Rhonda Stuart
The global population is aging By 2050, 21.4% people are projected to be aged > 60 years In Australia the number of people aged 85 and over projected to quadruple from 0.4 to 1.8 million by 2050 31% Australians >85 years currently in RACF Steady increase in residents requiring care Estimated that 6% of population (1.4 million) will need NH or SAH accommodation by 2030 Cohen. Science. 2003 Van Duin. CID 2012 DOHA. 2011
Functionally the home of the resident Types of care RACF = LTCF = Nursing home A diverse group of institutions that care for patients of all ages Intensity of skilled care provided varies widely Average resident is female > 80 years Long term care for > 6 months
Goals of care Quality of life Safety Cost minimization Staffing Most care provided by nursing staff nursing aides Resident to staff ratios differ to acute setting - understaffing Few physician visits and frequent covering medics Many medical decisions done by telephone Follow-up not always achieved Absence of infection control professionals and policies SHEA/APIC, 2008
Residents Impaired communication and non-localizing symptoms Comorbidities Chronic cognitive +/or physical impairments Immune senescence Atypical clinical manifestations of infection Invasive devices, incontinence, impaired mobility Frequent antibiotic exposure High frequency of social contacts enhancing cross transmission
Lack of robust data and diagnostic testing Access, timeliness Interpretation 90% inappropriate diagnostic work-up Radiology access Multiple laboratory providers Samples rarely taken, result availability poor Surveillance issues Multiple community pharmacies DDDs unavailable Loeb Infect Control Hosp Epidemiol 2000
Balance risk of not treating vs risk of antibiotic use Over-diagnosis of infection Low threshold for treatment Treatment of colonisation Delayed diagnosis of infection Lack of microbiological testing Transmission
Urine Non-catheterised women 25-50% Non-catheterised men 15-40% Chronic catheters 100% Oropharyngeal (COPD) Gram negative 23-43% Pressure ulcers Skin swab 97% Percutaneous feeding tubes Skin swab 80% Dyar et al. Clin Micro and Infect 2015
Fewer resources Less expertise Increased staff turnover Multiple duties of ICP Diagnostic facilities limited/off site Pharmacy limitations Medical record issues Limited research Smith. Infect Control Hosp Epidemiol 2008
Elderly at higher risk of infection 3-fold increased risk pneumonia 20-fold increased risk UTI Each RACF resident develops 1-3 infections per year (generally UTI or LRTI) Infection the most common cause of hospital admission 26-50% of transfers from RACF to hospitals To and fro nature of care MRGN risk
Nicolle 1996 Stevenson 2005 Lim 2012 Respiratory tract 0.46-4.4 1.75 (0.68, 2.88) 1.12 (1.0, 1.25) Urinary tract 0.1 2.4 0.6 (0.16, 1.01) 1.53 (1.39, 1.69) Skin/soft tissue <0.1 2.1 1.11 (0.68, 2.37) 0.61 (0.52, 0.71) Gastrointestinal 0 0.9 0.16 (0, 0.43) 0.15 (0.11, 0.21) Rate per 1000 patient days Variation in rates due to: Institutional population Case finding methods Diagnostic uncertainty? infection control? Rates of MRGN
Antibiotics commonly prescribed 60-70% residents receive antibiotics yearly Point prevalence - 4.8 15.2% Incidence - 4.0-7.3/1000 resident days Variation to prescribing Prescriber dependent rather than recipient driven Many (up to 75%) prescriptions are: Inappropriate Unnecessary Unnecessarily prolonged Van Buul. JAMDA 2013
Challenging clinical decisions to initiate antibiotics Difficulty in establishing a diagnosis Poor historians Atypical symptoms and chronic co-morbid conditions Ethical issues - comfort care and prolonging life Family expectations Therapy often empirical Lack of availability and use of laboratory and radiology One drug fits all Up to 38% of treatment initiated without direct physician contact Medication charts filled out monthly Follow-up variable Pettersson. Scan J Infect Dis 2008
Lack of resources for AMS Pharmacist availability Community pharmacy mainstay of prescribing Physician availability Advice Restrictive stewardship Audit and feedback Microbiology data Multiple providers Follow-up difficult
Limited Lim et al MJA 2012 37% of prescribed antimicrobials did not meet McGeer criteria for clinical infection Asymptomatic bacteriuria (20%) and URTI problematic Stuart et al MJA 2011 44% of prescribed courses did not meet criteria for bacterial infection Main indication - UTI
Substantial inappropriate use 40 70% Negative outcomes Antimicrobial resistance Diarrhea/Clostridium difficile Allergy Cost Toxicity/Interactions Direct and indirect effects Van Buul. JAMDA 2013
Ontario, Canada Population based administrative datasets Open cohort 110,656 residents, 50,953,000 resident days 607 nursing homes
Low Use = 20.4 45.7 Low Use = 20.4 45.7 Medium Use = 45.8 Medium 62.2 Use = 45.8 62.2 High Use = 62.3 192.9 High Use = 62.3 192.9
Ten fold variation in RACF antibiotic use Risk of adverse event high for those receiving antibiotics in a high use facility 14.3% / 13.5% / 12.9% (p < 0.001) 24% greater risk of adverse events in high use facilities Also high for those not receiving antibiotics 9.9% / 9.6% / 8.7% (p = 0.02) Antibiotic harm goes beyond the individual
Lack of evidence on which to base definitive recommendations for antimicrobial use in RACF
Lectures, pamphlets, guidelines may be less effective than in acute care setting Delaying commencement of antimicrobial treatment a few days after consultation had largest impact Waiting until infection declared itself meant many didn t fill script
What are RACF doing with respect to: Antibiotic use What is the antimicrobial prescribing pathway in RACF? What is the best way to address AMS? And what about.. Environmental cleaning Hand hygiene Vaccination
Larger Australian point prevalence surveys Ongoing individual surveillance Allow benchmarking Periodic surveillance for multi-resistant organisms Antibiotic formularies for residential care Guidelines eg UTI management Requires mean of auditing Multi-disciplinary teams to address prescribing ICP, ID, pharmacy Multi-faceted interventions Nurses General Practitioners Relatives
Discourage antibiotic prescribing without clinical examination Decrease phone prescribing Education Nursing, medical, patients, relatives Target areas where antibiotic misuse is common Prophylaxis, colonization, treatment duration Use locally adapted guidelines Diagnostic and therapeutic Reassess antibiotic use around day 3 Microbiology Limit unnecessary microbiological investigations Improve reporting from microbiology Use point of care diagnostic tests Integrate AMS into existing infection control Dyar et al. Clin Micro Infect 2015
Risk from poor HH due to high contact rates Scanty scientific evidence on HH Do the WHO 5 moments hold true in RACF? Unique issues dining areas, excursions, spontaneous touching kissing Survey 2013 ABHR available in 95% of facilities ABHR available in 28% of resident bedrooms Education on HH available in all except 3 facilities? auditing Stuart et al. Int Med J 2015
What is the best way to keep the environment clean?
Influenza vaccination of HCWs One of the areas which is evidenced based Influenza vaccination of residents Needs facility buy in Pneumococcal vaccination Zoster vaccination
Stuart et al. Int Med J 2015
Stuart et al. Int Med J 2015 Reported resident influenza vaccination rate in 2013 > 75% in 73% of facilities 50 75% in 17% of facilities < 50% in 11% of facilities Reported staff influenza vaccination rate in 2013 > 75% in 14% of facilities 50 75% in 26% of facilities < 50% in 60% of facilities
Stuart et al. Int Med J 2015 67% facilities claimed to be able to provide pneumococcal vaccination to residents Only 20% reported vaccination rates > 75% 45% were unaware of pneumococcal vaccination status
MRSA To screen or not to screen Decolonize or not Clostridium difficile A rich environment for outbreaks Environmental hygiene and AMS MRGN The new threat to RACF
Stuart et al. Int Med J 2015
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