Nursing Track LectureHow To Influence Your Physicians To

Prescribe Antibiotics Wisely

Michael J. Burns, MD FACEP FACP FIDSA

Professor

Emergency Medicine & Infectious Diseases

UC Irvine Medical Center

University of California Irvine School of Medicine

Learning Objectives

• Recognize that improving antibiotic use is a public health imperative

• Describe the role nurses can play in improving antibiotic use

• Recognize that your hospital should be providing nurses with education in antimicrobial stewardship

• Demonstrate that using antibiotics wisely in the ED can minimize harm and optimize clinical outcomes

• Explain how listing of incorrect antibiotic allergies, especially penicillin, in the electronic health record, is dangerous

Improving antibiotic use is a public health imperative

• Antibiotics are the only drugs where use in one patient can impact the effectiveness in another

• If everyone does not use antibiotics well, we will all suffer the consequences

• The need to improve antibiotic use is fundamentally a patient safety issue

• The overuse and misuse of antibiotics not only have implications for the individual patient, but also for population and societal health

Improving antibiotic use is a public health imperative

• Antibiotics are a shared resource, (and becoming a scarce resource)

• Using antibiotics properly is analogous to developing and maintaining good roads

Why we need to improve ED and in-patient antibiotic use

• Antibiotics are misused in hospitals• Antibiotic misuse adversely impacts

patients and society• Improving antibiotic use improves patient

outcomes and saves money• Improving antibiotic use is a public health

imperative

Antibiotics are misused in hospitals

• “It has been recognized for several decades that up to 50% of antimicrobial use is inappropriate”• IDSA/SHEA Guidelines for Antimicrobial

Stewardship Programs• http://www.journals.uchicago.edu/doi/pdf/10.1

086/510393

Antibiotics are misused in a variety of ways

• Given when they are not needed• Continued when they are no longer

necessary• Given at the wrong dose• Broad spectrum agents are used to treat

very susceptible bacteria• The wrong antibiotic is given to treat an

infection

The Rise of Antimicrobial Resistance

• MRSA (methicillin-resistant Staph aureus)

• Fluoroquinolone-resistance

• Multi-drug resistant Pseudomonas

• ESBL (extended spectrum beta-lactamase)-producing organisms: resistant to all 3rd generation cephalosporins

• CRE (carbapenemase-producing Enterobacteriaciae)

• Acinetobacter

• Fluconazole-resistant Candida species

• Ceftriaxone-resistant gonorrhea

• Cipro-resistant Salmonella, Shigella, & Campylobacter

• Macrolide- and clindamycin-resistant streptococci

• The newest one: E. coli with the mcr-1 gene: resistant to colistin and polymyxin

Resistant bacteria spread rapidly throughout the world

Bacteria possessing the New Delhi metallo-beta-lactamase-1 gene, coding for carbapenem resistance, originally found in India in 2008, were recently detected in bacteria in the Svalbard Islands of Norway

Adverse Effects of AntibioticsC. difficile colitis

Adverse effects of antibiotics

Achilles tendon rupture from

fluoroquinolone

Fluoroquinolone Adverse Effects

• Hypoglycemic coma and hyperglycemia, even in non-diabetics

• Psychiatric/CNS effects, including agitation, delirium, disorientation, seizures, memory impairment, tremor, dizziness, insomnia, hallucinations, suicidal ideation

• Ruptured aortic aneurysm; aortic dissection

• Tendinitis and tendon rupture: especially the Achilles tendon

• Peripheral neuropathy

• C. difficile and multiple drug resistant organisms

• Many others: : retinal detachment, vasculitis, arthralgias and myalgias which can last for weeks after drug cessation, anemia, neutropenia, thrombocytopenia, QTc prolongation, severe allergic reactions including Stevens-Johnson syndrome.

Toxic Epidermal Necrolysis from a 2-week course of TMP-SMX prescribed for “sinusitis”

Erythema multiforme major(Stevens Johnson syndrome)

from levofloxacin prescribed for “bronchitis” in an asthmatic

Antimicrobials: It’s a Balancing Act

What is the Nurse’s Role in Hospital Antibiotic Stewardship Practices?

• American Nurses Association White Paper: Redefining the Antibiotic Stewardship Team, Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurses in Hospital Antimicrobial Stewardship Practices, 2017

Nurses are essentially unacquainted with the phrase “antimicrobial stewardship”

• In a consensus statement from the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society, antibiotic stewardship has been defined as:

“coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal antibiotic drug regimen, including dosing, duration of therapy, and route of administration.”

Inappropriate Antibiotic Prescribing

• Antibiotic prescribing in U.S. acute care hospitals is common and often unwarranted

• As many as half of hospitalized patients receive at least one antibiotic and in up to 50 percent of these patients, antibiotics are unnecessary or inappropriate

• Such antibiotic misuse contributes not only to adverse drug reactions, like C. difficile, but to the emergence of antibiotic-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE).

Engaging Nurses in Improving Antibiotic Use

• The CDC core elements call for a multidisciplinary approach to improving antibiotic use

• As of January 2017, The Joint Commission is requiring hospital antimicrobial stewardship programs to demonstrate inter-professional engagement to address core performance elements and expand antibiotic stewardship reach

• Both CDC and The Joint Commission specifically highlight the need to engage nurses as part of this multidisciplinary effort

Some specific suggestions for nursing education in antimicrobial stewardship

include

• Microbiology – How specimens for microbiology testing should be

obtained

– How to interpret microbiology test results, especially susceptibility reports

– How to interpret the hospital’s antibiogram

– Basics of distinguishing asymptomatic bacteriuria from urinary tract infection and colonization from active infection

Some specific suggestions for nursing education in antimicrobial stewardship

include • Pharmacology

– Consideration for IV-to-PO conversions: what antibiotics and patients are good candidates

– General information on antimicrobial spectra for various classes of antibiotics

– Antibiotic interactions and incompatibilities

– Common adverse reactions to antibiotics, with special emphasis on responding to suspected C. difficile infections

– Information on therapeutic drug monitoring

– How to assess a patient for a potential allergy to penicillin

What education and training resources are needed to help nurses perform these roles?

• Microbiology education and training on how to both obtain cultures and interpret the results

• Education about infection versus colonization

• Assertiveness training to engage in discussions with the health care team

• Information on IV-to-PO switch criteria

• Training on taking an allergy history

What can we do to engage nursing leaders in stewardship efforts?

• Highlight the fact that nursing involvement in antibiotic stewardship is required by The Joint Commission.

• Make hospital leadership aware that the Centers for Medicare and Medicaid Services has proposed making Antimicrobial Stewardship Programs a Condition of Participation for acute care hospitals.

• Emphasize antibiotic stewardship as a key component of patient safety.

• Highlight the benefits of good antibiotic stewardship on nursing workload. For example, better IV- to-PO conversion will reduce time spent on medication administration.

• Add measures related to antibiotic use, like C. difficile infection, to Magnet Recognition Program criteria.

How can we engage nurses more and encourage them to participate in

antimicrobial stewardship programs?

• At the national level: – Explore avenues to have nurse engagement in ASPs included in

American Nurses Credentialing Center (ANCC) Magnet Recognition Program® criteria.

– Use The Joint Commission’s Medication Management standard and proposed Centers for Medicare and Medicaid Services Condition(s) of Participation on antimicrobial stewardship to guide nurse- relevant antibiotic stewardship tools and products.

• Bring stewardship issues to national stakeholder meetings.

• Add stewardship content to priorities for publication in nursing journals

How can we engage nurses more and encourage them to participate in

antimicrobial stewardship programs?• At the hospital level:

– Provide antibiotic stewardship education for bedside nurses. This could be provided by nurses already engaged in stewardship activities, infectious disease physicians, pharmacists, infection preventionists, or microbiologists.

– Include nurses in stewardship rounds. – Participate in journal clubs. – Develop specific content and messages for nurses as

part of any hospital effort to raise awareness about antibiotic use and resistance.

– Encourage nurse antibiotic stewardship champions at the unit level

Penicillin Allergy• The penicillins and cephalosporins are the treatment

of choice for most bacterial infections

• Use of alternative antibiotics often results in suboptimal treatment, more adverse effects, and contribute to antimicrobial resistance, and are associated with increase costs, more adverse effects and more drug reactions

• Patients who are labeled as allergic to penicillin may be given broad-spectrum antimicrobial agents that increase the risk of developing C. difficile infection, MRSA, VRE, and multiple drug resistant organisms

Penicillin allergy

• Only 2% of patients labeled as having penicillin allergy actually have a true allergy

• The most commonly reported penicillin hypersensitivity reaction is a delayed benign maculopapular rash, usually caused by a type IV hypersensitivity reaction. This type of reaction is not associated with anaphylaxis and may not recur with reexposure to penicillins.

• IgE mediated penicillin allergy wanes over time with 80% of patients becoming tolerant after 10 years

Penicillin Allergy

• Patients reporting penicillin allergy should be referred to an allergist for penicillin skin testing, but RN’s, NP’s, PA’s, pharmacists, and non-allergist physicians can be trained to safely perform penicillin skin testing using protocols developed by allergists.

Amoxicillin Challenge Test

• Amoxicillin challenge test: 250 mg PO and observe for one hour. Do not use another penicillin for the test.

• If no reaction one hour after amoxicillin, then all beta-lactams can be administered without any risk of an allergic reaction.

Penicillin Allergy

• If an amoxicillin challenge is tolerated (with or without penicillin skin testing), the medical record notation that a patient is allergic to penicillin should be deleted, as the chance of an IgE-mediated reaction is zero.

• EHR allergy modules: When penicillin is tolerated in a patient with a history of penicillin allergy, the active penicillin allergy should be deleted from the EHR. If there has been a reaction and the allergy cannot be deleted, then qualifying comments should be added. Examples: “penicillin skin test positive,” or “tolerates cephalexin” or “tolerates ceftriaxone.”

Antimicrobial StewardshipAvoid Unnecessary Antibiotic Use

• Antibiotics are over-prescribed in the ED for

– Bronchitis, URI’s, sinusitis

– Asymptomatic pyuria/bacteriuria

– Even when indicated, the duration of treatment is often too long

• ED-specific guidelines for antibiotic use should be adapted for your specific ED or your region, based on local antibiotic susceptibility patterns and your hospital’s formulary

Antimicrobial Stewardship

• Clinical decision support systems for ED antibiotic use can be integrated into an EMR antibiotic ordering system

• When an antibiotic is prescribed in the ED for a discharged patient, close telephone contact, or other method of contact, should be done to assure that patient is on the correct antibiotic when antimicrobial susceptibilities are available

The New Antibiotic Mantra“Shorter Is Better”

UCI Antimicrobial Stewardship Initiatives

Urine cultures

• Do not obtain urine for UA or culture from an indwelling Foley catheter

– if need urine, remove the Foley, insert new catheter, then obtain urine for culture

• Do not order urine cultures in the absence of symptoms or signs of urinary tract infection

• Do not treat asymptomatic pyuria and bacteriuria

• Strict use criteria for insertion and removal of Foley catheters

Selected References

• Olans RD: Good nursing is good antibiotic stewardship. American Journal of Nursing 2017; 117: 58.

• American Nurses Association White Paper: Redefining the Antibiotic Stewardship Team, Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurses in Hospital Antimicrobial Stewardship Practices, 2017

Selected References

• Shenoy: Evaluation and management of penicillin allergy, a review. JAMA 2019;32:188. Audio review of the article:https://edhub.ama-assn.org/jn-learning/audio-player/17143729

• Nebraska Medicine Penicillin Allergy Guidance Document 2017: available free at https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/penicillin-allergy-guidance.pdf

• Spellberg B: The new antibiotic mantra – “Shorter is Better”. JAMA Internal Medicine 2016;76:1254

• May L: A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Annals of Emergency Medicine 2013;62:69