antibiotic stewardship in the long term care setting › wp-content › uploads › 2016 › 04 ›...
TRANSCRIPT
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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LouieTJetal.NEnglJMed2011;364:422-431.
Fidaxomycin Vs. Vancomycin
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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
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Questions?
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