I MPROVING DRUG USE TO ENHANCE INFECTION PREVENTION : ANTIBIOTIC STEWARDSHIP AND BEYOND CDI Prevention Partnership Collaborative Workshop May 16,

10/11 Team call 11/11 Kickoff Workshop 12/11 Coaching Call 1/12 Leadershi p call Refresher call Regional workshop s 4/12 Antibiotic Stewardsh ip Call (overview + PPI us) 4&5/12 Regional Antibiotic Stewardship Workshops 6/12 Statewide Learning & Sharing Workshop MEASURE / MONITOR Hospital / Long Term Care Partnerships C. Difficile Prevention Partnership Collaborative 2

Upcoming Events ¡ June 22 nd 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 Roberts 3

Contacts Susanne Salem-Schatz Fiona Roberts, MA Coalition for Prevention of Medical Errors Helen Magliozzi, MA Senior Care Eileen McHale, Department of Public Health 4

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 5

Faculty Disclosure ¡ Today’s presenters have no financial interests or relationships to disclose. 6

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 8

The importance of prudent use of antibiotics 9

Bad Bugs No Drugs 10

The burden of infection in long term care 12 studies in North America: – infections per 1000 resident-care days –Rate of death from infection per 1000 resident-care days Strausbaugh et al. Infection Control and Hospital Epidemiology 2000, 21(10), p

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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

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A Balancing Act Appropriate initial antibiotic while improving patient outcomes and healthcare Antimicrobial Therapy 16 Unnecessary Antibiotics, adverse patient outcomes and increased cost

What is Antimicrobial Stewardship? Antimicrobial stewardship involves the optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost. Dellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11: Paskovaty A, et al IJAA 2005;25:1-10 Simonsen GS, et al Bull WHO 2004;82: Ultimate goal is improved patient care and healthcare outcomes 17

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 18

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 19

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 20

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 Control 21

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 23

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 24

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. 25

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. 26