Antibiotics in Long Term Care

David Gary Smith, MD, FACP

Abington Memorial Hospital

Audience Response System

• Keypads- must return them

• Real time polling of audience

• Anonymity

Do you really want to hear a talk about antibiotics and LTC?

Yes

- and

als

o driv

e nai

..

No- I

woul

d rath

er li

st..

49%

51%1. Yes- and also

drive nails into my fingers

2. No- I would rather listen to elevator music

What is your profession?

Nurs

e

MD/D

O

Soci

al W

ork

Adm

inis

trato

r

Oth

er c

linic

al

31%

27%

0%

13%

29%

1. Nurse

2. MD/DO

3. Social Work

4. Administrator

5. Other clinical

Goals

• Outline of the antibiotic “problem”

• Guidelines for antibiotic use– address over utilization

• Antibiotics and the “Goals of Care” dilemma

• Existential model for patient centeredness at the bedside

Patterns of Antimicrobial Use in NH Residents with Advanced Dementia• Approximately 1 year of f/u

• 66% (n=142) received at least one course of antimicrobial therapy

• 540 prescribed courses

• 42% (n=42) of decedents received antibiotics within two weeks of their death and 41courses were administered parenterally

D’Agata E, Mithcell S, Arch Int Med 2008;168:357-361

Antibiotic Therapy in the Demented Elderly Population:

Redefining the Ethical Dilemma• Low likelihood of benefit

• Emerging resistance

• Avoidance of “goals of therapy” discussion

• Easier to treat than to raise the “D” word

• Costs

Schaber M, Cormelli Y, Arch Int Med 2008;168:349-350

2 Studies on Benefit of Educational Program on Antibiotic Use in LTCF• Reported frequency of suboptimal

antibiotic use- 25-75%

• Educational interventions reduced errors by approximately 20%

• Post intervention adherence to protocol rates- 40-77%

Scwartz D , et.al. JAGS, 2007;.55:1236-1242Monette J, et.al. JAGS, 2007; 55:1231-1235

Case

• 88 y.o. with indwelling foley and dementia. The clinical attendant calls because the urine is dark and the culture revealed >100,000 colonies E. Coli. She wants to know what antibiotic do you want to use. No allergies. No fever.

What is your opinion?

TM

P/Sulfa

Am

oxaci

llin

Lev

aflo

xaci

n

Tra

nsfer

for I

V antib

i...

No tr

eatm

ent

26%

19%

11%

28%

17%

1. TMP/Sulfa

2. Amoxacillin

3. Levafloxacin

4. Transfer for IV antibiotics

5. No treatment

Minnesota Guidelines

• No indwelling catheter– Acute dysuria or– Fever >38.9 (102 F) and at least one of the following:– Urgency– Frequency– Suprapubic pain– Hematuria– CVA tenderness– New onset urinary incontinence

Minnesota Guidelines

• Indwelling Foley

• Need at least one of the following:

• Fever >38.9 (102)

• New CVA tenderness

• Rigors

• New onset of delirium

Another call from same NH

• 78 yo patient with COPD and has new cough with yellow sputum. Temp is normal. Pulse is 80. Respiratory rate is 15. No delirium, rigors.

What is your opinion?

PO

Lev

oflo

xaci

n

PO

Azit

hrom

ycin

Oth

er P

O a

ntibio

tic

Tra

nsfer

to h

ospita

l fo...

No a

ntibio

tics

needed

30%

16%

9%

16%

28%

1. PO Levofloxacin2. PO Azithromycin3. Other PO

antibiotic4. Transfer to

hospital for IV antibiotics

5. No antibiotics needed

Minnesota Guidelines

• Fever > 38.9 (102 F) and one of the following:– Respiratory Rate>25– Productive cough

• Or• Fever > 37.9 (100 F) and cough and at least one

of the following:– Pulse >100– Delirium– Rigors– Respiratory Rate >25

Minnesota Guidelines

• Or

• COPD history and purulent cough*

• Or

• New infiltrate on chest xray and at least one of the following:– Respiratory rate > 25– Productive cough– Fever > 37.9 (100 F)

Same nurse calls you about another case

• 83 yo with dementia has a fever of 37.9 (100 F) and some aspects of a delirium. You are on call for this patient who is followed by your partner. She has no other focal symptoms or signs. Do you want to start antibiotics?

What is your opinion?

Wat

chfu

l wai

ting

Sen

d her

to th

e hosp

ital

PO

Lev

aflo

xaci

n

Cal

l her

prim

ary

car..

.

28%

15%

32%

26%

1. Watchful waiting

2. Send her to the hospital

3. PO Levafloxacin

4. Call her primary care physician in AM

Minnesota Guidelines

• Fever with unknown focus of infection

• Fever > 37.9 (100 F) and at least one of the following:

• New Delirium

• Rigors

Do you think that antibiotics are over-utilized?

Yes N

o

0%

100%1. Yes

2. No

Do you have protocols in place to guide management?

Yes N

o

0%

100%1. Yes

2. No

Contributors to unnecessary antibiotic use

• Antibiotics are overused in LTCFs? (% agree)– MD 82– Nurse Practitioner 91– Director of Nursing 66– Infection Control 80

• Established protocols– Facilities 31– Providers 16

Gahr P et.al. J Amer Ger Soc 2007;55:471-474

What do you think the most important factor is in this overuse?

Fam

ily p

ress

ure

Nurs

e pre

ssure

Cogni

tive

impai

rmen

t

Lac

k of c

lear

guid

elin

es

Oth

er

28%

20%

7%

22%23%

1. Family pressure

2. Nurse pressure

3. Cognitive impairment

4. Lack of clear guidelines

5. Other

Contributors to unnecessary antibiotic use

• Factors which contribute to unnecessary use of antibiotics– Pressure from nurse- 54-56%– Pressure from family- 21-28%– Resident cognitive impair.- 57-58%

• Need for:– Education for nurses- 62-73%– Education for MDs/NPs- 35-57%– Nursing guidelines- 60-70%

Gahr P et.al. J Amer Ger Soc 2007;55:471-474

Lessons so far…

• We suck (my teenagers classification) at making decisions about antibiotics

• Part of the reason we suck is the lack of clear guidelines, protocols, reminders, systems of accountability….

• We all tend to avoid or butcher the “goals of treatment” discussion– Overestimate benefit of Abs etc.– Avoid the “D” word

Good News

• We can do something about “it”, if we care to do something about it.

• Antibiotic Protocol champion that has stature and power!!!!

"If you want the truth to stand clearbefore you, never be for or against.

The struggle between "for" and against"is the mind's worst disease.

- Sent-Ts'an (aka Seng Tsan) c. 700 C.E.1

Existential Issues

• Talk about a patient who challenged us recently on service.

• The details of the case have been changed to protect the identity of all participants except for me.

• Goals of case– Talk about barriers to genuine patient

centered care– Discuss a way of overcoming those barriers

Case

• 39 y.o. Persistent Vegetative State patient is admitted for her 5th presentation for a suspected pneumonia. She has been at home with her family in this state for 8 months. The family noted a change in her breathing and slight increase in her secretions.

• Subintern (fourth year medical student) on service is sent in to see patient but she is clearly terrified by the assignment. Why?

View from subintern and attending

• How do I approach a patient in a PVS? The family? My feelings of hopelessness? My inability to form a relationship with the patient? How do I determine the goals of care? Can I even see the patient?

• Coping style- pretend that there is no patient as person but just a biological preparation (a petri dish) with bacteria that need antibiotics.

View from subintern and attending

• Additional feelings deal with the resource utilization; distracting the clinicians from someone who really needs our attention; the absurdity of the whole situation.

• These feelings underlie a lot of the ethics consults concerning patient futility received by ethics committees.

• Tension- between a family that demands care and the clinicians who see no purpose in providing that care

How do you feel about caring for such a patient?

Ver

y Sad

Angry

abou

t the

was

t...

No fe

elin

g at a

ll

Oth

er

27%

22%

28%

23%

1. Very Sad

2. Angry about the waste of resources

3. No feeling at all

4. Other

What would you recommend to the family?

IV a

ntibio

tics

With

hold a

ntibio

tics

Pal

liativ

e ca

re c

onsult

Oth

er

0%

100%

0%0%

1. IV antibiotics

2. Withhold antibiotics

3. Palliative care consult

4. Other

Feeling and Impact on Care

• Elkman- “Your face is the mirror of everything inside”

• The family could sense a clinical disdain by the hospital staff in the past toward them for wanting to continue care

Do you think you can “fake” that you care?

1. Absolutely

2. Definitely not

3. Never thought about it

4. Other

The medical student and I walked through the ER curtain and beheld a scene of great devotion by the husband and the daughterfor the patient that was transformative for us.

This case

• Any prior thought, conceptions, feelings were totally washed away.

• We just stood there and beheld a scene of biblical proportion.

• Our direction was given us from within the scene at the bedside.

An Approach

• Suspension of Values

• Interiorization

• Letting go and the insight will emerge

Senge P, et.al. Presence: An Exploration of Profound Change in People, Organizations and Society. 2004

Generalizability

• Can everyone do this?

• Does it take much time?

• How will it ultimately affect me?

Downside

• None

Patient Centered

• There is no better model out there for a truly patient centered experience!

Summary

• We can certainly do a better job prescribing antibiotics or any other type of treatments for our patients

• We have to embrace this whole area as primarily important especially given all the other very important initiatives that we should embrace

• We have to avoid yielding to the forces within medicine that obliterates all of our humanities