Antibiotic Stewardship - Fine Tuning Your Program for Purposeful Change

Antibiotic Stewardship - Fine Tuning Your Program for Purposeful Change Kaylee Adams PharmD, BCGP Medication Managers, LLC Stacey Rexrode PharmD, BCGP Jude Rx, LLC Disclosure We have no relevant financial relationships with manufacturers of any commercial products and/or providers of commercial services discussed in this presentation. 1

Objectives 1. Identify and develop achievable outcome measures (QAPI) for your Infection Prevention and Control Program (IPCP) that will drive purposeful change in your facility. 2. Discuss how to communicate and document antibiotic medication appropriateness with providers, patients, and families. Bonus Objectives 1. Understand how to utilize antibiograms to develop empiric treatments of choice 2. Optimize antimicrobial data collection surveillance Background CMS requires that all Long Term Care facilities have an Infection Prevention and Control Program (IPCP) as of 11/28/2017 Regulation: Must have antimicrobial use protocols and system for monitoring antimicrobial use 2

Antimicrobial Use Protocols Developing Empiric Treatments of Choice Involving Admitting Hospitals Already in regulation that hospitals must have an antimicrobial stewardship program Initiating contact/communication with hospital stewardship staff Utilize facility hospital liaisons May communicate with case managers or steward themselves Offer to meet in person welcomes buy-in Eliminate omissions during transitions of care Accurate communication of total duration of therapy Broad à narrow spectrum Unnecessary high cost / broad spectrum antimicrobials 3

Obtaining Antibiograms Utilize new contacts at the admitting hospital for most current antibiogram May call lab or microbiology departments Some may be unwilling to share due to proprietary information Will be used to develop empiric treatments of choice for your facility Discussed later Some labs may create facility specific antibiogram great! Note most common LTC facility culture source is urine à sputum, wound and blood are rare Cumulative Antimicrobial Susceptibility of Bacteria and Yeast from Cultures at Cleveland Clinic All patients - Main Campus January 1 December 31, 2016 Gram Negative Bacilli % Susceptible Organism (number tested): Ampicillin Amp/Sulbactam Piperacillin/ Tazobactam Cefazolin Enterobacteriaceae Citrobacter freundii complex (423) 0 0 89 0 88 88 99 98 99 96 96 99 96 87 96 Citrobacter koseri (281) 0 91 99 98 99 99 99 99 99 99 99 100 99 99 93 Enterobacter aerogenes (375) 0 0 89 0 91 90 99 98 99 100 99 100 99 99 19 Enterobacter cloacae complex (720) 0 0 83 0 83 82 98 88 99 97 97 100 94 89 43 Escherichia coli (14,438) 59 64 97 89 95 95 96 99 99 93 93 99 83 80 97 Klebsiella oxytoca (553) 0 61 93 65 95 96 96 99 99 98 97 100 98 93 89 Klebsiella pneumoniae (3,140) 0 82 93 92 94 94 94 98 98 96 95 99 94 88 41 Morganella morganii (181) 0 0 95 0 93 84 99 99 99 81 92 100 75 72 0 Proteus mirabilis (1,444) 85 93 99 95 99 98 99 94 100 94 95 100 81 85 0 Proteus vulgaris (54) 0 72 100 0 91 100 98 92 100 100 100 100 98 100 0 Providencia rettgeri (53) 0 0 94 0 96 94 100 98 100 0 0 100 91 87 0 Providencia stuartii (60) 0 0 100 0 98 98 100 98 100 0 0 100 25 62 0 Serratia marcescens (307) 0 0 95 0 98 99 99 97 99 96 90 99 98 99 0 Non-Enterobacteriaceae Acinetobacter baumannii complex (173) 0 67 51 0 32 57 65 0 62 62 68 68 60 62 - Acinetobacter spp. (32) 0 84 66 0 66 73 85 0 94 100 93 100 88 81 - Pseudomonas aeruginosa (1,930) a 0 0 86 0 0 89 89 0 85 87 94 95 81 0 - P. aeruginosa, mucoid (188) b 0 0 79 0 0 80 75 0 74 79 88 87 58 0 - Pseudomonas putida (48) 0 0 78 0 31 100 98 0 90 98 97 97 94 4 - Stenotrophomonas maltophilia (170) c 0 0-0 0 58-0 0 0 0 0 0 98 - a P. aeruginosa additional susceptibility rates: aztreonam, 44% (n=81); ceftolozane-tazobactam, 77% (n=77); colistin, 94% (n=257). b Mucoid P. aeruginosa additional susceptibility rate: aztreonam, 72% (n=181). c S. maltophilia additional susceptibility rates: levofloxacin, 70% (n=122); ticarcillin-clavulanate, 56% (n=118); minocycline, 97% (n=122). Ceftriaxone Ceftazidime Cefepime Ertapenem Meropenem Gentamicin Tobramycin Amikacin Ciprofloxacin Trimethoprim/ Sulfamethoxazole Nitrofurantoin (urine only) 4

Getting Started Three infectious disease states of focus Urinary Tract Infection (UTI) Lower Respiratory Tract Infection (LRTI) Skin and Soft Tissue Infection (SSTI) Can create facility specific uropathogen antibiogram Must contain at least 30 isolates to be statistically significant Urinary Tract Infection - UTI Nitrofurantoin (Macrobid ) May be used with creatinine clearance above 30 ml/min (2015 Beers Criteria) Generally great susceptibility Cephalexin (Keflex ) Should be considered a viable option based on susceptibility Generally not used in the community due to 4x daily administration TMZ-SMX (Bactrim ) Should not be used empirically if regional susceptibility falls below 80% 1 Ciprofloxacin (Cipro ) No longer in treatment guidelines, should be avoided unless no other alternatives exist due to risks of adverse events (FDA warning). 5

FDA Strengthens Warning on Fluoroquinolones 7/10/2018 2 Hypoglycemia Altered Mental Status (can present after 1 st dose) Disorientation, agitation, nervousness, reduced cognition, delirium Previous warnings (still relevant) Tendon rupture Muscle/joint pain Fluoroquinolones should be avoided in the treatment of bacterial sinusitis, acute exacerbation of chronic bronchitis, and uncomplicated urinary tract infection, unless no alternatives exist. Lower Respiratory Tract Infection - LRTI Pneumonia in LTC is considered community acquired pneumonia (CAP) with the presence of co-morbidities treatment options 1 : Levofloxacin -or- Moxifloxacin Azithromycin + high dose Amoxicillin (or Augmentin) -or- Doxycycline Duration of therapy should only be for 7 days based on most recent guidelines IDSA and American Thoracic Society Guidelines 2016 1. Mandell LA, et al. Clin Infect Dis 2007;44:S27-72. 6

Skin and Soft Tissue Infections (SSTIs) Cellulitis Purulent cellulitis = staph species Non-purulent cellulitis = strep species Purulent cellulitis Assess regional prevalence of MRSA if high, chose Bactrim or Doxycycline based on resistance patterns Non-purulent cellulitis Cephalexin has excellent activity against strep species continue use 7

Uncomplicated UTI Empiric Treatment Nitrofurantoin 100 mg BID x 5 days Ineffective if CrCl < 30 ml/min 2 nd Line: Cephalexin 500 mg Q8H x 5 days 250 mg Q6H CrCl < 60 ml/min 250 mg Q8H CrCl < 30 ml/min Complicated UTI extend duration to 7 days Avoid Bactrim and Ciprofloxacin unless C&S confirms sensitivity due to regional resistance Pneumonia 1 st line: Amoxicillin 1 gm TID + Azithromycin 500 mg QD x 7 days 500 mg Q12H if CrCl < 30 ml/min 2 nd line/pcn Allergic: Levofloxacin 750 mg QD x 7 days QD à Q48H if CrCl < 50 ml/min Consider MDR pathogen if recent hospital stay or antibiotic use à consider IV therapy Levofloxacin can be given IV at same dose/duration Positive Cough/CXR can persist 4-6 weeks, not necessary to extend antibiotic duration; no test of cure COPD Exacerbation Augmentin 875-125 mg BID x 7 days 500-125 mg BID if CrCl < 30 ml/min PCN Allergic: Azithromycin 500 mg QD x 7 days Treat if increased dyspnea + increased sputum volume + increased sputum purulence Note: most commonly viral etiology Cellulitis Purulent (Staph sp.) 1 st line: Doxycycline 100 mg BID x 7-14 days 2 nd line: Bactrim DS 1 tab BID x 7-14 days Use SS tab if CrCl < 30 ml/min Regionally, ~50% of isolates are MRSA, and resistant to clindamycin Vancomycin 1 st choice if IV therapy indicated May continue until further debridement is not necessary, clinically improved and afebrile 48-72h Non-purulent: consider erysipelas à Strep sp. = Cephalexin as treatment of choice C. diff Mild to Moderate Metronidazole 500 mg PO TID x 10 days Severe Vancomycin 125 mg PO QID x 10 days Consider using PO Vancomycin for mild to moderate disease if currently receiving PO warfarin

Once Development is Complete Once empiric treatments of choice are developed, the medical director or infectious disease consultant should approve Once approved, all providers in the building should be educated on treatment protocols Face-to-face education preferred; medical director present if possible Form letter explaining stewardship and protocol available Inform that adherence to empiric treatments will be an outcome measure Work with dispensing pharmacy to ensure all antibiotic doses, including renal adjustments are in E-kit and readily available Family and Patient Education Selected education materials numerous available from CDC and AHRQ Develop a family/patient targeted mission statement surrounding stewardship Should be simple, but state, we strive to use antimicrobial agents only for appropriate infections at the correct dose and duration to minimize side effects, etc. Include these materials in the: Admission packets Around the facility LTC resident care conferences 1

Urinary Tract Infection (UTI) Educate staff on TRUE UTI versus asymptomatic bacteriuria NHSN and CDC Long Term Care Facility Component UTI (follows) Build criteria into EHR or nursing documentation system to streamline assessment 2

NHSN Long-term Care Facility Component Urinary Tract Infection Figure 1: Criteria for Defining Non-Catheter Associated Symptomatic Urinary Tract Infection (SUTI): Resident without an indwelling catheter (Meets criteria 1 OR 2 OR 3): SUTI Criteria 1 Either of the following: 1. Acute dysuria 2. Acute pain, swelling, or tenderness of the testes, epididymis or prostate OR SUTI - Criteria 2 Either of the following: 1. Fever + a 2. Leukocytosis b AND ONE or more of the following: Costovertebral angle pain or tenderness New or marked increase in suprapubic tenderness Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency OR SUTI - Criteria 3 TWO or more of the following: Costovertebral angle pain or tenderness New or marked increase in suprapubic tenderness Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency AND Either of the following: 1. Specimen collected from clean catch voided urine and positive culture with no more than 2 species of microorganisms, at least one of which is a bacterium of 10 5 CFU/ml 2. Specimen collected from in/out straight catheter and positive culture with any number of microorganisms, at least one of which is a bacterium of 10 2 CFU/ml NOTE: Yeast and other microorganisms, which are not bacteria, are not acceptable UTI pathogens SUTI + Fever can be used to meet SUTI criteria even if the resident has another possible cause for the fever (e.g., pneumonia) a Fever: Single temperature 37.8 o C (>100 o F), or > 37.2 o C (>99 o F) on repeated occasions, or an increase of >1.1 o C (>2 o F) over baseline b Leukocytosis: >14,000 cells/mm 3, or Left shift (> 6% or 1,500 bands/mm 3 ) https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-uti-protocol-current.pdf

System for Monitoring Antimicrobial Use Utilizing the surveillance spreadsheet for impactful data collection Surveillance Data Tracking Sample spreadsheet available Will describe valuable data fields next Depending on current process of antimicrobial tracking, may be a big change implement changes slowly to ensure proficiency and accuracy 1

Antimicrobial Data Surveillance Spreadsheet

Utilizing the Surveillance Spreadsheet Will also want to track resident location to identify any out breaks Each facility tends to have their own method for tracking location Can use separate sheets as previously mentioned

Utilizing the Surveillance Spreadsheet Important for nursing to completely document signs and symptoms indicating antimicrobial therapy will be crucial for determining if McGeer Criteria was met

Utilizing the Surveillance Spreadsheet Require providers to include associated diagnosis with each antimicrobial order Try to avoid vague verbiage such as leukocytosis, etc.

Utilizing the Surveillance Spreadsheet Comparing the culture result date with the antimicrobial start date will allow you to determine if therapy was empiric or targeted based on culture results If no culture is obtained, empiric treatments should always be followed

Utilizing the Surveillance Spreadsheet Be aware that chest X-rays may still be positive 4-6 weeks after therapy completion. This does NOT warrant continued therapy.

Utilizing the Surveillance Spreadsheet Documenting provider will allow you to determine who is adhering to empiric treatments of choice, and who will require reeducation.

Utilizing the Surveillance Spreadsheet Here is where you will define whether the infection was acquired within your facility remember the 72 hour rule.

Reporting the Data for QAPI Will need to define outcome measures to track efficacy and compliance with antimicrobial stewardship efforts Initial, simplistic outcome measures: UTI: Was empiric therapy followed if treatment was started prior to receipt of culture results? (Y/N) Was McGeer/diagnostic Criteria met? (Y/N) Pneumonia: Was empiric therapy followed? (Y/N) remember small likelihood of culture Was duration of therapy for only 7 days? (Y/N) Cellulitis: Was empiric therapy followed? (Y/N) remember small likelihood of culture Incidence of C. diff number of in-house acquired cases Time for YOUR successes and hardships speak up! What s been the key to your success and what s been holding you back? 1

Communication Antibiotic Stewardship for Healthcare Professionals, Patients, and Families Communication What are some communication goals in antibiotic stewardship? Patient Family Prescriber 2

Cases and Discussion Communication Techniques Shared Decision Making Team talk, Option talk, Decision talk Motivational Interviewing Engage, Focus, Evoking, Planning 3

Combination of Communication Techniques Shared Decision Making and Motivational Interviewing both support Patient autonomy Focus on engaging the patient: explore views, opinions, and options Both require Communication skills Developing trust Understanding and empathy Patient enablement to facilitate decision making and behavior changing Communication Approach Identify medication issue Assess readiness for change ( change talk ) Use objective data, ranges, comparative data Relate data to the patient Set tone Informational, nonconfrontational Empathetic 4

Communication Advice Provide advice with permission! Do you mind if we spend a few minutes talking about your medication?...what do you know about antibiotics Are you interested in learning more about antibiotics? I noticed on your medical history that you have series of antibiotic use for frequent urinary tract infections, do you mind if we talk about how different antibiotics affect the body? Short, focused discussions are best Delivery is key: Suggest versus telling. could or may instead of should Offer clarity Clarify what the patient wants to know Simple Communication Alternatives Responsibility and opportunity for change is placed in the patients control When patients are empowered to choose whether to change or what to change they: Decrease resistance to recommendations Increase investment in plan of care More willing to renegotiable treatment goals 5

Communication Affirmation Validates feelings and experiences I appreciate how hard it must have been for you to decide to come here. This is a big step in the healing process. Your commitment really shows by being at the bedside and joining care conferences. Motivational Interviewing: Change Talk Open Ended Questions What other medicines has Mr. O tried prior to this antibiotic? Decisional Balances What would be a good thing about delaying antibiotic therapy? What would be a not so good thing about another course of antibiotic therapy? 6

Motivational Interviewing: Change Talk Elaboration In what ways?, Tell me more, What does that look like?, When was the last time that happened? Look back How has frequent antibiotic use improved how you feel? How were things better before you took all of these medications? Look forward Should symptoms present in the next 1-2 days Motivational Interviewing: Change Talk Goals and values How does repetitive antibiotic therapy support your goal to feel better? Come alongside Perhaps your antibiotic is so important that you won t give it up, no matter what the cost? 7

Risks of Antibiotics Adverse Events Nausea, Diarrhea, More Infections, Antibiotic Resistance Renal Impairment Nitrofurantoin, Fluoroquinolones, Beta Lactams, Cephalosporins Drug/Food Interactions Warfarin, QTc Prolonging agents, Dairy, Vitamins, Supplements Administration Swallow whole, injections, take with food/water, sit upright Handling Emotions Effective responses to emotion Tangible help: I think I can help by Validation: Yes, this is a very anxiety provoking time for you, seeing your loved one not feeling his best. Reflective listening: It sounds like you are feeling upset with the plan to delay antibiotic therapy Legitimation: It is only natural to feel Less effective Reassuring: It will be fine. 8

Respond to Uncertainty State what is known and unknown Avoid Let s just wait and see I don t know Plan Discussions Admission Recertification, extension of services Family and facility care conference Goals of care (plan of care) discussions Change in patient status Change in location 9

Summary Start small with achievable outcomes and build on those successes Don t get too into the weeds with the interpretive guidance language Own it! Speak confidently about stewardship; use the tools and information you learned today Practicing effective communication will lead to increased patient satisfaction, and ultimately improve your defined stewardship outcome measures References Gupta K. Emerging antibiotic resistance in urinary tract pathogens. Infect Dis Clin North Am 2003; 17:243 59. Raz R, Chazan B, Kennes Y, et al. Empiric use of trimethoprim-sul- famethoxazole (TMP-SMX) in the treatment of women with un- complicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis 2002; 34:1165 9. FDA Updates warnings for fluoroquinolone antibiotics on risks of mental health and low blood sugar adverse events. U.S. Food and Drug Administration. Silver Spring MD. Available online: https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm612995.htm. [Accessed Aug 9 2018] Mandell LA, et al. Clin Infect Dis 2007;44:S27-72. Center for Substance Abuse Treatment (2013). Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) 35. Rockville, MD: Substance Abuse and Mental Health Administration, Center for Substance Abuse Treatment. Available online: https://store.samhsa.gov/shin/content//sma13-4212/sma13-4212.pdf [Accessed Aug 8 2018] Elwy G, Debledorf C, Epstein RM, et al. Shared Decision Making and Motivational Interviewing: Achieving Patient- Centered Care Across the Spectrum of Health Care Problems. Ann Fam Med. May/June 2014; 12(3):207-275. Epstein RM, Street RL Jr. Patient-Centered Communication in Cancer Care; Promoting Healing and Reducing Suffering. Nation Cancer Institute, NIH Publication No.07-6225. Bethesda, MD, 2007. 10

Antibiotic Stewardship - Fine Tuning Your Program for Purposeful Change Kaylee Adams PharmD, BCGP Medication Managers, LLC Kaylee@mmpharmacist.com Stacey Rexrode PharmD, BCGP Jude Rx, LLC Stacey.Rexrode@juderx.com 11