INFECTION CONTROL AND ANTIBIOTIC STEWARDSHIP

Speaker Disclosure INFECTION CONTROL AND ANTIBIOTIC STEWARDSHIP Philip Sloane, MD, MPH Dr. Sloane has received antibiotic stewardship related research funding from grant #R18 HS022846 01 and from task order contracts #HHSA290200710014I and #HHSA 290200600001 from the US Agency for HealthCare Research and Quality the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill Learning Objectives By the session s end, participants who remain awake will be able to: Identify the problems associated with antibiotic overprescribing in post acute and long term care settings State the core elements of effective antibiotic stewardship Discuss five situations in which antibiotics are commonly prescribed but seldom needed Describe five targets for measurement and benchmarking to use in antibiotic stewardship program, including those most likely to be required by CMS reporting Identify training resources to help medical providers and nursing staff practice antibiotic stewardship in post acute and long term care Crisis of Antibiotic Resistance Multi drug resistance increasingly common Over 20,000 deaths annually in U.S.A. from multidrug resistant infections Projected 317,000 deaths per year by 2050 1

1. Fewer New Antibiotics Being Developed What s Causing the Crisis? 2. Resistant Strains Spread Rapidly 3. Antibiotics Are Overused Average # Antibiotic Prescriptions Per Resident in One Year * Antibiotic Overprescribing: THE Major Cause of Bacterial Resistance The Average: Nursing Home Resident 4.6 antibiotic prescriptions per year 1 prescription every 80 days On antibiotics 10% of the time Medical Experts Estimate that Between 25% and 75% of median Antibiotics Prescribed to Nursing Home Residents are Not Needed Nursing Home Resistant Bacteria Galore results of skin, airway, skin and wound cultures in 82 residents of a Michigan nursing home MRSA CR GNR VRE 18% J Clin Micro 50(5); 1698 1703, 2012. 63% 72% 20 40 60 80 % of Nursing Home Residents with Positive Culture Reasons Antibiotics Are Prescribed Presumed Skin and Soft Tissue Infection Other Infection Respiratory Infection The most common other infection is C. difficile Presumed Urinary Infection The NEW NURSING HOME MANDATE CMS October 4, 2016: all nursing homes will be required, as part of infection control, to have: an infection control officer [deadline: November 28, 2016] An antibiotic stewardship program [deadline: November 28, 2017] https://www.federalregister.gov/documents/2016/10/04/2016 23503/medicareand medicaid programs reformof requirements for long term care facilities) Yes, this is a policy change Prescribing antibiotics just in case was accepted in the past, but now antibiotics should be given after careful, evidence based consideration of risks and necessity. This process of assuring the right antibiotic at the right time and in the right dose and duration is referred to as antibiotic stewardship 2

Antibiotic Stewardship in Nursing Homes: Optimizing Antibiotic Use Results of Our Research and Quality Improvement Program 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 <== Baseline Randomized Trial in 14 NHs Antibiotic Prescriptions Per 100 Resident Days Follow Up ==> Intervention Begun Mar Apr May Jun Jul Aug Sep Oct Nov Intervention Group All Indications Comparison Group All Indications 24% Reduction in Intervention Group Antibiotic Use at Beginning of Project, by Nursing Home 12 Working with a Nursing Home Chain Results after 1 year Average # Antibiotic Prescriptions Per Resident in One Year 11 10 9 8 7 6 5 4 3 2 1 Jan Apr 2015 0 E J H G R D T F Y Q W V CC EE Nursing Home Was Antibiotic Prescribing Reduced? Did More People Get Sick? All Antibiotics Antibiotics for Suspected UTI Antibiotics for Respiratory Problems Antibiotics for skin problems Reduced by 19.5% Reduced by 19% Reduced by 22% Increased by 12% Hospitalization rate 30 day readmission rate Sepsis Reduced by 11% Reduced by 31% No increase noted 3

Did Bacterial Resistance Change? How Antibiotic Use Changed in One Year by Nursing Home 12 Clostridium difficile infections MRSA infections Were urine MDRO rates reduced? Reduced by 11% Reduced by 8% We don t know yet Average # Antibiotic Prescriptions Per Resident in One Year 11 10 9 8 7 6 5 4 3 2 1 Jan Apr 2015 Jan Apr 2016 0 E J H G R D T F Y Q W V CC EE Nursing Home Issue #5: Does this person need antibiotics? Where to Start? The Five Most Common Errors in the Diagnosis and Management of Infections in Long Term Care Settings 82 year old man; two weeks of increased swelling in both legs, that often goes down at night. One week history nontender, red rash on his right leg, which has been gradually growing in size and redness. Temperature 98.1; leg has mildly indurated, nontender, scaly bright red inflammation on the anterior and medial shin. Pulses palpable; no calf tenderness; Homan's sign negative; WBC 5,800 without a left shift; venous Doppler examination normal. Antibiotics for this wound? Fifth most common error: Thinking red skin means infected skin Does this need antibiotics? One week later 4

Issue #4: Empirically Chosen Antibiotics for UTI - Data from 75 prescriptions and 1,580 positive cultures in 31 NHs - Antibiotic Prescribed Empirically (% of the time) Percent Resistant (% of isolates) Escherichia Coli (44%) Proteus (13%) Klebsiella pneumoniae (13%) Ciprofloxacin (26%) 57% 69% 11% TMP SMX (16%) 42% 45% 14% Nitrofurantoin (12%) 4% 98% 23% Ceftriaxone (11%) 17% 7% 11% Levofloxacin (7%) 58% 63% 8% HO-CDAD cases/1,000 pd Reducing Antibiotic Overuse Works: Impact of fluoroquinolone restriction on rates of C. difficile infection in a Community Hospital 2005 2006 Month and Year 2007 Infect Control Hosp Epidemiol. 2009 Mar;30(3):264-72. Recommended Duration of Antibiotic Therapy (non hospitalized patients) Type of infection Simple UTI (cystitis) COPD exacerbation Pneumonia without sepsis Cellulitis (lower extremity) Sanford Guide, 2015 ID Society ID Specialist YOUR Program 3 days 1 3 days 1 3 days? 3 10 days 2 3 5 days Until afebrile for 3d >5 days 4 >5 days 10 days 3 5 days 5 7 days?? Fourth most common error: Prescribing the wrong antibiotic and/or too long a treatment duration 1 TMP SMX 3 days; Nitrofurantoin 5 days; 2 Varies with drug, No therapy required in most cases; 3 Not diabetic; 4 Minimum 5 days (should be afebrile 48 72 hours); non ambulatory treat as HCAP; assess using score for severity Issue #3: Case Description Mr. Leonard, 76 year old nonsmoker 5 days of nasal congestion, sore throat and sneezing Hacking cough worse at night Decreased appetite, more tired Temp 99.4, other vitals normal, pulse ox 97% Placed on antibiotics Research Result: Cough Alone Increases 3x the likelihood of a LTC Patient Getting Antibiotics Question: Is cough alone a reason to give antibiotics? Why or why not? 5

Common Respiratory Tract Infections Infection Type Common Cause Common Symptoms Common Cold Viral Nasal congestion/sneezing Sore throat Dry cough +/ fever Acute bronchitis Viral Cough (+/ sputum) +/ Fever Pneumonia Bacterial or Viral Cough (+ sputum) Pleuritic chest pain Fever Influenza like illness Viral Sore throat Dry cough Fever Distinguishing Features Nasal symptoms Normal vitals (+/ fever) Unchanged lung exam Normal chest X ray Normal vitals (+/ fever) Abnormal vital signs Abnormal lung exam Infiltrate on chest X ray Mental status changes Chills Body aches Malaise Third most common error: Reaching for antibiotics as first line agents in acute bronchitis or mild COPD exacerbations Issue #2: Another Case History Is This Evidence Based Practice? Mrs. Jenkins, a 79 year old with stroke, incontinence Wet incontinence pad has odor No complaints Normal vital signs Nurse asks to have urine checked Is Cloudy or Smelly Urine a Reason To Give Antibiotics? Percent 90 80 70 60 50 40 30 20 10 0 Yes No Nurses Geriatricians Geriatr Nurs. 2005 Jul Aug;26(4):245 51. What Causes Changes in Urine Color or Odor? Diet Medications Dehydration Bacteria in urine If person is not sick, it s asymptomatic bacteriuria 6

Percentage with positive culture How Common is Asymptomatic Bacteriuria? FEMS Microbiol Lett 346; 1 10, 2013. Up to 30% Diabetic Adults Up to 50% Community Elderly Up to 75% LTC Elderly Nearly 100% Indwelling Catheter What should you do for Mrs. Jenkins? Should you get a urine culture just in case? Antibiotic Prescribing Decision when the Culture was Ordered No antibiotic 179 cases (70%) Antibiotic 75 cases (30)% Ordering a Urine Culture: A Gateway to Overprescribing? results of 254 randomly sampled cultures Culture Result <100K or Neg = 68 Pos = 111 <100K or Neg = 21 Pos = 54 Prescribing Decision when the Result was Reported 17 (25%) were prescribed antibiotic 99 (89%) were prescribed antibiotic 2 (10%) stopped and 19 (90%) continued or changed antibiotic 0 (0%) stopped and 54 (100%) continued or changed antibiotic Received Full Antibiotic Course 17 99 19 54 Second most common error: Over ordering urine cultures, and then treating the culture rather than the patient Bottom Line: 189 (74%) received a course of antibiotics, although 86% had a temperature less than 99 o F, 74% lacked documentation of any urinary tract specific signs or symptoms, and only 18% met the modified McGeer criteria for urinary tract infection. Why? Issue #1: Two Case Descriptions Mrs. White 84 year old with arthritis and moderate dementia Uncooperative with dressing Irritable Eats half of breakfast Says she s tired Ms. Blue 34 year old nurse Divorced, alone this weekend You were going to have lunch with her, but she cancels Low energy; not hungry Doesn t want to get dressed Doesn t want to deal with people 7

Both Have Similar Nonspecific Symptoms What You Might Think About Your Friend Ms. Blue Ms. White 84 year old with arthritis and moderate dementia Uncooperative with dressing Irritable Eats half of breakfast Says she s tired Ms. Blue 34 year old Divorced, alone this weekend Low energy ; not hungry Doesn t want to deal with people Doesn t want to get dressed Coming down with a virus Too much to drink last night Didn t sleep well Pain Stress Depression What the Nursing Supervisor Says About Ms. White Probably the urine. Needs an antibiotic. Most common error: Knee jerk reaction to look for a urine infection in every patient with nonspecific symptoms Thinking first of UTI when anything goes wrong with an old person is outdated knowledge that causes staff to jump to conclusions. 45 Jumping to conclusions In medical decision making the most common reason for medical errors What else could be causing Ms. White s fatigue, irritability, and poor appetite? The Big Seven: Common Reasons for Nonspecific Symptoms in Ms. White Dehydration Medication side effect Coming down with a virus Didn t sleep well Pain Constipation Stress / anxiety / depression 8

Active Interventions for Non Specific Symptoms Assess hydration status (and encourage fluids) Review current medications Look for signs of a respiratory or GI virus Think about sleep problems Ask about pain / discomfort Ask about constipation Look for sources of stress, anxiety or depression Monitor symptoms and vital signs (especially temperature) Use nursing interventions where appropriate Should we get a urine culture just in case Tips on Developing an Antibiotic Stewardship Program in Your Organization Importance of Leadership Interviews with 182 nursing staff and 50 medical providers from 31 nursing homes showed: Strong support for reducing antibiotic use DONs and nurse specialists felt more empowered to make changes than other nurses Medical specialists (e.g. geriatricians) felt more empowered and committed to change The Challenge of Leadership Turnover One year turnover rate in NC Nursing Homes: Administrator 25% Director of Nursing 54% Infection Control Nurse 57% Foster a Leadership Team Laboratory Medical Director Infection Control Nurse Focus on Communication Data and QAPI Consultant Pharmacist Director of Nursing 9

Decision Making Is a Team Sport Nurse Medical Provider Communication Nurse Provider Supervisor Probably the urine. Needs an antibiotic. Family Every time mother [Does X] she needs antibiotics NIMALE STONE VIDEO Communication Barriers Reported by Long Term Care Nurses Percentage of nurses citing as problem 40% 30% 20% 10% 0% Hurried by provider Lack quiet calling place Hard to reach provider J Patient Saf. 2009;5:145 152 Provider not respectful Nurse preparedness is a major facilitator of good communication J Patient Saf. 2009;5:145 152 Tools For Standardizing Communication Can Help Situation Background Assessment Review, Recommend & Notify JAMDA 15 (2014) 162 170 Geriatr Nurs. 2013 Jul Aug;34(4):295 301 2. RELEVANT INFO Medical history (diabetes, catheter) Medicines/med changes Recent labs Drug Allergies/advanced directives 3. VITAL SIGNS Blood Pressure Pulse Respiratory Rate Temperature (Fever 99 F or 1.2 F above baseline; include baseline & highest recorded 24 hrs) SBAR for Urinary Symptoms 1. SITUATION (brief summary of current problem) 4. NON-SPECIFIC S/S New or worsening confusion New or worsening agitation Decreased eating/drinking New or worsening weakness Sleepiness/less active or alert Decline in function Other non specific change 5. SPECIFIC S/S Suggests infection: New painful urination Blood in urine Suprapubic pain Flank pain New/worse frequency New/worse urgency Does NOT suggest infection: Urine odor Urine color change New/worse incontinence 6. ASSESSMENT (remember the BIG SIX and guidelines for urine testing) 7. REVIEW, RECOMMEND AND NOTIFY 10

SBAR for Urinary Symptoms 2. RELEVANT INFO Medical history (diabetes, catheter) Medicines/med changes Recent labs Drug Allergies/advanced directives 3. VITAL SIGNS Blood Pressure Pulse Respiratory Rate Temperature (Fever 99 F or 1.2 F above baseline; include baseline & highest recorded 24 hrs) 1. SITUATION (brief summary of current problem) 4. NON-SPECIFIC S/S New or worsening confusion New or worsening agitation Decreased eating/drinking New or worsening weakness Sleepiness/less active or alert Decline in function Other non specific change 5. SPECIFIC S/S Suggests infection: New painful urination Blood in urine Suprapubic pain Flank pain New/worse frequency New/worse urgency Does NOT suggest infection: Urine odor Urine color change New/worse incontinence Communicating with Residents and Families 6. ASSESSMENT (remember the BIG SIX and guidelines for urine testing) 7. REVIEW, RECOMMEND AND NOTIFY Dealing with Resident and Family Expectations Case Example Satisfaction is not severely impacted when antibiotics not given Communication and education are key BMJ. 1998 Sep 5;317(7159):637 42. Cochrane Database Syst Rev. 2013 Apr 30:4. J Gen Intern Med. 2014 Nov 6 Example: What to Say to the Family of a Man with a Viral Bronchitis Advise on what to expect: His cough might last several more days to several weeks, and it may take him a while to feel better. Respond to concerns about symptoms: We re going to help him feel more comfortable so his body can fight this virus. He ll need plenty of fluids and rest. Also, we ll give medicine for his fever and cough, and keep an eye on him. If Family Specifically Asks for an Antibiotic Prescription Mr. Leonard s chest cold is caused by a virus, and antibiotics won t help viruses. Giving him antibiotics when they aren t needed can cause side effects and may mean the antibiotics won t work when he really needs them. 11

Data Are Crucial CMS will require data monitoring and reporting Data are necessary for quality assessment and performance improvement (QAPI) Comparison data is helpful Statistics must be gathered regularly Rates should be computed Include urine culture results Core Outcomes Selected Process Measures Suggested QAPI Measures C difficile infection rate * MRSA infection rate * Urine infection treatment rates * Antibiotic prescriptions / 1,000 residentdays Percent of time on antibiotics Urine cultures: multidrug resistance rate Rate of hospitalization for sepsis Rate of fever among persons who had antibiotics initiated Average antibiotic prescription duration Urine cultures per 1,000 resident days * Current National Healthcare Safety Network (NHSN) measures Components of the UNC Antibiotic Stewardship QAPI Program We Provided Ongoing Training Resources for. Nurses Supervisors Providers Residents & Family On Line Nurse Training Modules MODULE TOPIC 1 Antibiotic Resistance in Nursing Homes: Causes & Consequences 2 Colonization vs Infection 3 Cloudy or Smelly Urine 4 Urinalysis and Urine Culture Results Posters for placement in nurses stations and break rooms 5 Nonspecific Symptom Quiz 6 Respiratory Infections 7 Skin Infection Dilemmas 8 Communicating With Health Care Providers 9 Infection Control 10 Summary: 12 Situations SBAR for gathering information before calling provider Quiz & Training Evaluation 12

Front Pocket card for nurses CD ROMs for medical providers to listen to while driving Front Back One pagers for medical providers Pocket card for medical providers We Assist with Data Systems Format for monthly facility statistics Format for recording data on each antibiotic prescription Guidance on periodic chart audits to evaluate documentation and concordance with McGeer criteria Generating rates and providing comparison data 13

5 minute video for residents and families Brochure for residents and families CAUTI CLIP 2 How We Can Help Your Organization training materials instructional guide for setting up your antibiotic stewardship program guidance for your infection control officer on monitoring and reporting hands on assistance in setting up your program, educating staff, and generating QI reports We are university based, not for profit nursinghomeinfections.unc.edu Promoting Wise Antibiotic Use in Nursing Homes Home Medical Providers Nurses Nursing Assistants Residents and Families Contact Us Facts about Antibiotic Overuse in Nursing Homes Adverse effects such as clostridium difficile infection are increasing. Between 25 75% prescriptions do not meet clinical guidelines. Few new antibiotics are being developed; so we need to preserve what we have. Why is this important? Health and well being of nursing home residents is the goal of care. Inappropriate overuse of antibiotics leads to serious complications. We need to change our thinking from just in case to only when needed Nurses Click here to complete our 10 module antibiotic stewardship training course and obtain up to 2 hours of CE credit. What you can do Medical providers Click here to download our Infection Management in Nursing Homes audiocasts, available for CME credit. Residents and Families Click here to download our educational brochure and fact sheet about antibiotic use in nursing homes. Thank You! 14