Over-prescribing of antibiotics has become a signifi-

cant problem in nursing homes. A urinary tract in-

fection (UTI) is the most common indication for the

prescribing of antibiotics in long-term care (LTC) set-

tings, and it is the condition most commonly associ-

ated with inappropriate antibiotic use. True cases

of UTI undoubtedly occur with some frequency in

nursing homes, but

there is compelling evi-

dence that UTI’s are

both over-diagnosed

and over-treated in this

setting.

The rise in antibiotic

resistance in LTC facili-

ties threatens to create

what the WHO (World

Health Organization)

has called the post-

antibiotic era, a poten-

tial future in which ex-

isting antimicrobial

therapies fail to treat

common, previously

treatable infections.

Recently, the Centers for Medicare

and Medicaid Services (CMS) have

cited an increasing number of

nursing homes for inappropriate

antibiotic use per the Unnecessary

Drug Surveyor Guidelines (F-Tag

329). Antimicrobial stewardship

is becoming an increasingly im-

portant focus in long-term care

settings. The Notice of Proposed

Rulemaking, Medicare and Medi-

caid Programs: Reform of Require-

ments for Long-Term Care Facili-

ties proposes that facilities must

establish an infection prevention

and control program, which must

include, (among other elements), an antibiotic stew-

ardship program with antibiotic use protocols and a

system to monitor antibiotic use.

By definition, symptomatic UTI requires the pres-

ence of symptoms along with significant bacteriuria.

The symtoms of UTI in community-dwelling older

adults are well defined and include urethritis

(dysuria and hematu-

ria), cystitis (urethritis

with urgency, frequen-

cy, and suprapubic

pain), and pyelonephri-

tis (flank pain, fevers,

and nausea/emesis that

may or may not be pre-

ceded by urethritis/

cystitis).

Currently,

there is no agreement

on an evidenced-based

definition for the symp-

toms of UTI in LTC resi-

dents, but it is impera-

tive to distinguish

symptomatic UTI from

asymptomatic bacteriu-

ria in this population.

Treatment of asymptomatic bacteriuria increases the

rate of adverse drug effects from the use of antimi-

crobial medicines; increases the rate of recurrent

infections with MDR (multiple drug resistant) bacte-

ria; and does not change survival, chronic genitouri-

nary symptoms, or the rate of symptomatic UTI. As a

result, the Infectious Diseases Society of America

(IDSA) does not recommend treatment of asympto-

matic bacteriuria.

The Loeb Criteria are commonly used by clinicians

for making treatment decisions for a suspected UTI

in the long term care setting. These criteria were

written based on evidence from randomized con-

trolled trials, observational studies, and qualitative

studies.

UTI’s in Long Term Care

A Publication of Neil Medical Group, The Leading Pharmacy Provider in the Southeast

July/August 2017

PHARM NOTES

Inside this issue:

UTI’s in Long

Term Care

1

Post Herpetic

Neuralgia

2

Sleep Aid

Alternatives

3

UTI’s in LTC:

conclusion

4-5

Clostridium Dif-

ficile: An Over-

view

6-7

Neil Medical

Group Contact

Information

8

continued on page 4

Volume 20, Issue 4

Post-Herpetic Neuralgia

Page 2

PHARM NOTES

Introduction

Postherpetic neuralgia is the most common chronic complica-

tion of herpes zoster,

also known as shin-

gles. Herpes zoster is

a viral infection caused

by reactivation of the

varicella-zoster virus,

which lies dormant in

sensory nerves after

initial infection, usual-

ly presenting as chick-

enpox in childhood.

The acute phase of

shingles usually begins

with prodromal symp-

toms, including ma-

laise, tingling or abnormal skin sensations, photophobia, and

fever, which may last 1-5 days. After the prodromal phase, a

painful, vesicular rash, develops, typically presenting at the

midline and may spread to the back and face, which crusts

over and heals over 2-4 weeks. Postherpetic neuralgia is pain

that occurs after a shingles outbreak and is due to destruction

of nerves extending from the spinal cord to the skin after the

varicella-zoster virus replicates in the basal ganglia. The dura-

tion of the pain varies greatly among patients, lasting any-

where from a few months to lifelong, but most cases resolve

spontaneously. It can cause extreme suffering and significant-

ly affect a patient's quality of life, as well as increase individu-

al and societal healthcare costs.

Epidemiology

The incidence of herpes zoster ranges from 3.4 -11 cases per

1000 patients, about 1 million cases per year in the U.S.

Postherpetic neuralgia pain has been reported in approximately

one-fifth of those patients three months after onset of symp-

toms and about 15% of patients report pain after two years.

Postherpetic neuralgia may affect up to 40% of patients over

age 50 and 75% of patients over age 75.

Risk Factors

Increased age, especially over age 50

More women are affected than men (60% of women vs.

40% of men)

Severity of prodromal symptoms, pain, and rash during

acute shingles phase

Ophthalmic involvement of herpes zoster

Patients with chronic illness (i.e. diabetes, COPD)

Immunocompromised patients (i.e. patients with HIV, or-

gan transplants)

Use of immunosuppressive medications (i.e. cyclosporine,

mycophenolate, azathioprine)

Signs and Symptoms Pain that may be chronic or paroxysmal

Pain that may be described as burning, stabbing, itching,

or electric shock-like

Types of pain

Dysesthesia: abnormal sensation that occurs with-

out a stimulus

Allodynia: pain that occurs without a non painful

stimulus

Hyperpathia: severe pain that occurs with a slight-

ly painful stimulus

Numbness or loss of sensory function to thermal and me-

chanical stimuli

Diagnosis

Postherpetic neuralgia is diagnosed after performing an exam

with history. It is defined as dermatomal pain persisting for at

least 90 days after the onset of the herpes zoster rash.

Treatment

Tricyclic antidepressants

Amitriptyline, nortriptyline, desipramine

Good evidence for efficacy, but many adverse ef-

fects

Capsaicin 0.075% or capsaicin 8% patch

May cause burning, stinging, and redness

May take up to 4 weeks for pain relief

Higher concentration patches have shown better

efficacy than cream

Good option for mild pain

Lidocaine 5% patches

Some evidence for efficacy

Good option for mild pain

Anticonvulsants

Gabapentin, pregabalin

Off-label use, some evidence for efficacy

May also improve sleep, which is often an issue

Opioid analgesics

Oxycodone, morphine sulfate, tramadol

Controversy over efficacy; adverse effects in-

creased in elderly patients

Should be considered as 3rd line option or in com-

bination with topical agents

Patients receiving treatment for postherpetic neuralgia should

be educated that pain relief may not be immediate and can take

weeks for benefits to be seen. Patients should also be in-

formed that several therapies may need to be tried before find-

ing an agent that works for them.

Prevention

The herpes zoster vaccination (Zostavax) has been shown

to significantly reduce the prevalence of herpes zoster and

therefore postherpetic neuralgia. Postherpetic neuralgia may

also be prevented with the use of antivirals, such as acyclovir,

valacyclovir, and famciclovir, and corticosteroids within 72

hours of initial onset of herpes zoster attack. Initiation of

amitriptyline after initial onset may reduce incidence of pain,

but more studies are needed to evaluate its role in preventing

postherpetic neuralgia. Article by Tami Harty, PharmD Candidate Wingate University School of Pharmacy

Page 3

Volume 20, Issue 4

There are several Popular Supplemental and Non-Pharmacologic Options for Sleep in the Elderly. Below is a sum-

mary of several options and the evidence supporting their use.

MELATONIN

Endogenous hormone involved in regulation of circadian rhythm

Levels may be decreased with benzodiazepine use and advanced age.

Sustained release 2-3mg preparations seem to increase sleep quality and sleep

Immediate release formulations (also 2-3mg) seem to decrease sleep latency.

Generally well tolerated, but reported adverse effects include daytime drowsiness, dizziness, and nausea.

CHAMOMILE TEA

Volatile oils in chamomile are thought to have activity in the central nervous system

Evidence that chamomile is effective for sleep is lacking/unavailable.

Chamomile tea is generally recognized as safe for consumption by the FDA.

May cause allergic reaction in patients who are allergic to ragweed.

AROMATHERAPY

Preliminary research suggests lavender oil may be helpful in patients with mild insomnia.

A more cost-effective method of providing aromatherapy is gauze soaked in lavender left at the bedside for up to 5 nights.

MUSIC THERAPY

Preliminary research suggests listening to classical and New Age music before bed improves sleep quality in elderly patients.

MAGNESIUM

Essential for ATPase activity. Intrinsic calcium channel blocker and NMDA antagonist.

Evidence that oral or topical magnesium helps with sleep is lacking/unavailable.

Oral magnesium may cause diarrhea, nausea, and GI irritation. 5-HTP

Endogenous precursor of serotonin produced from L-tryptophan.

Only animal studies and case reports exist suggesting efficacy in sleep disorders.

May cause drowsiness, dizziness, nausea, or epigastric pain.

Avoid with SSRIs and other serotonergic agents due to overlapping mechanism of action.

No standard doses studied for insomnia, but 50-200mg doses are commonly available.

VALERIAN ROOT

Extract from perennial flower root brewed historically as tea to help with insomnia.

Suggested mechanisms of action include GABA transaminase inhibition and adenosine-like activity.

Systematic reviews have found mixed efficacy in improving sleep quality.

Few reported adverse effects.

Studied doses for insomnia range from 450 to 900mg.

Sleep Aid Alternatives for the Elderly

Article by Phillip R. Transou PharmD Candidate

Page 4

UTI’s in Long Term Care………………………...Continued from page 1

PHARM NOTES

2005 Loeb Diagnostic Minimum Criteria for Order-

ing a Urine Culture

Fever > 100 degrees F and 1 (ONE) or more of the fol-

lowing:

Dysuria

Urgency

Flank Pain

Shaking Chills

Urinary Incontinence

Frequency

Gross Hematuria

Suprapubic pain

OR

If no fever, order urine culture if there is new onset

burning on urination or 2 (TWO) or more of the fol-

lowing:

Urgency

Flank pain

Shaking, chills

Urinary Incontinence

Frequency

Gross Hematuria

Suprapubic pain

OR

If fever > 100 degrees F, but 2 or more symptoms of

NON-UTI infection exist, DO NOT ORDER A URINE

CULTURE

2005 Loeb Minimal Criteria for initiating Antimi-

crobials:

Positive Urine Culture (> 100,000 CFU/ml) AND dysu-

ria

OR

Positive Urine Culture (>100,000CFU/ml) and 2 (TWO)

or more of the following:

Fever

Urgency

Flank Pan

Urinary Incontinence

Shaking Chills

Frequency

Gross hematuria

Suprapubic pain

Asymptomatic bacteriuria is defined as the presence

of bacteria in urine on microscopy or quantitative

culture in a specimen obtained from a patient who

does not have typical symptoms of a urinary tract

infection. It is widely recognized that asymptomat-

ic bacteriuria should not be treated with antibiotics

in the elderly population. Treating asymptomatic

bacteriuria does not reduce mortality and can cause

harm. Guidelines suggest that for every three people

treated with antibiotics, one will experience harm.

Evidence also suggests that treating asymptomatic

bacteriuria in nursing home patients who have chron-

ic stable incontinence does not improve incontinence

in the short-term.

Unnecessary antimicrobial therapy poses serious

threats. Antibiotic use is one of the largest risk fac-

tors for having an adverse drug event, many of which

may be preventable. In a study of 2 Rhode Island

nursing homes, inappropriate antibiotic prescribing

for asymptomatic bacteriuria was associated with a

12% incidence of Clostridium difficile colitis within 3

weeks, and an 8-fold increased risk of Clostridium

difficile colitis within 3 months of treatment.

Urine testing

should only

be performed

when there is

a reasonable

likelihood the

resident may

have a UTI, as

judged by

meeting at

least minimal

criteria for

initiating an-

tibiotics.

Some clini-

cians will give

orders to re-

test the urine

after comple-

tion of the

course of an-

tibiotics.

Current

guidelines

from the Infectious Disease Society of America

strongly recommend AGAINST testing of asympto-

matic residents and this is a core message of the

AMDA and American Geriatric Society’s (AGS) Choos-

ing Wisely Campaigns. Repeat urine testing in resi-

dents with no symptoms is never indicated and

should not be performed.

So what about treating a resident who is experiencing

a change in condition involving confusion or anxiety

and is deemed by staff “just not acting like herself/

himself”? When contacted, the prescriber (MD, FNP,

PA) is generally expected to take some tangible ac-

tion. The above symptoms could easily be due to de-

hydration, a new medication, depression with re-

Page 5

Volume 20, Issue 4

duced oral intake, or any number of other conditions.

Many clinicians now consider “watchful waiting” as an

intervention to reduce antimicrobial prescribing and

have initiated observation protocols that include moni-

toring vital signs, attention to hydration status, repeat-

ed physical assessments by nursing home staff, and

prompt communication of any changes in condition.

Informing residents and family members about obser-

vation protocols can also be reassuring. (see example

below)

Obtain vital signs (BP, Pulse, Resp Rate,

Temp, Pulse Ox) every _____hrs for

________days

Record Fluid intake each shift for

____________ days

Increase fluid intake: 120ml of juice or wa-

ter every 2hrs x 72 hours

Increase hygiene measures: cleanse anogeni-

tal area with soap and water after each in-

continence episode or toileting

Schedule toileting/diaper check or diaper

change every 2 hours

Monitor complaints of dysuria, urinary fre-

quency, or flank pain and report to charge

nurse

Assess for bladder pain and retention

Obtain the following blood

work____________________________________

Consult pharmacist to review medication

regimen

Notify MD/NP/PA if condition worsens, or if

no improvement in _________ hours

Contact MD/NP/PA with an update on resi-

dent’s condition on_______________________

Under Federal nursing home guidelines, all nursing

facilities must have an infection control program that

“investigates, controls, and prevents infections in the

facility”. It is expected that the medical director be

actively involved in oversight of this program, and

that the facility communicates information about in-

fection control to the attending physicians. Since UTI

is the most commonly diagnosed infection in LTC set-

tings, and since the prevalence of UTI’s is one of the

publically reported nursing facility quality measures,

facilities have a strong incentive to ensure they track

and manage UTI’s appropriately.

UTI management should be considered as a quality as-

surance and performance improvement (QAPI) initia-

tive by all LTC facilities. Appropriate QAPI targets are

those that are prevalent, pose significant safety and

liability risks, are associated with higher costs, and

have the potential to significantly impact resident

quality of life. The medical director might review resi-

dents being frequently treated for UTI, collaborate

with practitioners and nursing staff to establish mini-

mum criteria for ordering urine diagnostics, communi-

cate findings from the facility’s urinary antibiogram

with clinicians, or promote the use of decision support

tools such as a standardized communication form for

reporting changes in a resident condition (such as Situ-

ation, Background, Assessment, Response – SBAR

forms). The infection control program should track

the incidence of UTI’s within a facility using a stand-

ardized definition, such as that described by the Loeb

criteria. The facility should also track the rate of anti-

microbial starts when minimal criteria for antimicrobi-

al therapy are not met. This information should be

shared with the medical director and performance

feedback could be provided to individual clinicians.

The medical director should also work with the infec-

tion control program to establish continuous training

for staff regarding symptoms of UTI’s and criteria that

should be met before consideration is given to urinary

testing.

Resident and family education are also important.

AMDA’s and the American Geriatrics Society’s Choos-

ing Well Campaigns are tools that can be used to edu-

cate residents, families, as well as staff and physi-

cians. Another educational tool specifically designed

for LTC is the recently developed Agency for

Healthcare Research and Quality pamphlet, Not All In-

fections Need Antibiotics .

Practitioners must rely on consensus-based criteria for

the diagnosis of UTI. Identifying signs and symptoms

localized to the urinary tract is an important factor

to avoiding over-treatment of asymptomatic bacteriu-

ria. For patients with significant advanced cognitive

impairment who cannot reliably report symptoms, the

presence of fever, leukocytosis, or hemodynamic in-

stability alone may be adequate to justify initiation of

antimicrobial therapy. However, the use of other non-

specific symptoms such as fatigue or mental status

changes alone in diagnosing or treating UTI is not rec-

ommended.

Over-reliance on urinary tests such as urinalysis and

urine cultures leads to unnecessary treatment of

asymptomatic bacteriuria, as well as adverse drug

events, Clostridium difficile infection, and antimicro-

bial resistance. There is no role for ordering urine

tests in asymptomatic residents as tests of cure. Ob-

servation and monitoring of residents for whom the

diagnosis of UTI is unclear is a best practice that al-

lows for further data gathering, can provide reassur-

ance to residents and family members, may optimize

antimicrobial therapy, and minimizes the chance of

misdiagnosis. Facilities should consider addressing

UTI management as part of their QAPI process.

Article by Rhonda Gentry, RPh, BCGP Neil Medical Group

Clostridium Difficile: An Overview

Page 6

PHARM NOTES

Clostridium difficile (C. diff) is a spore-forming bacte-

ria that is usually spread by the fecal-oral route. The

bacterium produces two toxins that can cause mild

to severe diarrhea, colitis or pseudomembranous co-

litis. C. diff was estimated to cause almost half a mil-

lion infections in the United States in 2011, and

29,000 died within 30 days of the initial diagnosis.

C. diff has become the most common cause of

healthcare–associated infections in U.S. hospitals,

and the excess healthcare costs related to C. diff

infection are estimated to be as much as $4.8 billion

for acute care facilities alone. Some people are

asymptomatic carriers of either a toxigenic or

nontoxigenic strain of the Clostridium difficile bac-

terium. Among the elderly, carriage rates may be

higher, especially in those in long term care facili-

ties (LTCFs). In one study of an epidemic in a LTCF,

51% of asymptomatic carriers had toxigenic C. dif-

ficile indicating that LTCFs may be a reservoir for

cases of C. diff infections.

The two biggest risk factors for developing Clostrid-

ium difficile infection (CDI) are exposure to antibi-

otics and exposure to the organism, usually through

admission to a health-care facility. Receipt of anti-

microbials increases the risk of CDI because it sup-

presses the normal intestinal flora, thereby provid-

ing a suitable environment for C. diff to flourish. All

antibiotics can cause CDI, but those that carry the

most risk are clindamycin, cephalosporins, and fluo-

roquinolones. Being on multiple antibiotics and long-

er duration of antibiotic therapy also increases the

risk of CDI. Other risk factors in-

clude older age, gastrointestinal

surgery or manipulation, nasogas-

tric tube feeding, reduced gastric

acid (through the use of proton

pump inhibitors), receiving chemo-

therapy, serious underlying disease

and long length of stay in

healthcare settings.

Symptoms indicative of CDI include

watery diarrhea (at least three bow-

el movements per day for two or

more days), fever, abdominal pain,

nausea, and loss of appetite. A diag-

nosis of CDI is made by the pres-

ence of symptoms (usually diar-

rhea) and either a stool test positive

for C. diff toxins, or colonoscopic

findings revealing pseudomembranous colitis. Since

C. difficile carriage is common, especially in patients

on antimicrobial therapy, only unformed stools

should be tested, unless the patient has an ileus. A

Page 7

positive result in a patient without diarrhea is likely

not clinically significant and may complicate care.

When collecting stool sample for testing, it is im-

portant to note that Clostridium difficile toxin is very

unstable. The toxin degrades at room temperature and

may be undetectable within 2 hours after collection of

a stool specimen. A False-negative test results occurs

when specimens are not promptly tested or kept re-

frigerated until tested. Treatment for CDI should be

initiated promptly to prevent complications

such as toxic megacolon, perforations of the co-

lon, sepsis, or even death.

CDI treatment is based on the severity of

presentation. Clinical presentation of CDI can be

mild, moderate, severe, or complicated depend-

ing on factors such as serum creatinine level,

white blood cell count, and blood pressure. Met-

ronidazole, although not FDA approved for the

treatment of CDI is used for mild to moderate

disease. Severe and complicated CDI are treated

with oral vancomycin. Intravenous vancomycin

does not have a place in CDI treatment as it is

systemically absorbed without significant con-

centration at the site of infection. Fidaxomicin

was approved in 2011 for CDI treatment but its

place in therapy is not clearly defined. A problem with

antibiotics used to treat CDI is that the infection re-

turns in about 20 percent of patients. During the first

recurrence, the treatment used to manage the initial

CDI episode is the recommended treatment. Tapered

oral vancomycin or fidaxomicin is recommended for a

second recurrence of CDI. Fecal microbiota transplant

(transplanting stool from a healthy person to the co-

lon of a patient) may be considered after 3 recurrenc-

es. There is limited evidence for the use of adjunct

probiotics for treatment or to decrease recurrenc-

es in patients with recurrent C. difficile. Whenever

there is a confirmed case of CDI, all unnecessary

or inciting antibiotics should be discontinued. Lax-

atives, stool softeners, anti-motility agents, and

proton pump inhibitors without a true indication

should all be discontinued.

Since the C. diff is spore-forming, it can live a long

time on surfaces such as toilet seats, telephones,

and doorknobs. Cleaning and disinfecting surfaces

and reusable devices can help curtail the spread of

the bacteria. Standard EPA-registered hospital dis-

infectants are not effective against C. diff spores

except EPA-registered disinfectants with a spor-

icidal claim. In patients with known or suspected

CDI, contact precautions should be initiated. Patients

should be placed in private rooms if available, or with

other infected patients. Gown and gloves should be

worn when entering the rooms of patients with CDI.

Good hand hygiene should be performed after remov-

ing the gloves. Alcohol does not kill C. diff spores, so

washing hands with soap and water (for at least 15

seconds with vigorous friction) is more efficacious

than alcohol-based hand rubs. Each institution should

have strategies for prevention, policies for rapid de-

tection, and guidelines for the management of Clos-

tridium difficile infection.

Volume 20, Issue 4

Article by Kwasi Adu Nyarko, PharmD Candidate Wingate University School of Pharmacy

PHARM NOTES

Kinston Pharmacy

2545 Jetport Road

Kinston, NC 28504

Phone 800 735-9111

Louisville Pharmacy

13040 East Gate Parkway

Suite 105

Louisville, KY 40223

Phone 866-601-2982

Mooresville Pharmacy

947 N. Main Street

Mooresville, NC 28115

Phone 800 578-6506

To all the Pharm Notes Family,

More than a statistic…….My son-in law’s father, Ken Matthews, died five days after Easter. He was

too young…..65 years old. He was a father, a grandfather, a brother, a husband, an uncle and a

son. He was also my friend.

Ken was a veteran, so I’m sure when he started feeling poorly on that Saturday, and the closest VA

Hospital…..not so accessible at 90 minutes away….he opted to wait and call them the first thing

Monday morning. Josh found his Dad late Easter afternoon in such a weakened state, that he

called 911 and had him immediately transported to Cone Hospital. He was diagnosed quickly and

treatment was started. Sepsis.

That’s where the statistics come in. Recent studies have shown that once you are in septic shock,

initiating antibiotics quickly is crucial. If treatment starts within the first hour, there is an almost

80% chance of survival…...but if treatment is delayed by six hours,

the survival rate drops to 40% and continues to drop dramatically

with each passing hour. Ken’s multi-organ failure indicated it was

likely “too late” when he arrived at the hospital.

As health care providers, we rely so heavily on statistics and data.

That, in itself, is no comfort when it involves a loved one. Ken,

you’ll definitely be missed.

You were more than a statistic to us.

Till next time……..

Cathy Fuquay

Pharm Notes Editor

Pharm Notes is a bimonthly publication by Neil

Medical Group Pharmacy Services Division.

Articles from all health care disciplines pertinent

to long-term care are welcome. References for

articles in Pharm Notes are available upon request.

Your comments and suggestions are appreciated.

Contact: Cathy Fuquay (cathyf@neilmedical.com)

1-800-735-9111 Ext 23489

...a note from the Editor

Thank you for allowing Neil Medical Group to partner with

you in the care of your residents!