IMPROVING DRUG USE TO ENHANCE INFECTION

PREVENTION: ANTIBIOTIC STEWARDSHIP AND BEYOND

CDI Prevention Partnership CollaborativeWorkshop

May 16, 2012www.macoalition.org

      

              

               

                              

           

MEASURE / MONITOR

Hospital / Long Term Care Partnerships

C. Difficile Prevention Partnership Collaborative

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Upcoming Events June 22nd C. Difficile Prevention Partnership

Collaborative Learning and Sharing Workshop Learn additional strategies for C. diff prevention from local and

national experts, and your Massachusetts colleagues

Contact Fiona Robertsfroberts@macoalition.org

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Contacts 

                                                                              

Susanne Salem-Schatz

Fiona Roberts, MA Coalition for Prevention of Medical Errors

Helen Magliozzi, MA Senior Care

Eileen McHale, Department of Public Health

sss@hcqi.com

froberts@macoalition.org

hmagliozzi@maseniorcare.org

eileen.mchale@state.ma.us

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Program Overview Morning workshop: Antibiotic Stewardship Overview: Opportunities in long term care Appropriate diagnosis and treatment of UTI in acute and long term

care Communication about antibiotic treatment inside and across facilities:

working with with residents/ families, colleagues, and transferring facilities

 

ALL programs grant CME / CEUs for physicians, nurses, pharmacists and long term care administrators

 

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Faculty Disclosure

Today’s presenters have no financial interests or relationships to disclose.

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Antibiotic stewardship and the

opportunities in long term care

Paula Griswold

Massachusetts Coalition for the

Prevention of Medical Errors

Antibiotics in Long Term Care:why do we care?

• Antibiotics are among the most commonly prescribed classes of medications in long-term care facilities

• Up to 70% of residents in long-term care facilities per year receive an antibiotic

• It is estimated that between $38 million and $137 million are spent each year on antibiotics for long-term care residents

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The importance of prudent use of antibiotics

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Bad Bugs No Drugs

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The burden of infection in long term care

• 12 studies in North America:– 1.8-13.5 infections per 1000 resident-care

days– Rate of death from infection 0.04-0.71 per

1000 resident-care days

Strausbaugh et al. Infection Control and Hospital Epidemiology 2000, 21(10), p. 674-679

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The burden of resistance in long term care

• Rogers et al:– Over 3000 LTCFs– One year (2003)– Incidence of new infection caused by an

antibiotic-resistant organism was 12.7 per 1000 patients

Rogers et al. Journal of Infection Control 2008, Volume 36, Issue 7, Pages 472-475

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A Balancing Act

Appropriate initial antibiotic while improving patient

outcomes and healthcare

Antimicrobial Therapy

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Unnecessary Antibiotics, adverse

patient outcomes and increased cost

Why focus on long term care?

• Many long-term care residents are colonized with bacteria that live in an on the patient without causing harm

• Protocols are not readily available or consistently used to distinguish between colonization and true infection

• So, patients are regularly treated for infection when they have none– 30-50% of elderly long-term care residents have a

positive urine culture in the absence of infection

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Why focus on long term care?

• When patients are transferred from acute to long-term care, potential for miscommunication can lead to inappropriate antibiotic use

• Elderly or debilitated long-term care residents are at particularly high risk for complications due to the adverse effects of antibiotics, including Clostridium difficile infection

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Common long-term care scenarios in which antibiotics are not needed

• Positive urine culture in the absence of symptoms (cloudy or smelly urine should not be considered symptoms)

• Upper respiratory infection (common cold with or without fever, bronchitis, sinusitis not meeting clinical criteria for antibiotics)

• Abnormal chest x-ray without signs/symptoms of respiratory infection

• Positive wound culture in the absence of cellulitis, abscess or necrosis

• Diarrhea in the absence of positive C. diff toxin assay

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Long term facilities can*• Establish multidisciplinary teams to address

antibiotic stewardship and optimal drug use• Have protocols that outline the appropriate

circumstances for use of antibiotics• Review antibiotic culture data for trends suggesting

a worsening resistance problem• Have protocols ensuring that cultures are checked

and antibiotics adjusted according to culture results• Establish programs for periodic review of antibiotic

utilization

*Centers for Disease Control21

Long term facility providers should*

• Obtain cultures whenever available when starting antibiotics, and check results, adjusting antibiotics appropriately to the narrowest spectrum agent possible

• Avoid the use of antibiotics for colonization or viral infections, and keep the duration as short as possible

• Take care to effectively communicate with the transferring facility re pending lab results and plan for antibiotics and follow-up

*Centers for Disease Control 22

Nurses Can

• Be familiar with current protocols for testing and treatment of urinary tract infection

• Educate families and residents that many respiratory infections are caused by viruses and do not require antibiotics

• Identify advanced directives for limited treatment• Follow up with referring facility regarding pending

lab results

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Physicians / NPs can• Obtain cultures whenever available when starting antibiotics, and check

results, adjusting antibiotics appropriately to the narrowest spectrum agent possible

• Avoid the use of antibiotics for colonization or viral infections, and keep the duration as short as possible

• Encourage use of screening tools and protocols to decrease the use of unnecessary antibiotics.

• Educate fellow clinicians, staff and family members on appropriate use of antibiotics

• Implement measures to reduce the need for treating with antibiotics (avoidance of indwelling urinary catheters, maximizing immunization levels, decubitus ulcers, etc.

• Take care to effectively communicate with the transferring facility re pending lab results and plan for antibiotics and follow-up

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Pharmacists can• Get more involved with infection control issues in each facility serviced,

particularly antibiotic treatment of symptomatic versus asymptomatic UTIs.

• Review antibiotic utilization and, where possible, appropriateness; identify opportunities for improved prescribing to discuss at quarterly QI meetings.

• Educate physicians and nursing staff about targeted antibiotic use, using a narrow spectrum antibiotic based on culture results.

• Prepare updated and easily accessible protocols for certain antibiotics; monitor vancomycin trough levels and focus on monitoring for appropriate vancomycin doses, dosing intervals and duration of therapy

• Avoid simultaneous administration of “heavy metal” drugs (containing Fe, Ca, Zn, Mg, etc) with Quinolones. Either temporarily hold or administer these drugs AT LEAST Six (6) hours BEFORE or Two (2) hours AFTER the Quinolones.

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What facilities can do together• Develop communication tools to share critical information between

acute and long term facilities when patients are transferred– Culture results– Pending results– Treatments initiated (what, when, indication, stop date)– Precautions– Immunizations– History of C. difficile

• Ensure contact information is provided for follow up on patient history and pending test results.

• Establish cross-facility teams to address infection prevention and antibiotic stewardship.

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