Antibiotic Stewardship in Nursing Homes

Antibiotic Stewardship in Nursing Homes Philip D. Sloane, MD, MPH Elizabeth and Oscar Goodwin Distinguished Professor of Family Medicine Program on Aging, Disability, and Long Term Care, Cecil G. Sheps Center for Health Services Research University of North Carolina Chapel Hill, North Carolina March 26, 2018 Collaborative Studies of Long-Term Care University of North Carolina at Chapel Hill

Outline of Presentation 1. What is Antibiotic Stewardship and Why Is It Important for Nursing Homes? 2. CMS Mandate for Nursing Homes to Implement Antibiotic Stewardship 3. Key Quality Improvement Targets in Nursing Home Infection Management 4. Developing an Antibiotic Stewardship Program in Your Nursing Home

What is Antibiotic Stewardship? and Why Is It Important for Nursing Homes?

Antibiotic Stewardship Is A set of commitments and activities designed to: optimize the treatment of infections and reduce the adverse events associated with antibiotic overuse

In Operational Terms, Antibiotic Stewardship Is. A system of informatics, data collection, personnel, policies and procedures designed to assure that patients get: the right drug at the right time for the right duration

Why Antibiotic Stewardship Is Important for Society Overall and Specifically for Nursing Homes

Worldwide Crisis of Antibiotic Resistance Multi drug resistance increasingly common Over 20,000 deaths annually in U.S.A. from multidrug resistant infections Projected 317,000 deaths per year by 2050

http://www.bbc.com/future/story/20170328 12 questions we need to prioritise in 2017

What s Causing the Crisis? 1. Fewer New Antibiotics Being Developed 2. Resistant Strains Spread Rapidly 18 16 14 12 10 16 14 10 8 6 4 2 0 7 5 1 1983 87 1988 92 1993 97 1998 2002 2003 07 2008 12 3. Antibiotics Are Overused

Why the Focus on Nursing Homes Antibiotic usage tends to be quite high NHs with the highest prescribing rates tend to also have the highest clostridium difficile infection rates Residents LIVE there (as opposed to hospital)

Antibiotic Prescribing Rates across 31 North Carolina Nursing Homes Average # Antibiotic Prescriptions Per Resident in One Year * The Average: Nursing Home Resident 4.6 antibiotic prescriptions per year 1 prescription every 80 days On antibiotics 10% of the time median Nursing Home

Resistant Bacteria Now Commonly Colonize Nursing Home Residents results of skin, airway, skin and wound cultures in 82 residents J Clin Micro 50(5); 1698 1703, 2012. Bacterial colonies present MRSA CR GNR VRE 18% 63% 72% 20 40 60 80 % of Nursing Home Residents with Positive Culture

Clostridium Difficile: an Indicator of Antibiotic Overuse

Reasons Antibiotics Are Prescribed Presumed Skin and Soft Tissue Infection Other Infection The most common other infection is C. difficile Presumed Urinary Infection Respiratory Infection

CMS Mandate for Nursing Homes to Implement Antibiotic Stewardship

42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489 Reform of Requirements for Long-Term Care Facilities We are requiring facilities to develop an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program and designate at least one infection Preventionist (IP). That program should include antibiotic use protocols and a system to monitor antibiotic use. Implementation Timetable: Antibiotic Stewardship 11/28/2017 Infection Preventionist (IP) 11/28/2019 IP on Quality Assessment and Assurance Committee 11/28/2019

Yes, This is a policy change Prescribing antibiotics just in case was accepted in the past, but now antibiotics should be given after careful, evidence based consideration of risks and necessity. This session will provide guidance on key elements of antibiotic stewardship for your nursing home

F Tags that Surveyors Can Cite to Enforce Antibiotic Stewardship Federal Tag 441: Infection Control Federal Tag 329: Unnecessary Drugs Federal Tag 332/333: Medication Errors Federal Tag 428: Drug Regimen Review

Can Antibiotic Use be Safely Reduced?

2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 <== Baseline Education and QI Works: Results from Randomized Trial Antibiotic Prescriptions Per 100 Resident Days Follow Up ==> Intervention Begun Mar Apr May Jun Jul Aug Sep Oct Nov 24% Reduction in Intervention Group Intervention Group All Indications Comparison Group All Indications

Antibiotic Prescribing Rates in 28 Minnesota Nursing Homes 6 5 4 Average for 31 North Carolina Nursing Homes Average = 2.19 prescriptions per year 3 2 1 0 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA BB

Key Areas for Improvement in Nursing Home Antibiotic Use

Decision Making Can Be Complicated Nurse Provider Supervisor I learned in nursing school back in 1968 Family Every time mother [Does X] she needs antibiotics

Case #1 Mrs. Jenkins, a 79 year old with stroke, incontinence Wet incontinence pad has odor No complaints Normal vital signs What would you do and why?

Is This Evidence Based Practice?

What Causes Changes in Urine Color or Odor? Diet Medications Dehydration Bacteria in urine If person is not sick, it s asymptomatic bacteriuria

Is Cloudy or Smelly Urine a Reason To Give Antibiotics? Percent 90 80 70 60 50 40 30 20 10 0 Nurses Geriatricians Yes No Geriatr Nurs. 2005 Jul Aug;26(4):245 51.

What should you do for Mrs. Jenkins? Should you get a urine culture just in case?

Ordering a Urine Culture: A Gateway to Overprescribing? results of 254 randomly sampled cultures from 31 nursing homes Antibiotic Prescribing Decision when the Culture was Ordered Culture Result Prescribing Decision when the Result was Reported Received Full Antibiotic Course No antibiotic 179 cases (70%) Neg = 68 Pos = 111 17 (25%) were prescribed antibiotic 99 (89%) were prescribed antibiotic 17 99 Antibiotic 75 cases (30)% Neg = 21 Pos = 54 2 (10%) stopped and 19 (90%) continued or changed antibiotic 0 (0%) stopped and 54 (100%) continued or changed antibiotic 19 54 Bottom Line: 189 (74%) received a course of antibiotics, although 86% had a temperature less than 99 o F, 74% lacked documentation of any urinary tract specific signs or symptoms, and only 18% met the modified McGeer criteria for urinary tract infection. Why?

What Happened? Positive cultures were overtreated Negative cultures were ignored Most common reason cultures were ordered was mental status change, which is rarely due to urine infection Interestingly..The two sepsis cases that arose during 7 days post culture in these 254 patients were from non urinary sources and had negative urine cultures

Case #2: Two Different People Mrs. White 84 year old with arthritis and moderate dementia Uncooperative with dressing Irritable Eats half of breakfast Says she s tired

Case #2: Two Different People Ms. Blue 34 year old nurse Divorced, alone this weekend You were going to have lunch with her, but she cancels Low energy; not hungry Doesn t want to get dressed Doesn t want to deal with people

Both Have Similar Nonspecific Symptoms * Ms. White 84 year old with arthritis and moderate dementia Uncooperative with dressing Irritable Eats half of breakfast Says she s tired Ms. Blue 34 year old Divorced, alone this weekend Low energy ; not hungry Doesn t want to deal with people Doesn t want to get dressed * Nonspecific Symptoms don t relate to any particular body part or body system

What You Might Say to Your Friend Ms. Blue Coming down with a virus? Too much to drink last night? Didn t sleep well? Pain? Stress? Depression?

What the Nursing Supervisor Says About Ms. White Probably the urine. Needs an antibiotic. Turning to antibiotics as a knee jerk reaction. 38

Jumping to conclusions In nursing homes One of the biggest causes of unnecessary antibiotic use In medical decisionmaking the most common reason for medical errors What else could be causing Ms. White s fatigue, irritability, and poor appetite?

The Big Seven: Common Reasons for Nonspecific Symptoms Dehydration Medication side effect Coming down with a virus Didn t sleep well Pain Constipation Stress / anxiety / depression

Active Interventions for Non Specific Symptoms Assess hydration status (and encourage fluids) Review current medications Look for signs of a respiratory or GI virus Think about sleep problems Ask about pain / discomfort Ask about constipation Look for sources of stress, anxiety or depression Monitor symptoms and vital signs (especially temperature) Use nursing interventions where appropriate

Case #3 Mr. Leonard, 76 year old nonsmoker 5 days of nasal congestion, sore throat and sneezing Hacking cough worse at night Decreased appetite, more tired Temp 99.4, other vitals normal, pulse ox 97% Placed on antibiotics

Research Result: Cough Alone Increases 3x the likelihood of a NH Patient Getting Antibiotics Question: Is cough alone a reason to give antibiotics? Why or why not?

Common Respiratory Infections Infection Type Common Cause Common Symptoms Common Cold Virus Nasal congestion/sneezing Sore throat Dry cough +/ fever Acute bronchitis Virus Cough (+/ sputum) +/ Fever Distinguishing Features Nasal symptoms Normal vitals (+/ fever) Unchanged lung exam Normal chest X ray Normal vitals (+/ fever) Pneumonia Bacteria or Virus Cough (+ sputum) Pleuritic chest pain Fever Abnormal vital signs Abnormal lung exam Infiltrate on chest X ray Mental status changes Influenza like illness Virus Sore throat Dry cough Fever Chills Body aches Malaise COPD exacerbation Virus or bacterial Cough (+/ sputum) +/ Fever Normal chest X ray Normal vitals (+/ fever)

Case 4 Does this need antibiotics? One week later

Case 5 Does this need antibiotics? Two weeks later

Emergency Departments and Hospitals: Big Risk, Hard to Control Over Half of C Diff Infections in NHs Occur within a Month Post Hospital Discharge Source: Pawar et al, ICDHE 2012; 33:1107 12

Which Antibiotics Pose the Highest Risk of Clostridium difficile? Wenisch et al. Antimicrob Ag Chemother 2014; 58(9): 5079 83

Reducing Antibiotic Overuse Works: Impact of fluoroquinolone restriction on rates of C. difficile infection in a Community Hospital 2.5 HO-CDAD cases/1,000 pd 2 1.5 1 0.5 0 2005 2006 2007 Month and Year Infect Control Hosp Epidemiol. 2009 Mar;30(3):264-72.

Options Available to Reduce C Diff Post Hospitalization 1. Try to Reduce Antibiotic Burden Re evaluate need for antibiotics in the first place Re evaluate duration of antibiotic treatment Re evaluate choice of antibiotic 2. Probiotics Cochrane review (2013): moderate quality evidence suggests that probiotics are both safe and effective for preventing Clostridium difficileassociated diarrhea Source: Goldenberg, et al. Cochrane Database Syst Rev. 2013 May 31;5:CD006095.

Empirically Chosen Antibiotics for UTI are Often Ineffective (except at promoting resistance) - Data from 75 prescriptions and 1,580 positive cultures in 31 NHs - Antibiotic Prescribed Empirically (% of the time) Percent Resistant (% of isolates) Escherichia Coli (44%) Proteus (13%) Klebsiella pneumoniae (13%) Ciprofloxacin (26%) 57% 69% 11% TMP SMX (16%) 42% 45% 14% Nitrofurantoin (12%) 4% 98% 23% Ceftriaxone (11%) 17% 7% 11% Levofloxacin (7%) 58% 63% 8%

Recommended Duration of Antibiotic Therapy (non hospitalized patients) Type of infection Simple UTI (cystitis) COPD exacerbation Pneumonia without sepsis Cellulitis (lower extremity) Sanford Guide, 2015 ID Society David Weber 3 days 1 3 days 1 3 days 3 10 days 2 3 5 days Until afebrile for 3d >5 days 4 >5 days 10 days 3 5 days 5 7 days Actual NH Practice 1 TMP SMX 3 days; Nitrofurantoin 5 days; 2 Varies with drug, No therapy required in most cases; 3 Not diabetic; 4 Minimum 5 days (should be afebrile 48 72 hours); non ambulatory treat as HCAP; assess using score for severity

Recommended Duration of Antibiotic Therapy (non hospitalized patients) Type of infection Simple UTI (cystitis) COPD exacerbation Pneumonia without sepsis Cellulitis (lower extremity) Sanford Guide, 2015 ID Society David Weber Actual NH Practice 3 days 1 3 days 1 3 days 7.5 days 3 10 days 2 3 5 days Until afebrile for 3d >5 days 4 >5 days 7.8 days 10 days 3 5 days 5 7 days 9.6 days 1 TMP SMX 3 days; Nitrofurantoin 5 days; 2 Varies with drug, No therapy required in most cases; 3 Not diabetic; 4 Minimum 5 days (should be afebrile 48 72 hours); non ambulatory treat as HCAP; assess using score for severity

Summary: Situations Leading to Antibiotic Overuse 1. Urine appearance and odor 2. Urine test results 3. Nonspecific symptoms 4. Cough 5. Wounds 6. Red and swollen legs 7. Emergency departments and hospitals 8. Empirical antibiotic choice 9. Antibiotic treatment too long

Antibiotic Stewardship Works.sometimes

USING DATA TO MOTIVATE OR REINFORCE CHANGE Antibiotic Use Jan Apr 2015, by NH 12 Average # Antibiotic Prescriptions Per Resident in One Year 11 10 9 8 7 6 5 4 3 2 1 0 E J H G R D T F Y Q W V CC EE Nursing Home Jan Apr 2015

Change in Antibiotic Use 15 16, by NH 12 11 10 9 8 7 6 5 4 3 2 1 Jan Apr 2015 Jan Apr 2016 E J H G R D T F Y Q W V CC EE 0 Average # Antibiotic Prescriptions Per Resident in One Year Nursing Home

How to Develop an Antibiotic Stewardship Program in Your Nursing Home

#1: Commit Leadership / Create Team Agree to incorporate antibiotic stewardship into facility Quality Assurance and Performance Improvement goals, monitoring, and reporting Identify an infection preventionist (a.k.a. infection control nurse or infection specialist) and provide time Set up an antibiotic stewardship leadership team Communicate expectations to medical and nursing staff

Create an Antibiotic Stewardship Team and Make them Accountable Medical Director Director of Nursing Infection Preventionist Consultant Pharmacist Laboratory ID Consultant

#2: Gather and Report Data Core Outcomes Selected Process Measures Antibiotic prescriptions / 1,000 resident days Percent of time on antibiotics C difficile infection rate Urine cultures: multidrug resistance rate Rate of hospitalization for sepsis Rate of fever among persons who had antibiotics initiated in the nursing home, by infection site Proportion of prescriptions that are high C diff risk antibiotics, by infection site Urine cultures per 1,000 resident days

UNC Antibiotic Stewardship Start- Up Package Infection Tracking Excel Spreadsheets

UNC Antibiotic Stewardship Start- Up Package Antibiotic Prescribing Portion of Infection Tracking Spreadsheets

UNC Antibiotic Stewardship Start- Up Package Infection Tracking Excel Spreadsheets

UNC Antibiotic Stewardship Start- Up Package Infection Tracking Excel Spreadsheets

UNC Antibiotic Stewardship Start- Up Package Infection Tracking Excel Spreadsheets

#3: Educate Everyone Involved in Decision Making Nurses Providers Supervisors Residents and Family

UNC Antibiotic Stewardship Start- Up Package Implementation Manual A step by step guide explaining how to incorporate our materials into a program that will improve outcomes

UNC Antibiotic Stewardship Start- Up Package Training for Nursing Staff One hour in service DVD Pocket cards with key guidelines

UNC Antibiotic Stewardship Start- Up Package Posters to Provide Periodic Reminders to Staff

UNC Antibiotic Stewardship Start- Up Package Training for Medical Staff CD ROM of case discussions by university experts Pocket cards with key guidelines

UNC Antibiotic Stewardship Start- Up Package Educational Materials for Residents / Families Brochure entitled Why Not Antibiotics Website has 5 minute video

UNC Antibiotic Stewardship Start- Up Package Training DVD for Emergency Department Staff Multidisciplinary case discussions from UNC faculty on emergency department management of nursing home residents

Free and Modestly Priced Resources on the Web nursinghomeinfections.unc.edu

#4: Set Goals and Establish Policies Timetable for implementing program Data reporting Education Quality improvement reports? Involvement in collaborative Initial targets

Establishing Policies and Procedures Some say to do this first However, reviewing data and setting facility priorities may be better to do first Best policies and procedures are endorsed by facility staff and updated regularly AMDA will soon publish a report with sample policies and procedures for antibiotic stewardship

Evidence Based Strategies That Work Communication guidelines for nursing staff around suspected infections SBAR; protocols(e.g, asking for photos of skin problems) Publicizing antibiotic use statistics (QAPI) Antibiotic initiation protocols Antibiotic duration guidelines Antibiotic time out Protocol for ordering of urine cultures Protocol for management of urine culture results CRITICAL ROLE OF LEADERSHIP CANNOT BE OVEREMPHASIZED

Resources

https://nursinghomeinfections.unc.edu/