antibiotic stewardship and infection prevention

Antibiotic Stewardship and Infection Prevention Collaborative

Webinar SeriesJerry Wicker, BS, LNHA, CPHQ, CDP

Outreach Specialist, AFMCFeb. 14, 2019

Webinar 5 & 6

Julia Kettlewell, MPH, BSN, RNP

Quality Director

Mandy Palmer, RN, CPHQ, CPPS

Quality Manager

Michelle Sharp, MSN, RN, CPPS

Outreach Specialist, RN Team Lead

Nicole Bonecutter, BSN, RN, RAC-CT, CDP

Quality Specialist

Jerry Wicker, CPHQ, LNHA, CDP, BS

Quality Specialist

Meet Our Team

Goals■ Improve transitions of care for patients with Clostridium difficile infection (CDI)■ Empower pharmacists to incorporate antibiotic stewardship best practices in their

facility to improve stewardship capacity and implementation■ Expand implementation of evidence-based practices for prevention, identification

and control of multidrug resistant organisms (MDROs)

■ Arkansas Methodist Medical Center

■ Baptist Health-Little Rock

■ Baptist Health-North Little Rock■ Baxter Regional Medical Center

■ CHI St Vincent Hot Springs■ CHI St Vincent Little Rock

■ Conway Regional Medical Center

■ Drew Memorial Hospital■ Five Rivers Medical Center

■ Great River Medical Center■ Jefferson Regional Medical Center

■ Johnson Regional Medical Center

■ Mercy Hospital Fort Smith

■ North Arkansas Regional Medical Center■ North Metro Medical Center

■ Northwest Medical Center■ St. Bernards Medical Center

■ UAMS Medical Center

■ Unity Health White County ■ Washington Regional Medical Center

■ White River Medical Center

21 Participating PPS Hospitals

■ Baptist Health Arkadelphia

■ Bradley County Medical Center

■ Chicot Memorial Medical Center■ CrossRidge Community Hospital

■ Dallas County Medical Center■ DeQueen Medical Center

■ DeWitt Hospital

■ Fulton County Hospital■ Howard Memorial Hospital

■ Izard County Medical Center

■ Lawrence Memorial Hospital

■ Little River Memorial Hospital

■ Mercy Hospital Berryville ■ River Valley Medical Center

■ South Mississippi County Regional Medical Center■ Stone County Medical Center

16 Participating Critical Access Hospitals

§ Alma Health and Rehab

§ Capital Health and Rehab

§ Craighead Nursing Center

§ Fort Smith Health and Rehab

§ Good Samaritan Society – Hot Springs Village

§ Hillcrest Home

§ Hillview Post Acute and Rehab

§ Jonesboro Healthcare and Rehab

§ Lexington Place Healthcare and Rehab

§ Little Rock Post Acute Health and Rehab

§ Madison Healthcare and Rehab

§ Magnolia Healthcare and Rehab

§ Methodist Health and Rehab

§ Mountain View Health and Rehab

§ Randolph County Nursing Home

§ Searcy Health and Rehab

§ White Hall Health and Rehab

§ White River Healthcare

§ Woodlawn Heights

§ Woodland Hills Healthcare and Rehab

§ Woodruff County Health Center

21 Participating Nursing Homes

■ In-person and live-stream kickoff event• November 2018

■ Monthly webinar series with education, coaching and collaboration • Second Thursday of each month • Free Nursing and Nursing Home Administrator CEs

■ Expertise and resources at your finger tips• Web page packed with toolkits, resources and tools

■ Final outcomes face-to-face with livestreaming event• July 2019

What You Can Expect From Us

■ Attend monthly AS and IP webinars

■ Reach out with questions or needs to drugsandbugs@afmc.org

■ Utilize the online toolkit at www.afmc.org/drugsandbugs

■ Complete the post-assessment survey

■ Collaborate, participate and share!

What We Expect of You

Pre and Post Assessment Survey

■ Purpose• Measure the overall needs of recruited facilities and identify opportunities• Better target education and resources to meet your needs• Measure improvements made since the start of the collaborative

■ Pre-Assessment • 57/58 facilities completed• Reviewing some results today

■ Post-Assessment• Goal to improve results• Re-assess in late June 2019

Web page is live

■ It can all be found HERE: https://afmc.org/drugsandbugs• Toolkit/resources• Events• Pharmacy training scholarship application

Let’s take a look

TOOLKIT/ RESOURCES

APPLY NOW

OLD & NEW

§ Don’t miss out! 60 awards to be given to AR pharmacists§ Society of Infectious Disease (SIDP) certificate training on antibiotic stewardship • Open to all hospital or LTC pharmacists in the state• Currently have 37 applicants (32 hospital, 5 LTC)• Apply today at www.afmc.org/drugsandbugs

Matching Scholarships for Pharmacists

■ Chat• Use the chat feature to send your questions or comments to all

panelists:

• Please, do not communicate directly to the speaker■ The speaker will not be checking the chat during this session

• All questions will be fielded by our panelists and addressed in the order in which they are submitted

Housekeeping Items

■ Sharing• When you want to share, use the hand raise feature and we will unmute

your line. It is located to the right side of your screen just below your name. • Put your hand down when your question has been acknowledged by clicking

the hand again.

Housekeeping Items

§ Associate Professor of Pharmacy Practice, UAMS College of Pharmacy

§ Lead antimicrobial stewardship pharmacist at St. Bernards Medical Center

§ Member of the Arkansas Department of Health’s Antimicrobial Stewardship Subcommittee

§ Chair of the Arkansas Association of Health-System Pharmacists’ Antimicrobial Stewardship Task Force

Dr. Marsha Crader, PharmDPharmacist

Welcome, Marsha

■ Abbreviated pre-assessment survey results■ Opportunity to ask questions and share■ UTI and asymptomatic bacteriuria overview

(including Q&A since January webinar)• Marsha Crader, PharmD

■ Facility examples• Julie Carman APRN FNP-BC, Progressive Care Medical Group• Brooke Johnson, PharmD, Northwest Health System

■ Lessons learned • Attendees sharing

Webinar Outline

■ When completing the NHSN annual survey, does your facility have a process in place to ensure data is collected and reported based on feedback from a multidisciplinary team?• Yes 49 (86%)• No 8 (14%)

Pre-assessment Survey Results: NHSN Survey Collaboration

■ Does your facility produce an antibiogram (i.e., cumulative antimicrobial susceptibility report) annually?• Yes 48 (84.2%)• No 9 (15.8%)

Pre-assessment Survey Results: Antibiogram

■ Does your facility share the antibiogram with prescribers?• Yes 46 (80.7%)• No 11 (19.3%)

■ Is education provided to prescribers and health care personnel on antibiograms?• Yes 31 (54.4%)• No 26 (45.6%)

■ Does your facility have a process to eliminate duplicates by including only the first isolate of a species per patient, irrespective of body site, or culture susceptibility result?• Yes 27 (56.3%)• No 21 (43.8%)

■ Does your laboratory use Clinical and Laboratory Standards Institute (CLSI)

minimum inhibitory concentration breakpoints to determine culture and

susceptibility results?

• Yes 43 (75.4%)

• No 14 (24.6%)

■ Do they suppress/hide susceptibility results that do not match CLSI

recommendations or receive alerts to address antibiotic therapy choices with the

physician?

• Yes 2 (14.3%)

• No 12 (85.7%)

Pre-assessment Survey Results: Microbiology

■ Does your pharmacist(s) and/or ID physician(s) work with microbiology to determine which antibiotics are tested andreported with specific organisms?• Yes 36 (63.2%)• No 21 (36.8%)

Pre-assessment Survey Results: Microbiology

■ Does your facility utilize specific criteria to determine when or if urinalysis and/or urine cultures should be performed?• Yes 36 (63.2%)• No 21 (36.8%)

■ Are your prescribers and frontline staff educated on the criteria?• Yes 34 (94.4%)• No 2 (5.6%)

Pre-assessment Survey Results: UA and Urine Culture

■ Prescribers and other health care personnel appropriately order and collect specimens• Yes 42 (73.7%)• No 10 (17.5%)• Process monitored 12 (21.1%)

Pre-assessment Survey Results: Specimen Collection

■ What other questions do you have?■ What changes have you made since the

last webinar or since the collaborative started?

Discussion

■ Question: A nursing home is having issues with hospitals in its area only collecting UAs with no urine cultures. Based on that information alone, they are starting antibiotic therapy in ED and admitted patients.

■ Answer: The complete answer is to come in the webinar discussion today, but it will take communication with the local hospitals and providers to help change this practice. A UA alone does not provide complete data when assessing a nursing home resident’s need for antibiotics, particularly if the patient is on the correct antibiotic based on culture and susceptibility results. Not having the urine culture also does not allow providers to de-escalate antibiotic therapy.

Q&A Since January Webinar

Antibiotic Stewardship: UTI and Asymptomatic Bacteriuria

Arkansas Antibiotic Stewardship and Infection Prevention CollaborativeFeb. 14, 2019

Marsha Crader, PharmD

■ Marsha Crader, PharmD, has no conflicts of interest to report

Disclosures

■ Describe how to determine if a patient’s presentation indicates a urinary tract infection, colonization (i.e., asymptomatic bacteriuria), or contamination

■ Discuss antibiotic selection, dosing, and length of therapy considerations

■ Provide examples of antimicrobial stewardship opportunities (e.g., documentation, education, processes, transitions of care)

Objectives

Lower Urinary Tract■Cystitis• Infection of bladder

■Prostatitis• Infection of prostate

■Asymptomatic bacteriuria• Colonization, no infection• No symptoms

Upper Urinary Tract■Pyelonephritis• Infection of the kidney

■Renal/perirenal abscess

Common Types of Urinary Tract Infection (UTI)

■ Signs/symptoms■ Urinalysis (UA)■ Urine culture

UTI Determination

Common■ Dysuria■ Frequency■ Urgency■ Suprapubic/Costovertebral angle

tenderness pain/tenderness■Mental status change

• Just because a geriatric patient is confused does not mean that he/she has a UTI

• http://www.amjmed.com/article/S0002-9343(13)00930-3/pdf

Nonspecific■Fatigue■ Irritability■Malaise■Nausea/vomiting■Headache■Abdominal/back pain

Signs and Symptoms of Lower UTI

Signs and Symptoms■Can exhibit lower UTI symptoms■Fever■Flank pain

Lab/Imaging Findings■Leukocytosis■WBC casts■Abnormalities on imaging

Signs and Symptoms and Lab/Imaging Findings of Upper UTI

■ Considerations for patients with urinary catheters• New onset or worsening fever, rigors, altered mental status, malaise, or lethargy with

no other identified cause• Flank pain• Costovertebral angle (CVA) tenderness• Acute hematuria• Pelvic discomfort• Changes in urine color, odor or cloudiness by itself does not indicate infection

■ Considerations for spinal cord injury patients with urinary catheters• Increased spasticity• Autonomic dysreflexia• Sense of unease

Signs and Symptoms of Catheter-Associated UTI (CAUTI)

■ Signs/Symptoms■ Urinalysis (UA)■ Urine culture

UTI Determination

1) Does the patient have signs or symptoms of a UTI when assessment is possible?■ Patients with chronic indwelling urinary catheters may have a

“positive” UA for UTI without infection◦ Catheters can irritate the lining of the bladder wall causing pyuria (i.e., WBCs in

urine)■ Neutropenic patients will not have a “positive” UA since urine WBCs

will not be increased

What to Consider Before Ordering a UA or Urine Culture

2) Did the patient come into the hospital with a chronic catheter, especially if placed >=2 weeks prior to admission?

orDid the patient have a chronic catheter placed >= 2 weeks in the hospital prior to urine specimen collection?■ If yes, order removal or replacement of current catheter before urine

specimen is collected to avoid colonized organisms that may have formed a biofilm on the catheter and influence what organisms are identified in the culture

3) When is a patient considered to have a CAUTI by Infection Prevention?■ Simplified definition: If a patient with a catheter has urine

specimen(s) collected and is considered to have a UTI two midnights after admission or placement of catheter in the inpatient setting

■ Markers of Infection• WBC elevated (>5 to TNTC)■ Indicates pyuria (more sensitive than leukocyte esterase)■ Normal value: 0-4■ WBCs may be elevated for inflammatory disorders

◦ Chronic urinary catheter usage, STDs, renal tuberculosis, interstitial nephritis■ WBCs will not be elevated in neutropenic patients

Urinalysis – Microscopic UA

■ Markers of Infection• Leukocyte esterase present (trace, small, moderate or large)■ Enzyme released by WBCs presumably in the response to bacteria in the

urine■ Normal value: negative

■ Markers of Infection• Nitrite positive■ Normal value: negative■ Positive value usually indicates Gram (-) bacteria◦ Enterobacteriacea bacteria can convert nitrate to nitrite in urine

• Examples of bacteria that do not convert nitrate to nitrite: Enterococcus, Pseudomonas and Acinetobacter

◦ False positives and negatives may occur

■ Markers of infection• Bacteriuria• Hematuria■ May be helpful to determine UTI since bacterial infection of the

transitional cell lining of the bladder can cause bleeding■ Vaginitis and urethritis do not cause blood in the urine

• Detection of pyuria, hematuria (RBCs), proteinuria or bacteriuria ■ None of these alone is specific for infection

■ Other considerations (not all inclusive)• Elevated numbers of epithelial cells (>5/high power field) may mean the

urine specimen is contaminated • Limitations of specific UA testing method at facility ■ See St. Bernards Medical Center (SBMC) examples on next slides

■ Leukocytes• Elevated glucose concentrations (>=3 grams/dL) may cause decreased test results• Cephalexin or high concentrations of oxalic acid may cause decreased test results• Tetracycline may case decreased reactivity, and high levels of the drug may case a

false negative reaction• Positive results may occasionally be due to contamination of the specimen by

vaginal discharge

■ Nitrite• False negative results may occur with shortened bladder incubation of the urine,

absence of dietary nitrate, or the presence of nonreductive pathological microbes.■ Examples of bacteria that do not convert nitrate to nitrite: Enterococcus,

Pseudomonas and Acinetobacter

SBMC UA Limitation Examples

■ pH• Bacterial growth by certain organisms in a specimen may cause a marked

alkaline shift (pH >8.0), usually because of urea conversion to ammonia■ Urea-splitting organisms include Proteus, Klebsiella, Ureaplasma urealyticum■ High pH may also signify struvite kidney stones

■ Blood• Captopril may reduce sensitivity• Certain oxidizing contaminants, such as hypochlorite, may produce false

positive results• Microbial peroxidase associated with UTI may cause a false positive reaction

■ Protein• Visibly bloody urine may cause falsely elevated results

■ Specific gravity• The Bayer SG test is dependent on ions in urine and results may differ from

those obtained with other specific gravity methods when certain nonionic urine constituents, such as glucose, are present

• Highly buffered alkaline urines may cause low readings, while the presence of moderate quantities of protein (100 to 750 mg/dL) may cause elevated readings

White Cells LeukocyteEsterase

Nitrite Bacteria

Not infected <5 (-) (-) (-)

Definitely

infected

>10 (+) (+)

May also be (-)

depending on

causative

microorganism

Note: (+) UA in catheterized patient is not useful since pyuria and hematuria may be

present without UTI

Interpreting UA

■ Signs/Symptoms■ Urinalysis (UA)■ Urine culture

UTI Determination

■ Review full culture report, not just susceptibilities• Colony forming units/mL (CFU/mL) is vital to diagnosis depending on the

how urine was collected • If questionable results, question patient how urine collected, review nursing

notes/ I&Os, etc.■ Was the patient on antibiotics prior to urine collection?

What to Consider When Reviewing Urine Culture Results

■ Availability of results

• Gram stains within ~24 hours of collection

■ Subjective findings determined under a microscope by personnel

• Final culture results within ~72 hours of collection unless rapid diagnostic

testing available

■ Usually objective findings determined by automated instrument

■ Empiric treatment based on antibiogram should be switched to

targeted treatment based on patient-specific culture results

What to Consider When Reviewing Urine Culture Results

■ Collected from clean catch/voided urine• Infection present

■ > 100,000 CFU/mL with symptoms• No infection present

■ Growing bacteria without symptoms◦ Contamination

• Lab result may indicate <1,000 CFU/mL or <5,000 CFU/mL skin flora◦ Colonization (i.e., asymptomatic bacteriuria)

• Lab result may indicate as high as >100,000 CFU/mL of an organism• See exceptions that may require treatment on “Infection, Colonization

or Contamination?” slides

Urine Culture

■ Collected from indwelling/in-and-out Foley catheter• Infection present

■ >1,000 CFU/mL* with symptoms■ *Technical definition, but some utilize >5,000 or >10,000 CFU/mL

• No infection present■ > 1,000 CFU/mL without symptoms indicates asymptomatic bacteriuria

Urine Culture

■ Should correlate UA with urine culture• UA should be positive with corresponding diagnostic bacteria CFU/mL (based

on collection source) • UTI diagnosis with (-) UA and (-) urine culture

■ Possibly received antibiotics prior to UA and /or urine culture (e.g., as home med, on MAR at hospital or nursing home prior to transfer, on admit)

• (+) UA with (-) urine culture (i.e., without corresponding diagnostic CFU/mL)■ Possible early phase of infection■ CFU/mL may be lower if voided specimen not collected from first morning urine

(e.g., uncomplicated symptomatic UTIs in nonpregnant women)

Infection, Colonization or Contamination?

■ (-) UA and (+) urine culture• (-) UA should not typically be treated unless collected neutropenic patient

suspected of UTI or those few patient populations where asymptomatic bacteriuria should be treated

• Possible contamination■ Identification of multiple organisms generally indicates contamination

• Possible asymptomatic bacteriuria if no symptoms present• Possible overgrowth of bacteria if not promptly transported to lab

■ (+) UA and (+) urine culture• UTI• Possible inappropriate culture collection

■ Collected from catheter bag■ Organism(s) are possible colonizers and Foley catheter was not removed/exchanged

prior to collection

Infection, Colonization or Contamination?

■ Definition• (+) urine culture without symptoms• Common colonizers include: E. coli, E. faecalis, E. faecium, Klebsiella, etc.

■ Typical patients (not all inclusive)• Chronic indwelling Foley catheters

■ Patients can colonize within 48 hours of catheter placement• Neurogenic bladder • Urinary stoma• Long-term care residents• Age >65 years

Asymptomatic Bacteriuria

■ Not an infection therefore not treated unless high-risk patient• High-risk patients

■ Undergoing genitourinary surgery (e.g., transurethral prostate resection)■ Neutropeunic■ Pregnant■ Renal transplant à controversial

• Unnecessary treatment can lead to increased UTIs and more resistant UTIs■ https://www.ncbi.nlm.nih.gov/pubmed/22677710■ https://www.ncbi.nlm.nih.gov/pubmed/26270684

Asymptomatic Bacteriuria

CID;2005;40:643-654.

Asymptomatic Bacteriuria Prevalence

■ Candida urine colonization is common with and without a catheter• Associated with DM, advanced age, renal transplants, indwelling

catheter/stent, broad spectrum antibiotics, etc.

■ Treatment is typically not indicated in asymptomatic patients• Asymptomatic candiduria usually resolves after catheter removal/replacement• Persistent asymptomatic candiduria should probably be treated in patients who

are immunocompromised (e.g, neutropenic, renal transplant) or those undergoing genitourinary surgery

• Fluconazole and Amphotericin B (original formulation, not liposomal) may be used for treatment, but Echinocandins do not concentrate in the urine

Asymptomatic Candiduria

■ Time for thought• What other questions do you have?

Discussion

■ UTI classifications■ Common pathogens■ Antibiotic therapy

• Choice considerations• Dose• Duration

UTI Treatment

Uncomplicated■Female■No urologic

abnormalities■No stones■No catheter

Complicated (not all inclusive)■ Men■ Pregnancy■ Urologic abnormality

• Obstruction, hydronephrosis, renal tract calculi or colovesical fistula■ Post-instrumentation

• Nephrostomy tubes, ureteric stents or bladder catheters■ Other chronic conditions such as spinal cord injury and neurogenic

bladder• More likely to have polymicrobial and multi-drug resistant organisms

(MDROs)■ Immunocompromised■ DM■ Recurrent infections despite adequate treatment

• MDRO potential

Classification of UTI

Uncomplicated■ E. coli■ Klebsiella spp.■ Proteus mirabilis■ Staph saprophyticus■ Enterococcus*

* Enterococcus may be a normal colonizer or pathogen

Complicated■ Any uncomplicated microorganisms■ Enterobacter spp.■ Citrobacter spp.■ Pseudomonas aeruginosa■ Staph aureus

Potential UTI Pathogens

■ Uncomplicated cystitis• Nitrofurantoin• SMX-TMP• Fluoroquinolones*• Beta-lactams

■ e.g., cephalexin, ceftriaxone

• Fosfomycin (?)

■ Complicated cystitis• Potentially

uncomplicated antibiotic choices

• Piperacillin-Tazobactam• Carbapenems• Aminoglycosides• Vancomycin• Daptomycin• Linezolid

■ Pyelonephritis• Potentially

aforementioned options except nitrofurantoin

*Due to local susceptibilities and new FDA warnings, try to avoid fluoroquinolones when possible

Potential Empiric Therapy

■ ESBLs or Amp C producers■ Pseudomonas■ Enterococcus (if true pathogen)■ Intrinsic resistance• e.g., Nitrofurantoin

Empiric Therapy Considerations

§ Urinary penetration/excretion is good (>90%): § Aminoglycosides§ Amoxicillin§ Amoxicillin-clavulanate§ Fosfomycin§ Cefazolin§ Cefepime§ Cephalexin§ Ciprofloxacin

§ Colistin§ Ertapenem§ Levofloxacin§ TMP-SMX§ Vancomycin§ Fluconazole§ Amyphotericin B§ Flucytosine

https://www.asp.mednet.ucla.edu/files/view/guidebook/Infectious_Syndromes_-_Urinary_Tract_Infections.pdf

Antibiotic Urinary Concentration

§ Urinary penetration/excretion is variable (30 to 60%): § Cefpodoxime

§ Ceftriaxone

§ Doxycycline

§ Tetracycline

§ Linezolid

§ Urinary penetration/excretion is poor (<30%):§ Azithromycin

§ Clindamycin

§ Oxacillin

§ Tigecycline

§ Caspofungin

§ Posaconazole

§ Voriconazole

https://www.asp.mednet.ucla.edu/files/view/guidebook/Infectious_Syndromes_-_Urinary_Tract_Infections.pdf

Antibiotic Urinary Concentration

■ Allergies• Obtain real allergy information• 10% of patients in the United States report having an allergy to penicillin, but

fewer than 1 percent have a true IgE-mediated reaction• Approximately 80% of patients with IgE-mediated penicillin allergy lose their

sensitivity after 10 years■ Fluoroquinolone FDA alerts• https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm51

3183.htm• https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforH

umanMedicalProducts/ucm612979.htm• https://www.fda.gov/Drugs/DrugSafety/ucm628753.htm

Other Antibiotic Considerations

■ TMP-SMX in patients on spironolactone• Sudden risk of death in elderly patients taking concomitantly • https://www.ncbi.nlm.nih.gov/pubmed/25646289

■ Concomitant warfarin• Possible interactions: TMP/SMX, fluoroquinolones, fluconazole, etc.

■ QTc prolongation• Associated with fluoroquinolones, fluconazole, etc.

■ Concurrent bacteremia• Prefer bactericidal and >=90 percent bioavailability when selecting oral

antibiotic

Other Antibiotic Considerations

Renal dosing

• Most antibiotics require renal dosing■ e.g., TMP-SMX, Amoxicillin-

clavulanate, Nitrofurantoin, Fluoroquinolones

Concentration versus time-dependent antibiotics• Fluoroquinolones

Dosing Considerations

■ Uncomplicated• Nitrofurantoin x5 days• Bactrim DS x3 days• Fluoroquinolone x3 days• Beta-lactams x3-7 days

■ Complicated• Catheter-associated UTI (CAUTI)

■ 7–14 days◦ Consider how quickly the

patient improved, if the Foley catheter was able to be removed/replaced, etc.

Cystitis Length of Therapy

■ Uncomplicated• Levaquin x5 days or Cipro x7 days

• Bactrim x14 days

• Beta-lactam x10-14 days

■ Complicated• Hospitalized patients require 7–

14 days of therapy

■ Consider how quickly the

patient improved, if the Foley

catheter was able to be

removed/replaced, etc.

Pyelonephritis Length of Therapy

■ Does the patient have symptoms?■ Correlate UA and urine culture

• If UA (-), typically do not treat unless high risk• Urine culture (+) in the following scenarios:

■ Clean catch (voided specimen): >100,000 CFU/mL■ Intermittent or indwelling Foley catheter: >1,000 CFU/mL*

■ Be careful not to treat asymptomatic bacteriuria, including candida colonization• Pyuria does not indicate an infection in catheterized patients

UTI Summary

■ If asked about empiric therapy options, refer to Sanford Guide, UpToDate, or guidelines along with current antibiogram

■ When appropriate, de-escalate to antibiotic with good renal concentration

■ Length of therapy is based on type of UTI and antimicrobial agent used

UTI Summary

■ Time for thought• What other questions do you have?

Discussion

■ Hospital algorithm■ Long-term care criteria and SBAR

UTI Determination Examples

https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/uti-asbu-guidance-final.pdf

Urine Culture Algorithm

Must meet one of the following criteria:§ Criteria 1

• Painful urination§ Criteria 2

• Fever* plus at least one of the following:■ Frequency, urgency, incontinence,

bloody urine, pain in area over urinarybladder (just above the pubic bone withno other known cause), flank pain or tenderness

■ *See tool for specific fever definition§ Criteria 3

• No fever, but at least two or more of theaforementioned symptoms

https://www.telligenqinqio.com/resource/our-work/antibiotic-stewardship-in-long-term-care/antibiotic-stewardship-in-long-term-care-resources/suspected-urinary-tract-infection-uti-action-tool/

Long-term Care Tool to Determine Urinalysis and Urine Culture Ordering Practices

https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T1-SBAR_UTI_Final.pdf

AHRQ Long-term Care UTI SBAR

■ Documentation• Requiring indication (i.e., symptoms) or utilization of SBAR for urine cultures• Improving processes for labeling of urine specimens (e.g., void vs catheter)

Antimicrobial Stewardship Considerations

■ Education/processes• Improving processes for collection and prompt transport of specimens

■ Do not collect just because urine is cloudy, changed color or has odor• Reflexing urine culture from (+) UA• Suppressing culture results?• Ensuring previous cultures are reviewed for changes in initial empiric therapy• Knowing when to treat versus not to treat positive urine culture• Prompting de-escalation and appropriate duration

■ Transitions of care• Home health and nursing homes

■ Same education on collection and transporting of specimens• Working to disseminate UA and culture results to appropriate provider and

current location of patient• Do not test for cure• Ensuring patient does not receive another course of antibiotics (i.e.,

antibiotic duration too long)

■ Infectious Diseases Society of America Guidelines (IDSA)• Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women

■ https://academic.oup.com/cid/article/52/5/e103/388285• Diagnosis, Prevention, and Treatment of Catheter-Associated UTIs in Adults

■ https://academic.oup.com/cid/article/50/5/625/324341• Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults

■ https://academic.oup.com/cid/article/40/5/643/363229

■ ProCE webinar (free)• See through the Cloudiness: Antimicrobial Stewardship Initiatives for

Asymptomatic Bacteriuria■ http://proce.learnercommunity.com/catalog/Pharmacist?2=page/2/page-

size/10/tags/ede8f66b-d026-4423-9979-5b93a5fc0c7a/sort-option/Title

Additional References and Resources

Julie Carman, APN FNP-BCProgressive Care Medical Group

■ 10 myths on UTIs■ Methods for preventing the “myths”■ Coordinating with your provider on symptomatic

treatment/antibiotic stewardship

Outline

■ Myth #1: The urine is cloudy and smells bad. My patient has a UTI.

■ Myth #2: The urine has bacteria present. My patient has a UTI.

■ Myth #3: My patient’s urine sample has >5 squamous epithelial cells per low-power field and the culture is positive. Because the culture is positive, I can disregard the epithelial cell count and treat the UTI.

Myths Regarding the Diagnosis and Treatment of UTIs

J Emerg Med. 2016;51(1):25-30.

■ Myth #4: The urine has positive leukocyte esterase. My patient should have a urine culture performed, has a UTI, and needs antibiotics.

■ Myth #5: My patient has pyuria. He/she must have a UTI.■ Myth #6: The urine has nitrates present. My patient has a UTI.■ Myth #7: All findings of bacteria in a catheterized urine sample

should be diagnosed as a UTI.

J Emerg Med. 2016;51(1):25-30.

■ Myth #8: Patients with bacteriuria will progress to a UTI and should therefore be treated.

■ Myth #9: Falls and acute altered mental status changes in the elderly patient are usually caused by UTI.

■ Myth #10: The presence of yeast or candida in the urine, especially in patients with indwelling urinary catheters, indicates a candida UTI and needs to be treated.

J Emerg Med. 2016;51(1):25-30.

https://www.ofmq.com/sites/default/files/McGeer%20Criteria%20for%20LTC%20Urinary%20Tract%20Infections.pdf

McGeer’s Criteria for UTIs

https://www.ofmq.com/sites/default/files/McGeer%20Criteria%20for%20LTC%20Urinary%20Tract%20Infections.pdf

McGeer’s Criteria for UTIs

Brooke Johnson, PharmDNorthwest Health System

* CHS 158 corporate hospital network * Tri-campus hub and spoke model stewardship program* Bentonville- 128 bed acute care hospital * Springdale- 222 bed acute care hospital * Willow Creek- 64 bed women’s hospital

Northwest Health System

Asymptomatic Bacteriuria Rule

Must include both of the following AND

* An active order for an anti-infective agent* AND* Urine culture resulted in an identifiable

organism

Must include one of the following

* Urinalysis is positive for leukocyte esterase within the last 14 days

* OR* Urinalysis is positive for WBC (>10 wbc/hpf)

within the last 14 days

* This patient may not warrant antibiotics if the indication is for UTI. The absence of leukocyte esterases or pyuria (WBC in urine > 10) is highly suggestive of contamination. Asymptomatic bacteriuria should not be treated unless patient is pregnant, neutropenic, or scheduled for urologic procedure.

Suggested Action

* Does not account for multiple sites of infection* Includes all routes of administration * IT challenges

Limitations

■ Time for thought• What other questions do you have?• What are you doing well that you can share with

the group?

What Can I Ask or Share?

https://www.healthy.arkansas.gov/programs-services/topics/hai-certification-trainings

Continuing Medical Education (CME)

■ The visits are:• Nonregulatory• Collaborative• Confidential• Exempt from any FOI request• Approximately a two- to four-hour, face-to-face time commitment

Infection Control Readiness Assessment (ICAR) Visits

■ What’s in it for you?• Infectious disease physician will lead the review• We will report to you with strengths and recommendations• Policies/protocols from our team and other facilities/CDC• Good ideas and suggestions we have learned from other assessments• Recommendations on where to focus education and training

Infection Control Readiness Assessment (ICAR) Visits

You can also email adh.hai@arkansas.gov

Kelley Garner, MPH MLS (ASCP)CM

Healthcare-Associated Infections ProgramArkansas Department of Health

Phone: 501-661-2296Kelley.Garner@Arkansas.gov

Want to Schedule an ICAR visit?

■ This visits are:• Nonregulatory• Confidential• Collaborative• Exempt from any FOI request• 100 percent voluntary• On-site, face-to-face meetings (approximately 1–1.5 hour time commitment)

Statewide Antimicrobial Stewardship Initiative (SASI) Visits

■ What are the benefits of participating?• Antimicrobial stewardship pharmacist fellow will lead the review• Highlight the strengths of your antimicrobial stewardship program• Provide any noted recommendations to help your program continue to grow• Share antimicrobial stewardship resources complied by our team• Provide recommendations and opportunities for education with your

medical staff• Provide an outside voice of support for your program

Statewide Antimicrobial Stewardship Initiative (SASI) Visits

Corey Lance, PharmD Pediatric Infectious

Diseases/Antimicrobial

Stewardship and Public Health Fellow

Arkansas Department of Health

501-614-5279

Corey.Lance@arkansas.gov

Kelley Garner, MPH MLS (ASCP)CM

Healthcare-Associated Infections

Program Coordinator and Epidemiology

Supervisor

Arkansas Department of Health

501-661-2296

Kelley.Garner@arkansas.gov

You can also email adh.hai@arkansas.gov

Want to Schedule a SASI Visit?

Dates 12/13/18 1/10/19 2/14/19 3/14/19 4/11/19 5/9/19 6/13/19Antibiotic Stewardship

Antibiograms Tracking and Reporting

UTI Asymptomatic Bacteriuria

Pharmacy-Led Interventions Allergies

Bugs and Drugs

Infection Related

Community and Patient Education

Infection Prevention

Surveillance and Laboratory

Data Education Cleaning Isolation Hand Hygiene

Antibiotic Stewardship

Webinar Series

■ Learn from one another■ Send us your stories of stewardship and infection control • Lessons you have learned• Barriers you had or are encountering• Successful ways you have overcome barriers

■ Ask questions of our experts• Use this opportunity to expand your knowledge• Get specific about your needs, gaps or understanding

■ Email us at drugsandbugs@afmc.org

Tell Us Your Stories, Ask Us Your Questions

■ Be sure to complete the post-webinar survey■ Link located in the chat■ We use your feedback to:

• Improve the webinar experience• Develop content for further discussion• Identify opportunities for improved learning• Identify ways in which we can better meet your needs

We Need Your Feedback!

■ Complete the post-webinar survey to obtain your CEs.■ You must enter a valid email address. This is how you will receive

your certificate. ■ One email address per survey. ■ CE certificates will be emailed after survey closes COB February 15.■ Link to the survey is located in the chat. You can access it there, or

type the link into your web browser. https://www.surveymonkey.com/r/FNTF3VT

Nursing/Nursing Home Administrator CEs

Webinar Series

Thank you for attending

Webinar 5 & 6

antibiotic stewardship and infection prevention

Documents

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