. Overview of purpose of an Antimicrobial 5 Stewardship Program minutes 1. Overview of toolkit/tools to be implemented 10 minutes 1. Discussion of changes to workflow (a) Step-by-step discussion of what toolkit use would look like in nursing home (e.g., where blank forms are kept, how they will be handled in the workflow, where will completed forms be kept, etc.) (b) Determine individuals responsible for specific processes and steps (c) Identify potential barriers and how to address them 1. Start-up activities: Identify activities to be carried out to use the tools (e.g., creation of new forms, data collection, meetings or letters for communication, trainings, etc.) 1. What is a realistic timeline for starting the program? This estimate should consider time for training, developing policies, and informing others (such as the prescribing clinicians and labs). 1. Schedule monthly team meeting to review progress and address questions/problems 1. Identify the next steps and agenda for next meeting 20 minutes 10 minutes 5 minutes 5 minutes 5 minutes Action Items Person responsi ble Introduce New Policies and Procedures to Staff This tool includes a draft policy and a draft set of procedures. As needed, the antimicrobial stewardship program team should request the nursing home s management or corporate office to help develop, review, edit, and approve all policies and procedures. 2018 DON Boot Camp 8

The policy should include the following information and should be provided to staff prior to a new intervention: A statement of the nursing home s commitment to quality care A statement of the purpose and scope of the program, including what the antimicrobial stewardship program plans to accomplish A description of the program and its goals The date the new program will begin A list of who will participate in the new program A set of procedures should be developed and communicated before each intervention toolkit is introduced. New procedures should include the following information: The goal(s) of the intervention What tools will be used The date on which the procedures were issued or revised How the intervention will be implemented Identification of the staff responsible for the intervention Required documentation signed by nursing home management authorized to approve the intervention If applicable, a description of how information about the intervention will be communicated to prescribing clinicians and/or other facilities such as hospitals A description of how and when training for nursing staff and, if applicable, prescribing clinicians, will be conducted A description of what quality monitoring will include (see Monitor and Sustain Stewardship toolkit) 2018 DON Boot Camp 9

Sample Policy Letter TO: [Relevant staff] FROM: [Antimicrobial stewardship program team] RE: [Name of antimicrobial stewardship program intervention] DATE: [Date] Antibiotics are among the most commonly prescribed pharmaceuticals in long-term care settings, yet reports indicate that a high proportion of antibiotic prescriptions are unnecessary. The adverse consequences of unnecessary antibiotic use include adverse drug reactions or interactions, the development of Clostridium difficile infections, the emergence of multidrug resistant organisms, antibiotic failure, increased mortality, and greatly increased costs. The Centers for Disease Control and Prevention characterizes antibiotic resistance as one of the world s most pressing public health threats. Unnecessary prescribing practices by clinicians and overuse of newer, broad-spectrum antibiotics when either no antibiotic or an older narrow-spectrum drug would suffice are believed to be the primary contributors to this problem. As a result of the above complexities, nursing homes are increasingly recognized as reservoirs of antibiotic-resistant bacteria. To address these issues, [Name of nursing home] has developed an antimicrobial stewardship program that will [briefly describe goal of selected intervention]. Antimicrobial stewardship is the act of using antibiotics appropriately that is, using them only when truly needed and using the right antibiotic for each infection. This program includes tools, policies, and procedures that aim to guide nursing home staff toward more responsible and effective use of antibiotics. To achieve our goal, [Name of nursing home] will be [briefly describe specific activities the home will undertake]. This effort, to be implemented beginning [DATE], is crucial to improving outcomes for our residents and the nursing home as a whole. Your participation will be essential. [NAME AND TITLE OF AUTHORIZING OFFICER] [DATE] Sample Procedure Letter TO: [Relevant staff] FROM: [antimicrobial stewardship program team] RE: [Name of antimicrobial stewardship program intervention] DATE: [Date] Purpose and Scope This procedure covers the use of [name of form or tool] at [nursing home name]. Antibiotics are among the most commonly prescribed drugs in long-term care settings, yet reports indicate that a high proportion of antibiotic prescriptions are unnecessary. The use of this procedure can help reduce unnecessary prescribing and lead to fewer antibiotic failures and/or adverse events. The procedures that will be put into place are described below. Questions can be directed to the antimicrobial stewardship program team at [provide contact information]. Responsibility for Implementing the Procedure [Identify who will implement the procedure] Procedures [Add details specific to nursing home] Documentation [List and attach any documents that will be used, including clinical guidelines, tools, training materials, and monitoring/tracking documents.] Records [List any records that will be kept in conjunction with the program (for example, the infection control log).] [NAME AND TITLE OF AUTHORIZING OFFICER] 2018 DON Boot Camp 10

Sample Policy for Medical Record Referral Form Nurses completely fill out the Medical Record Referral Form. Use in all situations when a resident has a new problem and infection may be suspected, and is being referred to a medical care provider, including transfer to an emergency department or hospital. Procedure Patients suspected of having an infection are assessed and referred to a prescribing clinician or, as necessary to the emergency department or hospital. The form should be used to collect and convey information. The form is used on an as needed basis any time an infection is suspected, regardless of type of infection. The purpose of this policy is optimize antibiotic use in nursing homes and reduce unnecessary use of laboratory tests and antibiotics. The form should be provided to the prescribing clinician and/or emergency department or hospital as appropriate. Procedure 2. Monitor and Sustain Stewardship: Convene a meeting of the antimicrobial stewardship program team to discuss how and what to monitor Use the Antibiotic Use Tracking Sheet Use and Evaluate Progress through the Monthly Summary Reports Communicate Results to Prescribing Clinicians Review and Update Guidelines 2018 DON Boot Camp 11

Convene a meeting of the Antimicrobial Stewardship Program Suggested Agenda for an Antimicrobial Stewardship Program Team Meeting on Monitoring Time Agenda Topic 1. Brief review of antimicrobial stewardship program goals 5 minutes 1. How does antimicrobial stewardship program fit in with existing infection control or 5 minutes quality improvement (QI) efforts? 1. What measures are needed to evaluate progress towards goals? Options range from simple to very complex. 15 minutes (a) Examples of simple measures: (1) the rate of antibiotic use (e.g., the number of fluoroquinolones used), or (2) use of diagnostic criteria tools (e.g., number of Suspected UTI SBAR forms used). (b) Examples of moderately complex measures: (1) number of antibiotic prescriptions divided by the number of resident days, or (2) number of tests done compared to the number of infections treated. (c) Example of complex measures: (1) Focus on a particular infection and look at the rate of compliance with prescribing criteria; or (2) Examine compliance with antibiogram (e.g., percentage of prescribed antibiotics that were appropriate given the susceptibilities indicated by the current antibiogram). 1. What information is already being collected and what new information should be 10 minutes tracked to show whether the nursing home is making progress on specific shortand long-term goals? Examples: Percentage of antibiotic prescriptions, number of residents receiving antibiotics, number and type of infections, number of staff receiving training. 1. Can we use current information collection procedures, or do we need new ones? 5 minutes 1. How will tracking efforts fit into daily and monthly workflows and task 15 minutes responsibilities? Who will track? What format? What information is needed? How will information be obtained? Who will calculate the numbers into monthly/quarterly/annual reports? 1. What summary reports are needed? 5 minutes 1. How will the information in reports be used? Who will see the reports? How often will the antimicrobial stewardship team discuss the results and assess progress? Monthly or bimonthly? 5 minutes 2018 DON Boot Camp 12

Use the Antibiotic Use Tracking Sheet Indicate HAI Resident name Admit Admit On-set Type of Infec- diagnostic tool Signs & used and Symp-toms whether criteria /CAI /NHAI /Other Noso- X-ray or Lab Results (Organism Prescribing Clinician Rx date and /identifier Room # Date From Date tion were met comial* identified) (PC) duration Antibiotic name Dose *HAI = hospital-acquired infection; CAI = community-acquired infection; NHAI = nursing homeacquired infection; Other Nosocomial = acquired in another health care setting Use and Evaluate Progress through the Monthly Summary Reports The monthly summary report can provide an overview of prescription rates as well as information regarding a specific infection. The example below focuses on UTIs. The report can be customized according to the needs of each nursing home s antimicrobial stewardship goals. For example, a nursing home may wish to omit repeat prescriptions for the same infection, or to track these prescriptions separately. 2018 DON Boot Camp 13

Summary Report of Infections and Antibiotic Use (This example focuses on data for evaluating antibiotic use for suspected UTIs) Month Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec TOTAL Number of Resident Days Number of Antibiotic Rx Number of Antibiotic Rx divided by Number of Resident Days Number of Residents Receiving Antibiotics for UTI (incl. Repeats) Number of UTI SBAR Forms Used Number of UTIs That Met Diagnosti c Criteria Number of Negative Cultures Summary Report of Antibiotic Agents in Use (This example focuses on tracking use of specific antibiotics of concern in the nursing home) Jan Month [Antibiotic Name] [Antibiotic Name] [Antibiotic Name] [Antibiotic Name] [Antibiotic Name] [Antibiotic Name] [Antibiotic Name] In each cell, enter the number of prescriptions or residents receiving this agent Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec TOTAL 2018 DON Boot Camp 14

Communicate Results to Prescribing Clinicians [Date] From: [Nursing Home Name] Dear Dr./Mr./Ms. [insert last name of prescribing clinician] This [quarterly / monthly] report is provided for your reference as we continue to monitor antibiotic use in our nursing home. Between 25 percent and 75 percent of antibiotics are prescribed unnecessarily for nursing home residents. 1 This leads to unnecessary side effects, including multi-drug resistant organisms and health careassociated infections. As a result, [nursing home name] has implemented an antimicrobial stewardship program. antimicrobial stewardship program. This report provides information regarding your prescriptions for antibiotics for residents over the past [month / 3 months]. The report is for your information only and is meant to help you maintain an awareness of trends in infections and antibiotic use in your residents at this nursing home. or residents over the past [month / 3 months]. The report is for your information only and is meant to help you maintain an awareness of trends in infections and ic criteria guidance, or current antibiogram could be provided with this report. This report provides information regarding your prescriptions for antibiotics for residents over the past [month / 3 months]. The report is for your information only and is meant to help you maintain an awareness of trends in infections and antibiotic use in your residents at this nursing home. Resident Name Infection Type/Diagnosis Last Treated Organism Identified Rx Date Rx Duration Antibiotic Name Dose Met Minimum Criteria Optional: A copy of the antimicrobial stewardship program policies, diagnostic criteria guidance, or current antibiogram could be provided with this report. 2018 DON Boot Camp 15

Review and Update Guidelines This report provides information regarding your prescriptions for antibiotics for residents over the past [month / 3 months]. The report is for your information only and is meant to help you maintain an awareness of trends in infections and antibiotic use in your residents at this nursing home. Antibiotic Stewardship Practice Guidelines and Formulary: 2018 DON Boot Camp 16

Consultations for simple infections were once regarded as straightforward however the management of infection is becoming more complex. Multiple drug regimens offer more opportunities for drug interactions and patients may see several prescribers which necessitates a very careful history of medication use. More patients are presenting with a decline in renal function due to increasing age or illness. There are new pressures on the choice and use of antibiotics with resistant strains and the emergence of infections such as C. difficile putting pressure on an already limited formulary of antimicrobials. The following acronym is a useful safety check when prescribing antimicrobials, to avoid being A PRIME example of the pitfalls of antimicrobial prescribing: A P R I M E Allergy Pregnancy or pediatric Renal function Interactions Methotrexate Effective choice Be aware of combination drugs (e.g. Septra/Septra DS (co-trimoxazole) - contains trimethoprim and sulfamethoxazole), and which drug class the antimicrobial belongs to. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high-dose metronidazole. In children AVOID tetracyclines. A number of antibiotics require dose adjustment in renal impairment. Be aware of antibiotic interactions, particularly with oral contraceptives, warfarin, statins, theophylline and immunosuppressants. Interactions with other medicines are most notable with macrolides and quinolones. Deaths have occurred as a result of trimethoprim interacting with methotrexate. Two factors to consider: 1) the patient - consider the points detailed above 2) known or likely causative organism 2018 DON Boot Camp 17

Mean duration of illness and symptoms It may be helpful to offer all patients: Advice about the usual natural history of the illness and the average total length of the illness Advice about managing symptoms (e.g. analgesics for managing pain/fever) Infection (acute) Bronchitis / Cough Common cold Otitis media Rhinosinusitis Tonsilitis / Pharyngitis Average duration 3 weeks 11/2 weeks 4 days 21/2 weeks 1 week Note: these are average durations; approximately 50% of all patients will experience symptoms for longer The graph below provides an estimate of the duration of common cold symptoms: Upper Respiratory Tract Infections Tonsillitis Sinusitis, acute Tonsillitis is commonly viral and rarely needs treatment with an antibiotic. Sore throats should not be treated unless there is good evidence that they are caused by S. pyogenes. 90% of cases resolve in 7 days without antibiotics. Amoxicillin and other broad-spectrum penicillins should NOT be used for the blind treatment of a sore throat. No antibiotic Phenoxymethylpenicillin (Penicillin V) 500mg QID Oral 10 days Penicillin allergy: Clarithromycin 250mg - 500mg BID Oral 5 days Many sinusitis infections are viral. Symptomatic benefit of antibiotics is small and 80% of cases will resolve in 14 days without <12 weeks duration antibiotics. Antibiotics should only be considered if the infection is severe or if symptoms have lasted for >7 days. No antibiotic Amoxicillin 1g TID Oral 7 days Penicillin allergy: Clarithromycin 500mg BID Oral 7 days OR Doxycycline 200mg on first day then 100mg daily Oral 7 days Sinusitis, chronic Inform the patient of the natural course of chronic sinusitis and that it may last for several months; referral is not usually or recurrent required unless the episodes are frequent. Recommend use of analgesics/antipyretics when required. >12 weeks duration Consider if a short-course of an antibiotic is appropriate; if required, treat as acute. 2018 DON Boot Camp 18

Upper Respiratory Tract Infections (continued) Otitis media, acute or recurrent The benefits of antibiotics for otitis media are regularly questioned. Consider not prescribing an antibiotic in acute diagnosis; recommend analgesia for the first three days and consider a delayed prescription. No antibiotic Amoxicillin 500mg-1g TID Oral 5 days Penicillin allergy: Clarithromycin 250mg-500mg BID Oral 5 days Otitis externa If infection is recurrent, or if treatment fails, take a swab for culture. Mild cases: 2% Acetic acid ear spray One spray into the affected ear at least three times a day Ear 7 days Moderate to severe cases (or where acetic acid has failed): Topical ear preparation containing a corticosteroid with an antibiotic (e.g. Flumetasone with Clioquinol ear drops); Treat for 7 days. AVOID preparations containing an aminoglycoside antibiotic (e.g. gentamycin, neomycin) in patients with a perforated tympanic membrane. Lower Respiratory Tract Infections Acute bronchitis, uncomplicated Acute bronchitis with bacterial infection Commonly viral - antibiotics are not normally indicated. No antibiotic Indicated by the presence of purulent sputum, crackles and raised temperature. Amoxicillin 500mg-1g TID Oral 5 days Amoxicillin Clavulanic Acid 500/125mg TID Oral 5 days Thought to be associated with greater incidence of C. difficile infections Penicillin allergy: Doxycycline 200mg on first day then 100mg daily Oral 5 days OR Clarithromycin 500mg BID Oral 5 days Community acquired pneumonia Review at 48 hours. Patients with unresponsive pneumonia, including post-influenza (which could be due to S. aureus or other atypical organism), should be referred to hospital. Amoxicillin 500mg-1g TID Oral Up to 7 days with review Alternative (if penicillin allergy) or add on: Clarithromycin 500mg BID Oral Up to 7 days with review OR Doxycycline 200mg on first day then 100mg daily Oral Up to 7 days with review 2018 DON Boot Camp 19

Lower Respiratory Tract Infections (continued) Chronic obstructive pulmonary disease (COPD) with infective exacerbations 30% of cases are viral - use antibiotics if purulent sputum and increased dyspnoea and/or increased sputum volume. There is insufficient evidence to recommend prophylactic antibiotic therapy in the management of stable COPD. Amoxicillin 500mg TID Oral 5 days Doxycycline 200mg on first day then 100mg daily Oral 5 days Clarithromycin 500mg BID Oral 5 days Bronchiectasis, infective exacerbation Before prescribing an antibiotic, send expectorated sputum sample (after deep coughing) for culture and sensitivity testing (even if patient is taking long-term antibiotics). Do not await results of culture before prescribing an antibiotic. Previous microbiology cultures (if available) should guide antibiotic choice; when previous cultures are not available prescribe an antibiotic from the options listed below. Review response to empirical treatment when sputum results are available. If patient responding well, continue prescribed antibiotic. If poor response, prescribe a different antibiotic based on the culture results. Amoxicillin 500mg TID Oral 10-14 days Penicillin allergy: Clarithromycin 500mg BID Oral 10-14 days Urinary Tract Infections In treatment failure (or if unsure) consider resistant organism as the cause and consult microbiology Urinary tract infections are generally self-limiting; on average, antibiotics shorten the duration of symptoms by about a day If symptoms are mild, dipstick test the urine to guide treatment decisions; consider not prescribing an antibiotic, especially if the urine dipstick test is negative for nitrites, leucocyte esterase and blood If symptoms are moderate to severe, offer to prescribe an antibiotic; do not dipstick test the urine as the decision to offer an antibiotic is not influenced by urine dipstick test results Asymptomatic bacteriuria in patients aged over 65 should not be treated UTI, simple (female patient) No fever or flank pain Not pregnant UTI, simple (male patient) No fever or flank pain 1st episode only: Trimethoprim Not with methotrexate Recurrent episodes: Nitrofurantoin Mid-Stream Urine must be sent for culture 1st episode only: Trimethoprim Not with methotrexate 200mg BID Oral 3 days 100mg BID Oral 3 days 200mg BID Oral 7 days Recurrent episodes: Nitrofurantoin 100mg BID Oral 7 days Mid-Stream Urine (MSU) must be sent for culture UTI, multi-drug resistant Gramnegative bacteria Adjunctive treatment with pivmecillinam (oral), ertapenem (intravenous infusion), or fosfomycin (oral) may be required Note: Intravenous ertapenem for the treatment of UTIs caused by multi-drug resistant Gram-negative bacteria is an off-label use 2018 DON Boot Camp 20

Urinary Tract Infections (continued) In treatment failure (or if unsure) consider resistant organism as the cause and consult microbiology Infection Formulary Choice Dose Route Duration of Treatment UTI, lower in CHILDREN Trimethoprim Age 3-5 months: 4mg/kg BID Oral 3 days Not with methotrexate 6 months - 5 years: 50mg BID Oral 3 days 6-11years: 100mg BID Oral 3 days Nitrofurantoin Age 3 months - 11 years:750micrograms/kg QID Oral 3 days UTI, upper in CHILDREN Amoxicillin Clavulanic Acid Age 3-11 months: 0.5mL/kg of 125/31mg suspension TID Oral 7 days (contains amoxicillin) 1-5years: 5mL of 250/62mg suspension TID Oral 7 days 6-11years: 10mL of 250/62mg suspension TIDS Oral 7 days Thought to be associated with greater incidence of C. difficile infections If the child has a penicillin allergy, seek advice from microbiology UTI in PREGNANCY MSU must be sent for culture. Treatment should be delayed if possible until culture results are available. If urgent empirical treatment is required then consider prescribing an antibiotic from the options below; patients should be reviewed after 48 hours (or according to the clinical situation) to check response to treatment and the results of the urine culture. Repeat MSU for culture 1 to 2 weeks after end of treatment. Nitrofurantoin 100mg BID Oral 7 days Trimethoprim 200mg BID Oral 7 days Not with methotrexate Cefalexin 500mg BID Oral 7 days Thought to be associated with greater incidence of C. difficile infections Urinary Tract Infections (continued) In treatment failure (or if unsure) consider resistant organism as the cause and consult microbiology UTI, long-term Antibiotic prophylaxis is not usually indicated but may be considered on the advice of a consultant microbiologist. suppressive treatment If other specialists request prescribing of a prophylactic antibiotic, seek advice from microbiology. Pyelonephritis MSU must be sent for culture. Refer if patient fails to improve significantly within 24 hours of starting antibiotic or if pyrexial with other risk factors e.g. pregnancy. There is a risk of undertreatment or underestimation of the severity of this condition. Pregnant patients should be referred to hospital. Amoxicillin Clavulanic Acid 500/125mg TID Oral 14 days (contains amoxicillin) Thought to be associated with greater incidence of C. difficile infections Penicillin allergy: Ciprofloxacin 500mg BID Oral 7 days Thought to be associated with greater incidence of C. difficile infections Indwelling catheter Bacterial colonisation is inevitable in long-term catheterised patients; urethral catheters should be changed only when clinically necessary or according to the manufacturer's current recommendations. With regard to the formation of struvite (encrustation), some patients develop this problem routinely and good practice would be to record the lifespan of 3 consecutive catheters and base the optimum time to change the catheter on this. Bladder instillations or washouts must not be used to prevent catheter-associated infection. Ensure the patient remains well hydrated. Only if patient is systemically unwell take a CSU for antibiotic sensitivity and consider treatment Please ensure urine specimens are labelled correctly i.e. CSU or MSU; USING A DIPSTICK IS NOT APPROPRIATE Antibiotic use for suppression of recurrent infection in this group is not supported as it is likely to encourage multi-drug resistant organisms 2018 DON Boot Camp 21

Genital Tract Infections Prostatitis, acute Antibiotic penetration of the prostate is generally very poor. Quinolones and trimethoprim are the most effective antibiotics as they have greater penetration into the prostate. Quinolones are preferred to trimethoprim as they are effective against a broader range of urinary pathogens. MSU should be sent for culture. Ofloxacin 200mg BID Oral 28 days then review Thought to be associated with greater incidence of C. difficile infections Ciprofloxacin 500mg BID Oral 28 days then review Thought to be associated with greater incidence of C. difficile infections Trimethoprim 200mg BID Oral 28 days then review Not with methotrexate Epididymo-orchitis There is no specific treatment for mumps epididymo-orchitis. Oral corticosteroids and antibiotics are not routinely recommended. In older patients the infection is normally due to coliforms, 98% of which are resistant to tetracyclines. Ciprofloxacin 500mg BID Oral 10 days Thought to be associated with greater incidence of C. difficile infections Ofloxacin 200mg BID Oral 14 days Thought to be associated with greater incidence of C. difficile infections Pelvic inflammatory disease Metronidazole 400mg BID Oral 14 days AND Ofloxacin 400mg BID Oral 14 days Thought to be associated with greater incidence of C. difficile infections Ceftriaxone 500mg IM Single dose AND Metronidazole 400mg BD Oral 14 days AND Doxycycline 100mg BD Oral 14 days Genital Tract Infections (continued) Bacterial vaginosis If STD suspected refer to GUM for treatment, contact tracing and follow-up. In pregnancy seek advice from obstetrics or GUM. Metronidazole 400mg BID Oral 7 days Metronidazole 0.75% vaginal gel 5g applicatorful at night Vaginal 5 nights Treatment with oral metronidazole is preferred Clindamycin 2% cream 5g applicatorful at night Vaginal 7 nights Chlamydia trachomatis Treat contacts and azithromycin is the most effective option; it is recommended by WHO and is more effective than erythromycin and amoxicillin. Azithromycin 1g Oral Single dose Doxycycline 100mg BID Oral 7 days Vaginal candidiasis Not pregnant The partner may also be the source of reinfection and, if symptomatic, should be treated with clotrimazole 1% cream 2-3 times daily until symptoms settle, or for up to 14 days. Clotrimazole 10% vaginal cream 5g applicatorful at night Vaginal Single dose Clotrimazole pessary 500mg at night Vaginal Single dose Fluconazole capsule 150mg Oral Single dose Vaginal candidiasis in PREGNANCY In pregnancy, the lower-dose longer-treatment duration regimens are more effective than the single-dose intra-vaginal treatments. Clotrimazole pessary 100mg at night Vaginal 6 nights Miconazole 2% cream 5g applicatorful BID Vaginal 7 days 2018 DON Boot Camp 22

Gastro-intestinal Tract Infections Campylobacter Usually no antibiotics in mild disease. In severe disease or in patients with co-morbidity seek advice from microbiology. Salmonella Shigella Usually no antibiotics in mild disease. In severe disease or in patients with co-morbidity seek advice from microbiology. Be aware that the Shiga and Shiga-like toxins, produced by some strains of S. dysenteriae and E. coli O157:H7, have been associated with approximately 70% of cases of hemolytic uremic syndrome (HUS) in children. Usually no antibiotics in mild disease. In severe disease or in patients with co-morbidity seek advice from microbiology. Antibiotics can increase the risk of complications. E. coli 0157 colitis Treat as advised by microbiologist. Antibiotics are not normally recommended as they may increase the risk of haemolytic uraemic syndrome. Traveller s diarrhea Mostly self-limiting and will need supportive management only. Send a stool specimen if person is systemically unwell, there is blood or pus in the stool, diarrhea is persistent and giardiasis is suspected, if they have recently received antibiotics or been in hospital, if the person is immunocompromised or if other pathologies are a possibility (e.g. parasites). Gastro-intestinal Tract Infections (continued) C. difficile toxin positive diarrhea For management of a patient with unexplained diarrhea or suspected C. difficile infection see flowcharts on pages 25 & 26 Stop offending antibiotic if possible. If patient on a PPI, review and stop if possible. If antibiotics are required for another infection seek advice from microbiology. Severity of C. difficile: Mild: not associated with an increased white cell count (WCC). It is typically associated with less than three episodes of loose stools (defined as loose enough to take the shape of the container used to sample it) per day. Moderate: associated with an increased WCC (but less than 15 x 109/L) and typically associated with 3-5 loose stools per day. Severe: associated with a WCC greater than 15 x 109/L, or an acutely increased serum creatinine concentration (that is, greater than 50% increase above baseline), or a temperature higher than 38.5 C, or evidence of severe colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity. Mild: No treatment Mild to Moderate (initial episode): Metronidazole 400mg TID Oral 10-14 days I Severe or recurrent infection: Seek advice from microbiology 16 2018 DON Boot Camp 23

Gastro-intestinal Tract Infections (continued) Giardiasis Metronidazole 2g daily Oral 3 days OR 400mg TDS Oral 5 days Cryptosporidium Acute diverticulitis Treatment not readily available and not normally indicated. Seek specialist advice for immunocompromised patients and those in poor health. Consider antibiotics if patient shows systemic symptoms e.g. pyrexia, pain, raised CRP. Review within 48 hours or sooner if symptoms deteriorate. Arrange admission if symptoms persist or deteriorate. Amoxicillin Clavulanic Acid ) 500/125mg TID Oral 7 days Thought to be associated with greater incidence of C. difficile infections Penicillin allergy: Metronidazole 400mg TID Oral 7 days AND Ciprofloxacin 500mg BID Oral 7 days Thought to be associated with greater incidence of C. difficile infections Helicobacter pylori Avoid amoxicillin-containing regimens for those with known or suspected penicillin allergy. Check for recent use of clarithromycin or metronidazole; this may promote resistance, resulting in eradication failure. For those recently treated with clarithromycin (up to 1 year), choose a regimen containing amoxicillin and metronidazole. For those recently treated with metronidazole (up to 1 year), choose a regimen containing amoxicillin and clarithromycin.. Omeprazole 20mg BID Oral 7 days AND Clarithromycin 500mg BID Oral 7 days AND Amoxicillin 1g BID Oral 7 days Omeprazole 20mg BID Oral 7 days AND Clarithromycin 250mg BID Oral 7 days AND Metronidazole 400mg BID Oral 7 days Miscellaneous Acne, moderate to severe For mild to moderate acne, topical treatments are usually sufficient. Consider an oral antibiotic (combined with either a topical retinoid or benzoyl peroxide) if there is acne on the back or shoulders that is particularly extensive or difficult to reach, or if there is a significant risk of scarring or substantial pigment change. Refer all people with severe acne for specialist assessment and treatment. Doxycycline 100mg once daily Oral Minimum of 8 weeks Erythromycin 500mg BID Oral Minimum of 8 weeks Bites, human/animal Animal bite (cat or dog): Thoroughly irrigate the wound Assess tetanus and rabies risk Antibiotics are advised if the wound is less than 48 hours old and the risk of infection is high. Prescribe oral antibiotics for all cat bites, animal bites to the hand, foot or face, puncture wounds, wounds requiring surgical debridement, wounds involving joints, tendons, ligaments or suspected fractures, people with a prosthetic valve or joint, people at risk of serious wound infection (e.g. diabetic, cirrhotic, asplenic or immunosuppressed) and wounds that have undergone primary closure Send cultures if wound appears to be infected Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of local or systemic infection For other animals: Seek specialist advice Human bite: Thoroughly irrigate the wound Assess risk of tetanus, HIV and hepatitis B and C Antibiotic prophylaxis advised for all human bite wounds under 72 hours old, even if there is no sign of infection Amoxicillin Clavulanic Acid 250/125mg - 500/125mg TID Oral 7 days Thought to be associated with greater incidence of C. difficile infections 2018 DON Boot Camp 24

Miscellaneous (continued) Bites, human/animal (continued) Penicillin allergy: Animal/human bite: Metronidazole 200mg - 400mg TID Oral 7 days AND Doxycycline 100mg BID Oral 7 days Human bite only: Metronidazole 200mg - 400mg TID Oral 7 days AND Clarithromycin 250mg - 500mg BID Oral 7 days Cellulitis (routine swabs not required for leg ulcers) People with mild or moderate cellulitis with no systemic illness or uncontrolled co-morbidities can usually be managed in primary care. If MRSA suspected (i.e. previous infection, colonisation, or failure to respond), take a swab. If serious, IV treatment may be required - refer to microbiology. Orfloxacillin 400mg BID Oral 7-14 days Penicillin allergy: Clarithromycin 500mg BID Oral 7-14 days Cellulitis, water contact If cellulitis has arisen from wound contaminated with fresh or salt water please discuss with microbiologist Cellulitis, facial Amoxicillin Clavulanic Acid (contains amoxicillin) 500/125mg TID (consider admitting to hospital if patient febrile and ill) Thought to be associated with greater incidence of C. difficile infections Oral 7-14 days Miscellaneous (continued) Conjuctival infections Most conjunctivitis is viral and self-limiting. Bacterial conjunctivitis is usually unilateral and also self-limiting. It is characterized by red eye and mucopurulent (not watery) discharge. Contact lenses should not be used during treatment with topical antibiotics, or if untreated infection is present. Soft contact lenses should be avoided until at least 24 hours after treatment has been completed. Non-disposable contact lenses must be thoroughly cleaned before re-starting use.. No antibiotic, or consider a delayed prescription Chloramphenicol 0.5% drops AND/OR One drop 2 hourly for 2 days then 4 hourly Eye Continue for 48 hours after healing; usual treatment duration 7 days Chloramphenicol 1% ointment Apply QDS for 2 days then BID or once daily at night if used with eye drops Eye Continue for 48 hours after healing; usual treatment duration 7 days If chloramphenicol not suitable: Fusidic acid 1% gel Apply BID Eye Continue for 48 hours after healing; usual treatment duration 7 days Dental abscess Impetigo Refer to dentist Systematic review indicates topical and oral treatment produces similar results. As resistance is increasing, reserve topical antibiotics for very localized lesions. Note some strains of Staph. aureus are resistant to sodium fusidate - do not repeat topical treatment if treatment failure. National guidance states that mupirocin should be reserved for MRSA. Orfloxacillin 400mg QD Oral 7 days Penicillin allergy: Clarithromycin 250mg-500mg BD Oral 7 days 2018 DON Boot Camp 25

Miscellaneous (continued) Leg ulcers, infected Not normal colonisation; significant cellulitis around the ulcer, purulent discharge and patient systemically unwell Bacteria will always be present. Antibiotics do not improve healing unless there is active infection. Culture swabs and antibiotics are only indicated if there is evidence of clinical cellulitis, increased pain, enlarging ulcer or pyrexia. If a swab is indicated, swab the base of the ulcer after cleaning; do not swab the exudate. Do not use topical antibiotics. Ofloxacin 400mg BID Oral 7-14 days Penicillin allergy: Clarithromycin 500mg BID Oral 7-14 days Mastitis, infective Ofloxacillin 400mg BID Oral 14 days* Penicillin allergy: Erythromycin 250mg - 500mg QID Oral 14 days* *If symptoms fail to settle after 48 hours of antibiotic treatment: Check that the patient has taken the antibiotic correctly and send a sample of the milk for culture If culture results are available, treat with an antibiotic the organism is sensitive to If culture results are not available, treat empirically with oral Amoxicillin Clavulanic Acid 500/125mg, TID for 14 days; seek specialist advice if the woman is unable to take a penicillin-related antibiotic Review treatment when culture results are available Infection Formulary Choice Dose Route Duration of Treatment Meningococcal disease, suspected Transfer patient to hospital immediately. Administer a single dose of penicillin G injection unless the patient has a history of anaphylaxis (not allergy). Penicillin G CHILD aged under 1 year: 300mg IV Single dose CHILD aged 1-9 years: 600mg IV Single dose CHILD aged 10 years and over: 1.2g IV Single dose ADULT: 1.2g IV Single dose If unable to administer by IV injection, give by IM injection. History of anaphylaxis to penicillin: Transfer to hospital Miscellaneous (continued) Severe necrotizing Admit to hospital immediately infections Wounds, badly soiled i.e. dirty, traumatic wounds Carefully clean the wound using normal saline, drinking-quality water, or cooled boiled water. Consider if debridement is required. Amoxicillin Clavulanic Acid 250/125mg - 500/125mg TID Oral 5 days Thought to be associated with greater incidence of C. difficile infections Penicillin allergy: Metronidazole 400mg TID Oral 5 days AND Clarithromycin 250mg BID Oral 5 days 2018 DON Boot Camp 26

Management of a patient with unexplained diarrhea - suspected Clostridium difficile infection (CDI): Guidance for MDs If a patient has diarrhea that is not clearly attributable to an underlying condition (e.g. inflammatory colitis, overflow) or therapy (e.g. laxatives, enteral feeding) then it is necessary to determine if this is due to CDI; send stool sample to microbiology and ensure that the request form clearly states that a C.difficile test is required Notified of positive sample by microbiology laboratory 1. Re-assess severity** (may affect treatment choice) 2. If symptoms are not resolving commence antibiotics for C. difficile *** 3. Stop precipitating antibiotics if possible 4. Stop anti-motility drugs 5. Review the requirement for, and dose of, PPI 6. An Infection Control Nurse will arrange Root Cause Analysis investigation BEGIN ROOT ANALYSIS INVESTIGATION Give the Nurses, CNAs and/or patient standard advice with regards to good hygiene and stress the importance of suitable and adequate fluids. Daily assessment necessary; STOOL SAMPLES FOR CLEARANCE ARE NOT REQUIRED Do not retest for C. difficile toxin if the patient is still symptomatic within a period of 28 days (unless symptoms resolve and then recur and there is a need to confirm recurrent CDI); note the symptoms and consult the duty microbiologist to discuss ** SEVERITY INDICATORS fever raised wbc raised crp (C-reactive protein) low albumin dehydration abdominal pain *** ANTIBIOTICS FOR PATIENT AT HOME: Oral metronidazole 400mg TID, 10-14 days If no response in 5 days seek advice from Physician Management of a patient with unexplained diarrhea - suspected Clostridium difficile infection (CDI): Guidance for Nursing Home Staff If a resident has diarrhea that is not clearly attributable to an underlying condition (e.g. inflammatory colitis, overflow) or therapy (e.g. laxatives, enteral feeding) then it is necessary to determine if this is due to CDI. 1. Commence recording every bowel movement 2. Implement environment cleaning with chlorine based products 3. Use gloves, aprons and strict hand hygiene, with soap and water DO NOT use alcohol gel (Allocate separate toilet or commode) Provide staff, resident, family carers and visitors with information on C. difficile and safe practice Clearance specimens are NOT required. Do not retest for C. difficile toxin if the patient is still symptomatic within a period of 28 days (unless symptoms resolve and then recur and there is a need to confirm recurrent CDI); note the symptoms and discuss with the MD. ISOLATE RESIDENT in single room Contact MD for further advice and send stool specimen (if requested) Ensure result is received from MD and record in notes IF POSITIVE FOR CLOSTRIDIUM DIFFICILE Discuss symptoms with MD - If symptomatic then treatment should be commenced If symptoms have stopped then treatment may not be required Keep isolated until no diarrhea for at least 48 hours and a formed stool has been passed Collect stool specimen and send to microbiology. In order for the specimen to be processed for CDI the sample must take on the shape of the container and be at least ¼ filled (to indicate the person has diarrhea) Specify C.difficile test on request form and include clinical details e.g. current and past antibiotics in the last six weeks Anti-diarrheal medication should not be used PPIs should be stopped if appropriate If symptoms do not improve within 48hrs inform MD 2018 DON Boot Camp 27

ANTIBIOGRAMS: THE NUTS AND BOLTS What Is an Antibiogram and Why Should a Nursing Home Use It? A nursing home-specific antibiogram may be an effective and inexpensive tool for improving appropriate antibiotic prescribing. An antibiogram is a report that displays the organisms present in clinical specimens that nursing homes send for laboratory testing aggregated across all residents for a certain time period along with the susceptibility of each organism to various antibiotics. Referring to an antibiogram report enables prescribing clinicians to make prompt, empirically based decisions. Because antibiograms provide information on local susceptibility patterns, they may help to reduce prescribing of antibiotics with high resistance rates in nursing homes and emergency departments. 2018 DON Boot Camp 28

How will antibiograms be created? The data for the nursing home antibiogram will be generated by the nursing home s contracted clinical laboratory, using the results from residents cultures collected at the nursing home over the past 12 24 months. The antibiogram will be formatted as a table that is easy for prescribing clinicians to read and use when making decisions about prescribing antibiotics for residents. Why are antibiograms important? Antibiotics are among the most commonly prescribed pharmaceuticals in long-term care settings, yet research indicates that a high proportion of antibiotic prescriptions are inappropriate. The adverse consequences of inappropriate prescribing practices are serious and have become a major public health concern. Using an antibiogram to guide empiric antibiotic selection can help to improve the likelihood that the antibiotic will be effective even before the bacteria have been identified by the laboratory. 2018 DON Boot Camp 29

What is the potential impact of using antibiograms? Research has shown that the use of antibiograms can result in reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures of antibiotics that are first prescribed. WILLIAM.DAY@PCSACONSULTANTS.COM (225) 324-8163 2018 DON Boot Camp 30