Antibiotic Stewardship in the Long Term Care Setting › wp-content › uploads › 2016 › 04 ›...

1

Antibiotic Stewardshipin the

Long Term Care SettingLisa Venditti, R.Ph., FASCP ,

Founder and CEO Long Term Solutions Inc.

845.208.3328LTSRX.com

Resistant Bacteria Crisis

• The Centers for Medicare & Medicaid Services (CMS) proposed a rule requiring all long term care facilities to establish an antibiotic stewardship program, including antibiotic use protocols and antibiotic monitoring

• The CDC charged pharmaceutical companies with inventing 10 new antibiotics by 2020 in an effort to get ahead of the crisis.

2

Strategies for an effective program

• Preauthorization

• Syndrome specific interventions

• Rapid diagnostic testing

3

Antimicrobial Use in Nursing Homes

• Primary indications for antibiotics:– Urinary tract infections– Respiratory tract infections– Skin and soft tissue infections

Fluoroquinolone ( Levaquin, Avelox, Cipro) use is common

25% to 75% of antibiotic use deemed inappropriate

Nicolle LE, et al; ICHE 2000 21:537-45 Van Buul LW, et al; JAMDA 2012;

13: 568.e1-568e13 Benoit et al. JAGS 2008; 56: 2039-2044

4

Some Common Situations Where Antibiotics are Used and Rarely Necessary

1. Positive urine culture in asymptomatic resident2. U/A and culture for cloudy or malodorous urine3. Non specific symptoms not referable to the

urinary tract4. Suspected or proven influenza with no

secondary infection5. Skin wound without cellulitis, sepsis,

osteomyelitis

5

Challenges in Clinical Decision to Initiate Antibiotics in the Nursing Home

• Family pressure

• Medical staff not available to perform an evaluation of the resident

• Low nurse to patient ratio and poor communication and assessment skills

• Diagnostic tests less readily available

• Colonization is common

6

Overuse of Antibiotics

Adverse drug effects:

• Antibiotic related side effects

• Interaction with other drugs

Antibiotic Resistance:

• Increase opportunities for transmission to other patients

C. difficile infections• Older adults are at higher risk of infections

7

SHEA and JAMDA Guidelines

• Minimum Criteria for Initiation of Antibiotics

• Algorithms for Treatment of Common Infections in LTCF

• Surveillance Definitions of Infections for Nursing Homes

• Full Guidelines available free on www.idsociety.org and www.shea-online.org

8

URINARY TRACT INFECTIONS

9

Urinary Tract Infections in Nursing Homes

• Most common indication for antibiotic use

• Accounts for 32-66% of prescriptions

• UTI is most common condition associated with inappropriate treatment secondary to asymptomatic bacteriuria

10

Asymptomatic Bacteriuria is CommonPrevalence

Women less than 60 years 3-5%

Elderly in Community SettingWomenMen

Elderly in Nursing HomesWomenMen

11-16%15-40%

25-50%14-40%

Patients with Indwelling Catheters 100%

11Nicolle LE, Clinical Infectious Diseases 2005;40(5): 643–54

UTI versus Asymptomatic Bacteriuria

Urinary Symptoms

Bacteria in Urine

Yes

UTI

NO

Asymptomatic Bacteriuria

12

Specific Urinary Tract Symptoms

Symptoms

• Dysuria

• Urgency

• Flank Pain

• Incontinence

• Frequency

• Hematuria

• Suprapubic Pain

NOT Symptoms

• New Onset Delirium*

• Mental Status Changes*

• Acting Funny

• Weakness

• Fatigue

• Decrease oral intake

• Falls/gait disturbances

• Foul Smelling /Cloudy Urine

13

* For residents without indwelling catheter

What to do in resident with Advanced Dementia?

A patient with advanced dementia may be unable

to report urinary symptoms, in this situation, it is

reasonable to obtain a urine culture if there are

signs of systemic infection such as fever, (increase

in temperature≥ 2o F from baseline), leukocytosis,

or chills, in the absence of additional symptoms

(e.g. new cough) to suggest an alternative source of infection

14

When to Treat UTI Microbiologic criteria Symptom criteria

No indwelling catheter

Positive urinalysis (WBC≥ 10/HPF)

and

Positive urine culture¥

(≥105 cfu/mL in voided

specimen ≥ 102 cfu/ml if in and out cath)

Acute dysuria

--OR--

Fever* + at least 1 of following (new or worsening):*

If no fever, 2 of the following (new or worsening)

•Urinary urgency

•Frequency

•Suprapubic pain

•Gross hematuria

•Urinary incontinence

Indwelling catheter

Positive urinalysis (WBC≥ 10/HPF)

and

Positive urine culture (≥103

cfu/mL)

At least 1 of the following (new or worsening):

•Fever*

•Rigors (shaking chills)

•Delirium

•Flank pain (back, side pain)

•pelvic discomfort

•Acute hematuria

15

*Fever: A single oral temperature 100o F(37.8oC); or repeated oral t ≥ 99oF (37.2oC); or Persistent rectal t

≥ 99.5oF (37.5oC); or an increase in t of > 2o F (1.1oC) over the baseline temperature Loeb M. BMJ 2005;331:669

How to set up an Antibiotic Stewardship Program

• Review the Core Elements of Antibiotic Stewardship from CDC

• Infection Control Committee members include clinical pharmacist and lab

• Antibiograms analyzed : See AHRQ Website

• Protocols on treating common infections developed

16

Antibiogram

• Antibiograms aggregate information about susceptibility patterns of organisms to commonly prescribed antibiotics.

• Antibiograms display the organisms present in clinical specimens for laboratory testing as well as the susceptibility of each organism to an array of antibiotics.

• Antibiograms are routinely prepared by hospital laboratories, over a period of months or years, but antibiograms are not routine in the nursing home setting.

17

MANAGEMENT OF UTI

18

UTI definitions

• Uncomplicated UTI – infection in a structurally/functionally normal urinary tract. Includes women post menopausal and with controlled diabetes

• Complicated UTI – patients with a structural or functional abnormality of the urinary tract. Includes men and any patient with structural urinary abnormalities

• Lower UTI – UTI without involvement of the kidneys (whether complicated or uncomplicated)

• Upper UTI/pyelonephritis – infection of the kidney

19

Cystitis/Lower UTI (Complicated or Uncomplicated)Agent Notes

1st line

Nitrofurantoin

•Most active agent against E.

coli

•Avoid if CrCl < 30 mL/min

•Avoid if systemic signs of

infection/suspicion of

•pyelonephritis or prostatitis

•Does not cover Proteus

TMP-SMX

•Drug-drug interactions with

warfarin

•Monitor potassium level if

concomitant use of

•spironolactone, angiotensin-

converting enzyme inhibitors

(ACEIs), angiotensin receptor

blockers (ARBs)

•Renal dose adjustments,

avoid if CrCl < 15 mL/min

2nd line Cephalexin • Active against E. coli,

Proteus, and Klebsiella20

21

Pyelonephritis/ Upper UTI

Agent Notes

1st line TMP-SMX

• Patient should receive 1

dose of IV/IM ceftriaxone

prior to starting oral therapy

2nd line Ciprofloxacin • If patient unable to tolerate

TMP/SMX

3rd line Beta-lactams

•Data suggests that oral

beta- lactams are inferior to

TMP/SMX or

fluoroquinolones for

pyelonephritis

•Initial dose of IV/IM

ceftriaxone and longer

treatment duration of 10-14

days are recommended

22

Severely ill patients (high fever, shaking chills, hypotension, etc.)

Agent Notes

1st line Ceftriaxone

• Can be used safely in

patients with mild penicillin

allergy (i.e. rash), cross-

reactivity very low

2nd line Gentamicin

•ONLY in patients who need

parenteral therapy and have

severe IgE mediated

penicillin allergy

•Significant

nephrotoxicity/ototoxicity

concerns

UTI Treatment DurationUTI Location Agent Duration

Uncomplicated UTI TMP/SMXQuinolones

3 days

Complicated UTI Any Agent 5 days

Pyelonephritis QuinolonesTMP/SMXB-Lactams

5-7 days10-14 days

Catheter Related UTI 7 days if rapid improvement10-14 days if delayed response

23

Hooten, TM, et al. Clinical Infectious Diseases 2010; 50:625–663 Gupta et al. Clinical Infectious Diseases 2011;52(5):e103–e120 Grigoryan L, et al. JAMA 2014;312(16):1677-1684Schaeffer AJ, et al. N Engl J Med 2016;374:562-71 Mody, L, et al JAMA. 2014;311(8):844-854

RESPIRATORY INFECTIONS

24

Respiratory Tract InfectionsSigns and symptoms Antibiotics

Upper Respiratory Tract infection (URTI)

Runny nose

Sore throat

cervical lymphadenopathy Dry

cough

X

Influenza like illness Fever with increased cough,

headache, myalgia, sore throat X

Bronchitis No COPD New or worsening cough Sputum production X

COPD exacerbation New or worsening cough and

sputum production ✔

Pneumonia (bacterial)

New or worsening cough,

sputum production, shortness

of breath pleuritic chest pain,

HR > 125/min

RR> 24/min, fever, O2

saturation <94% and + CXR

✔25

Nursing Home Pneumonia

CommunityAcquired PNA

HealthcareAssociated

PNA

NursingHome

Associated PNA

26

Healthcare Associated Pneumonia (HCAP)

HCAP: is defined as pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following: • Intravenous therapy, wound care, or intravenous

chemotherapy within the prior 30 days • Residence in a nursing home or other long-term

care facility • Hospitalization in an acute care hospital for two

or more days within the prior 90 days • Attendance at a hospital or hemodialysis clinic

within the prior 30 days

27

Suggested Pneumonia TreatmentAgents Dosing

1st line

Mild Azithromycin or 500mg PO for 3 days

Doxycycline 100mg PO twice a day x 7d

Moderate

Amoxicillin 1 gm PO 3 times a day x 7d

Cefuroxime 500mg PO twice daily x 7 d

Cefpodoxime 200mg or 400mg PO BID x 7d

Amoxicillin/Clavulanate 2 gm twice daily x 7d

Moderate to severe Ceftriaxone

1gm IM q day (switch to oral

when improved, afebrile, can

take oral meds)

2nd line Levofloxacin 500- 750mg PO Q24H x 7d

Moxifloxacin 400mg PO Q24H x 7d

28Mandel L, et al. IDSA/ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults.Clinical Infectious Diseases 2007; 44:S27–72

Skin and Soft Tissue Infections

29

Suspected Skin and Soft Tissue Infections

• New or increasing purulent drainage at a wound, skin, or soft-tissue site

or

• Fever (100oF] or a 2.4oF increase above baseline temperature)

• RednessTendernessWarmthNew or increasing swelling

30

Colonization Versus Infection

• Colonization: When an organism lives on your skin but not causing disease

• • Infection: When the organisms on your skin invade though a break in your skin, multiply and cause disease

31

Is it Cellulitis?

32

Purulent and Non purulent Cellulitis

33

34

Treatment for CellulitisDrug Regimen Indication

Amoxicillin

500mg PO TID

Dose Adjustment:

CrCl 10-30 = 500mg BID CrCl <10 = 500mg Q Day

Use for Strep Infections

Dicloxacillin 500mg PO q6h

Dose Adjustment:

None

Good for Strep or MSSA

Cephalexin

500mg PO q6h

Dose Adjustment:

CrCl 10-50 = 500mg q8-12h CrCl <10 = 250mg – 500mg q12-24h

Can use to treat Strep or MSSA

TMX/SMZ

1-2 DS tab PO BID

Dose Adjustment:

CrCl 15-30 = 50% of dose CrCl <15 = do not use

Use for MRSA (if susceptible) Not a

good option for Strep infections!

Clindamycin 450mg PO TID

Use for Strep or MRSA

(some strep resistant) Caution: High

risk of C. Diff. Only use if not other options available

35

36

C. DIFFICILE INFECTIONS

37

51%

23%

26%

Developed CDI

during

hospitalization

Developed CDI without recent healthcare exposure

95% received antibiotics

Developed CDI within 30 days post discharge from the

hospital68% were in sub-acute care

80% received antibiotics during hospitalization

58% were still receiving antibiotics at the time of transfer

JAGS 61:122–125, 2013

Antibiotics C. difficile Infection Risk

Frequent associated • Fluoroquinolones• Clindamycin • Cephalosporins (broad spectrum) • PenicillinsOccasionally associated • macrolides • TMP/SMZ Rarely associated • Aminoglycosies• Tetracylines• Metronidazole • Vancomycin

39

Treatment for C. difficile InfectionsInitial Episode

Mild disease Metronidazole 500 mg 3 times daily or 250 mg 4

times daily

Moderate Disease Vancomycin 125 mg 4 times daily

Severe Disease Hospitalization

First relapse As initial or fidaxomicin 200 mg twice daily

Second relapse Vancomycin taper over 6 weeks

Or fidaxomicin 200 mg twice daily

Subsequent relapse fidaxomicin 200 mg twice daily

Fecal microbiota transplant

ModifiedfromLefflerDA,LamontJT.NEnglJMed2015;372:1539-1548.

LouieTJetal.NEnglJMed2011;364:422-431.

Fidaxomycin Vs. Vancomycin

Probiotics

• Many strains and combinations exist

• Initial studies evaluating the use of probiotics for control of

antibiotic-associated diarrhea were underpowered for the

detection of protection against C. difficile infection.

• More recent studies have shown mixed results

• At present, probiotics have an uncertain effect on the

prevention of C. difficile infection

Questions?

43