Antibiotic Stewardship in the Post Acute and Long Term Care Settings Nancylee B. Stier, MD Michigan Medicine September 18, 2017

ATB Use in SAR/LTC Antibiotics are among the most frequently prescribed medications in nursing homes Up to 70% of residents in a nursing home receive one or more courses of systemic antibiotics per year.

ATB Harms risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions (i.e. rash, AIN, warfarin) Increases colonization and/or infection with antibiotic-resistant organisms.

Impact of fluoroquinolone restriction on rates of C. difficle infection HO-CDAD cases/1,000 pd 2005 2006 2007 Month and Year Infect Control Hosp Epidemiol. 2009 Mar;30(3):264-72.

ATB Resistance

Handwashing Did you know that four out of five germs that cause illness are spread by hands? Up to 30% of SNF staff have GNB on random hand culture. Cleaning hands is one of the most important steps health care providers - and all of us - can take to prevent the spread of infection-causing germs. Numerous studies show that infections can be prevented in the hospital if health care providers use proper hand hygiene. Keeping your hands clean is an important way to avoid getting sick or spreading germs to patients, coworkers, etc.  University of Michigan Hospitals and Health Centers, policy requires health care professionals to wash their hands or use a hand sanitizer before and after every patient contact. If you notice that someone has forgotten to practice appropriate hand hygiene, feel free to remind them. Taken from www.med.umich.edu/

Sample Commitment to Handwashing Given to patients upon their arrival with questions on the back to check off. Be a partner in your healthcare! Here at our facility, our goal is to provide you with the safest and highest quality healthcare. We use soap and water or hand sanitizer to clean our hands and help prevent the spread of germs. Become a partner in your healthcare and let us know how we’re doing! Please observe your healthcare providers while you are here/in clinic today to see if they are cleaning their hands before physical contact with you. Complete the reverse side of this card and hand it to the check-out clerk on your way out. Our check-out clerk will provide you with a token of our appreciation for completing this card.

Healthcare Infection Control Practices Advisory Committee HICPAC GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 Appropriate Urinary Catheter Use Proper Techniques for Urinary Catheter Insertion Proper Techniques for Urinary Catheter Maintenance

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 HICPAC Appropriate Urinary Catheter Use Insert catheters only for appropriate indications (see Table 2 for guidance), and leave in place only as long as needed. (Category IB) Urinary retention To assist in healing of open sacral or perineal wounds in incontinent patients To improve comfort for end of life care, if needed Avoid use of urinary catheters for management of incontinence.

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 HICPAC Appropriate Urinary Catheter Use (cont’d) portable ultrasound device to reduce unnecessary catheter insertions. cleaned and disinfected in between patients Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II)

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 Proper Techniques for Urinary Catheter Insertion Hand hygiene before and after procedure OR any manipulation of the catheter or site Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. (Category IB) Properly secure indwelling catheters after insertion to prevent movement and urethral traction.

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 HICPAC Proper Techniques for Urinary Catheter Maintenance Maintain unobstructed urine flow, no kinks, bag lower than bladder Use Standard Precautions, including gloves and gown as appropriate, during any manipulation of the catheter or collecting system. Drain regularly, avoid splashing, keep spigot untouched

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 HICPAC Proper Techniques for Urinary Catheter Maintenance Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II) If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. (Category IB)

GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 HICPAC Specimen Collection Obtain urine samples aseptically. (Category IB) If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (Category IB) Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (Category IB)

Think About Urine Cultures Before Ordering Obtaining Urine cultures leads to atb Rx! It is a health care Tradition GOAL would be to avoid unnecessary urine cultures. Examine pt and look at indications and pre-test probability of true infection before deciding to obtain a culture.

Asymptomatic Bacteriuria The diagnosis of asymptomatic bacteriuria should be based on results of culture of a urine specimen collected in a manner that minimizes contamination (A-II) Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (A-II). Screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate or invasive bladder instrumentation is recommended (A-I).

Asymptomatic Bacteriuria Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons. Premenopausal, nonpregnant women (A-I). Diabetic women (A-I). Older persons living in the community (A-II). Elderly, institutionalized subjects (A-I). Persons with spinal cord injury (A-II). Catheterized patients while the catheter remains in situ (A-I).

Asymptomatic Bacteriuria Pyuria is evidence of inflammation in the genitourinary tract and is common in subjects with asymptomatic bacteriuria. Pyuria is present with asymptomatic bacteriuria in 32% of young women, 30%–70% of pregnant women 70% of diabetic women, 90% of elderly institutionalized patients 90% of hemodialysis patients 30%–75% of bacteriuric patients with short-term catheters 50%–100% of individuals with long-term indwelling catheters in place, urostomies, suprapubic catheters.

McGeer (1991) –No catheter, 3 of the following: •Fever (>38⁰C) or chills •New or increased burning pain on urination, frequency or urgency •New flank or suprapubic pain or tenderness •*Change in character of urine •Worsening of mental or functional status (may be new or increased incontinence) *clinical (blood, odor, sediment) or lab-based changes

McGeer Criteria Updated Nimalie Stone, et al.ICHE, 2012;33:995-977 CDC/SHEA •Endorsements: medical and professional societies, US and Canada •Definitions revised based on published literature & expert opinion (not systematically validated) •Change: Urinary tract infection & respiratory tract infections •Added: Norovirus gastroenteritis & C. diff infection

Revisiting the McGeer Criteria Infect Control Hosp Epidemiol Revisiting the McGeer Criteria Infect Control Hosp Epidemiol. 2012 Oct; 33(10): 965–977 Infection surveillance definitions for LTC (McGeer Criteria) had not been updated since 1991. 2008 Infectious Diseases Society of America (IDSA) guideline for evaluating fever/infection in older adults residing in LTCFs: either (1) a single oral temperature greater than 100°F (2) repeated oral temperatures greater than 99°F or rectal temperatures greater than 99.5°F or (3) a single temperature greater than 2°F over baseline from any site

Revisiting the McGeer Criteria Infect Control Hosp Epidemiol Revisiting the McGeer Criteria Infect Control Hosp Epidemiol. 2012 Oct; 33(10): 965–977 The revised definitions take into account the low probability of UTI in residents without indwelling catheters if localizing symptoms are not present, as well as the need for microbiologic confirmation for diagnosis.

Criteria: UTI w/o Catheter CDC/SHEA (2012) If No catheter, both criteria 1 and 2 must be present: Criteria 1: At least 1 sign or symptom - •Acute dysuria or pain, swelling, tenderness (testes, epididymis, prostate) •Fever or leukocytosis and at least 1 of the following: -Acute costovertebral angle pain -Suprapubic pain -New/increase incontinence -Gross hematuria -New/increase urgency In the absence of fever or leukocytosis: 2 or more of the localizing urinary tract criteria shown above Criteria 2: At least 1 microbiology criteria: •>=10x5 CFU/ml of no more than 2 organisms in a voided urine sample •>10x2 CFU/ml of any number of organisms in-and-out catheter sample--?

McGeer vs CDC/SHEA UTI: McGeer Criteria •Fever: >38.0⁰C (100.4⁰F) •Mental status change or functional decline criteria for UTIs for both catheter and no catheter UTI: CDC/SHEA Criteria •Fever: Single temp >37.8⁰C (100⁰F), repeat temp >37.2⁰C (99⁰F), or 1.1C (2⁰F) over baseline •Urine culture required to define UTI •Add: Leukocytosis •Delete: Change in urine character

Decision pathway to reduce unnecessary diagnostic testing of urine samples in long-term care facilities (adapted from Crnich and Drinka)

CDC has Guidelines for ATB Stewardship in SNF Modified from the hospital guidelines Some guidelines are more easily adapted than others CDC recommends: All nursing homes take steps to: improve antibiotic prescribing practices and reduce inappropriate use.

Introducing ATB Stewardship Antibiotic stewardship refers to a set of commitments and activities designed to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use.” Get staff buy-in, keep it positive, education about their benefit with these measures Proceed with several angles to promote information

Summary of Core Elements for Antibiotic Stewardship in Nursing Homes Leadership commitment Demonstrate support and commitment to safe and appropriate antibiotic use in your facility Accountability Identify physician, nursing and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities in your facility Drug expertise Establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship for your facility Action Implement at least one policy or practice to improve antibiotic use Tracking Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in your facility Reporting Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff Education Provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic

ATB Stewardship Get the Five Provider orders for antibiotics should include clear documentation for FIVE elements: 1.drug, 2.dose, 3.route, 4.duration 5.indication. (1)Levaquin (2)500 mg (3)po x (4)7 days for dx (5)UTI Culture before ATB First dose STAT, order a drug available in your backup

ATB Stewardship Policies should discourage the use of: prophylactic antibiotics for prevention of UTI routine urine dipstick testing when evaluating a resident experiencing a change in condition. Limit the use of fluoroquinolone antibiotics strong relationship to C. difficile high rates of resistance among urinary pathogens, already present or induced

ATB Stewardship ATB Time Out 48 hours after start Identify appropriateness of continued ATB Tx Review Cx and Sens. Simplify atb therapy. Confirm the 5 elements are still appropriate Consider renal fxn in dosing