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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.

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Strategies for an effective program

• Preauthorization

• Syndrome specific interventions

• Rapid diagnostic testing

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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

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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

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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

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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

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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

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URINARY TRACT INFECTIONS

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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

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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

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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

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* 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

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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

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*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

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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.

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MANAGEMENT OF UTI

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Is it Cellulitis?

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Purulent and Non purulent Cellulitis

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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

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C. DIFFICILE INFECTIONS

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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

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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?

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