Antibiotic Stewardship in Long-Term Care: Asymptomatic Bacteriuria. Justin Rash, PharmD, CGP Erin Lockard, PharmD, BCPS

Transcription

1 Antibiotic Stewardship in Long-Term Care: Asymptomatic Bacteriuria Justin Rash, PharmD, CGP Erin Lockard, PharmD, BCPS

2 Objectives Discuss what antibiotic stewardship is and why it is important in long-term care (LTC) Identify tools for developing stewardship in LTC Define asymptomatic bacteriuria (ASB) and describe incidence in elderly LTC population Identify signs and symptoms of urinary tract infection and differentiate from ASB Determine patients who meet criteria for urine testing Describe risks associated with antibiotic use in elderly LTC population Utilize tools for monitoring UTI symptoms and communication with providers

3 What is Antibiotic Stewardship? Antibiotic Stewardship- optimize the treatment of infections while reducing the adverse events associated with antibiotic use 1 Up to 70% of residents in a nursing home received one or more courses of systemic antibiotics in one year % of antibiotics prescribed in nursing homes may be unnecessary or inappropriate 1 At least 2 million people become infected with antibioticresistant bacteria and 23,000 die from these infections 2

4 Who is Antibiotic Stewardship Important too? CMS State Operations Manual rewrite expected to have increased focus on this topic 6 Infection Prevention and Control Program Protocols for monitoring use Designated Infection Prevention and Control Officer- specialized training Staff Training Requirements Annual review and update Quality Measures Long-stay residents with urinary tract infection CDC 1 September 2015 Released Core Elements of Antibiotic Stewardship in Nursing Homes Checklist

5 What is the Problem with Over use? Increased adverse drug reactions Warfarin Increased adverse drug events Diarrhea, Hepatotoxicty, Ototoxicity, tendon rupture, Rash, Stevens Johnsons Syndrome, Neurotoxicity, Anaphylaxis, QT prolongation Antibiotic Resistance Drugs versus Bugs- Bugs always WIN Multidrug resistance Clostridium Difficile Infections 1 in 9 with healthcare associated C. Diff infection died within 30 days of diagnosis 1 30% of C. Diff diagnosed patients readmitted within 30 days 1 More then 80% of deaths associated with C. Diff infection occurred among patients aged 65 or older 3 Antibiotic pipeline has stalled

6 Stewardship Tools CDC 1 : AHRQ 5 Core Elements of Antibiotic Stewardship in Nursing Homes Not All Infections Need Antibiotics UTI SBAR Letter for Clinicians Power Point Presentation Antibiotic Pocket Cards

7 Stewardship Tools 4 Minnesota Department of Health: Minnesota Antimicrobial Stewardship Program for Long-term Care Facilities The Michigan Antibiotic Resistance Reduction Coalition (MARR) Long-term Care Toolkit Greater New York Hospital/United Hospital Fund: Antimicrobial Stewardship Toolkit Public Health Ontario: Antimicrobial Stewardship

8 Asymptomatic Bacteriuria (ASB) and UTI in Elderly Patients

9 Urinary Tract Infections in Elderly Most frequently diagnosed infection in LTC residents Over 1/3 of all nursing home infections 1 Incidence of symptomatic urinary infection that varies from 0.1 to 2.4 cases per 1000 resident-days 2 Presumed UTIs account for 20-60% of antimicrobial courses in LTCs 3

10 Principles of UTI Diagnosis Bacteria in the urine does not always = infection Urine can be colonized with bacteria in many patients, especially the elderly, and does not require treatment if not associated with symptoms of infection Diagnosis should be made primarily based on patient symptoms Urinalysis (UA) may rule out UTI, but not useful alone for diagnosis Urine culture results are used to guide antibiotic selection, not treatment initiation UTIs presenting without localized urinary symptoms are rare

11 Diagnosis of UTI in LTC Loeb Criteria/Updated McGeer Criteria: Patients without catheter Acute dysuria or fever ( 100⁰F or > 2.4⁰ higher than baseline) accompanied by the new or worsening presence of at least one of the following: Urgency Frequency Suprapubic pain Gross hematuria Costovertebral angle (CVA) tenderness Urinary Incontinence All symptoms should be new or acutely worse Criteria developed as a minimum to empirically treat with antimicrobial therapy in patients with laboratory evidence of UTI (pyuria, bacteriuria) Loeb M, et al Stone ND, et al. 2012

12 Diagnosis of UTI in LTC McGeer and Loeb criteria are not evidence based, based on expert consensus McGeer- 57% positive predictive value (PPV) and 61% negative predictive value (NPV) Loeb- 57% PPV, 59% NPV Pyuria (>10 WBC) and bacteriuria ( 10 5 CFU/mL) are not included in diagnostic criteria Juthani-Mehta M, et al. 2007

13 Diagnostic Complications in Elderly Patients High prevalence of asymptomatic bacteriuria Women 25-50%, Men 15-40% Non-specific symptoms with multiple causes Functional decline, mental status changes, fever alone, incontinence, falls, malodorous urine etc. Inability to express pain or other symptoms Susceptibility to UTI Immobility, poor hygiene, age-associated changes (estrogen deficiency, incomplete bladder emptying) Resident/Family expectations Catheterized patients

14 Catheterized Patients Catheters should be placed only when necessary and removed as soon as possible Prevalence of asymptomatic bacteriuria in catheterized patients: 9-23% of patients with short term catheter 100% of patients with long term catheter Diagnosis: Symptoms: new CVA tenderness, new onset of delirium, fever, rigors, increased spasticity, autonomic hypereflexia, malaise/lethargy If catheter recently removed: dysuria, urgency/frequency, suprapubic pain If the catheter has been in place for >2 weeks at the onset of UTI symptoms (and is still indicated), the catheter should be replaced Urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy Nicolle LE, et al Hooten TM, et al. 2010

15 Asymptomatic Bacteriuria Treatment of asymptomatic bacteriuria is not recommended* Treatment will NOT: Decrease symptoms Reduce risk of future UTIs Eliminate persistent bacteriuria Reduce mortality *Exceptions for treatment per IDSA guideline: pregnant women and patients undergoing urologic procedure for which mucosal bleeding is anticipated (ie. resection of prostate) Nicolle LE, et al. 2005

16 What s the Harm? Better Safe than Sorry Unnecessary antibiotics can cause significant harm: Harm to patient: Side effects- Rash/hives, diarrhea, nausea/vomiting Significant number of ER visits in elderly patients are Drug interactions medication related ADRs Yeast infection Increased antibiotic resistance Need for more expensive, IV antibiotics Clostridium difficle (C. diff) Harm to community: Multi-drug resistant organisms (MRDOs) Healthcare costs

17 Clostridium difficile Infection (CDI) CDI has 2 components: 1. C. difficile bacteria or spore must be ingested Infection prevention methods to reduce spread 2. Normal intestinal flora must be compromised Antibiotics have a major impact on gut flora CDI risk increases with increasing dose of antibiotic, number of antibiotics, and days of antibiotic therapy Inappropriate antibiotic prescribing was associated with a 12% incidence of C diff within 3 weeks and an 8-fold increase within 3 months Rotjanapan P, et al. 2011

18 It Starts with the Culture It s hard to ignore a positive test! Provider interpreting the culture often does not know patient's history of symptoms (or lack of symptoms), often do not evaluate the patient face to face Urine tests are a significant driver of antibiotic treatment Nurses play a pivotal role in the decision to culture urine and communication with provider about patient signs and symptoms

19 Criteria for Urine Testing: Non-catheterized Patients Fever ( 100⁰F) PLUS 1 of the following: Dysuria Urgency Flank pain Shaking chills Urinary incontinence Frequency Gross hematuria Suprapubic pain OR If no fever, 2 or more of the following: Urgency Flank pain Shaking chills Urinary incontinence Frequency Gross hematuria Suprapubic pain Loeb M, et al. 2001

20 Urine Culture Do NOT test: Following treatment for UTI in patient without further symptoms Test for cure Goal of treatment is symptom resolution, not sterilized urine Non-specific symptoms Mental status changes, cloudy/foul smelling urine, fever alone, etc. UTI without localized urinary symptoms is rare Consider alternative cause of symptoms: New medications, change in diet, dehydration, worsening chronic condition (renal failure, heart failure), change in environment, metabolic/electrolyte disorders

21 Watchful Waiting For patients who do not fit criteria for urine testing Document signs and symptoms, track for 3 days Worsening signs and symptoms warrant a call to provider, use SBAR communication tool Warning signs of serious infection: 2 or more SIRS criteria: (Temp < 96.8 F or >100.9 F, RR >20 bpm, HR >90, WBC >12), hypotension, other indicators of organ dysfunction Investigate and treat other causes Hydration, environment, etc. Involve resident and family in communication

22 True/False 1. Bacteria in urine always indicates infection 2. UTI often presents in the elderly with nonspecific symptoms alone, such as mental status changes 3. Risk of C diff increases with just one course of antibiotics 4. Asymptomatic bacteriuria is uncommon in the elderly LTC population 5. Antibiotic therapy is safe and causes few side effects 6. Urine that is cloudy or smelly should be cultured False, patients are frequently colonized with bacteria and do not require treatment if asymptomatic False, change in MS is a non-specific symptoms with many different causes True, one course of antibiotics can increase C diff risk 8-fold False, rate of asymptomatic bacteriuria up to 50% in this population False, antibiotics commonly have significant side effects, especially in the elderly False, these are not specific to UTI, may be caused by dehydration, etc.

23 Treatment of Symptomatic UTI Choice of Antibiotic treatment Based on national guidelines (IDSA), local susceptibility patterns, and patient factors Due to increasing resistance of Escherichia coli (E. coli) to fluoroquinolones (levofloxacin (Levaquin) and ciprofloxacin (Cipro)) and Bactrim (sulfamethoxazole/trimethoprim), these agents are no longer recommended for empiric treatment 1 st choice: nitrofurantoin (Macrobid) 100mg po BID (for patients with CrCl >30ml/min) 2 nd choice: cefuroxime (Ceftin) 250mg po BID

24 Local Antibiotic Resistance E. Coli sensitivity at Covenant Medical Center 90 Levaquin % Sensitive IDSA threshold for empiric therapy Bactrim Antibiotic Stewardship started at Covenant Medical Center

25 FDA Warning Levofloxacin/Ciprofloxacin In July 2016, the FDA issued a warning regarding the use of fluoroquinolone antibiotics: Health care professionals should not prescribe systemic fluoroquinolones to patients who have other treatment options for acute bacterial sinusitis (ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and uncomplicated urinary tract infections (UTI) because the risks outweigh the benefits in these patients. We have determined that fluoroquinolones should be reserved for use in patients who have no other treatment options

26 UTI Treatment Duration of therapy Uncomplicated UTI in women: Ciprofloxacin/levofloxacin, Bactrim: 3 days Nitrofurantoin: 5 days Penicillin, Cephalosporin: 7 days Complicated UTI in women and men: 7 days (may extend to days if delayed response (no symptom improvement after 72 hrs)) Catheterized patients: 7 days (10-14 days if delayed response) De-escalation Narrow antibiotic therapy when culture and sensitivity available Drekonja DM, et al. 2008

27 Penicillin Allergy Accurate and complete allergy history essential for appropriate antibiotic therapy Patients with a non-life threatening allergic reaction to penicillin (rash, hives, etc.) can usually tolerate a cephalosporin Cross reactivity estimated about 1%, highest with the 1 st generation cephalosporins (cephalexin (Keflex)) 8 Elderly patients who had a reaction to penicillin decades ago often will have outgrown the allergy, or were allergic to the impurities in early penicillin formulations is Sir Alexander Fleming,

28 UTI Prevention Systemic antibiotic therapy Few studies in elderly, but proven benefit in young women with 2 symptomatic UTIs within 6 months or 3 UTIs over 12 months Due to concerns for antibiotic resistance and antibiotic related side effects, use should be limited Not recommended in IDSA guideline for prevention in catheterized patients Estrogen therapy Proposed mechanism: regulation of vaginal flora Topical vaginal estrogens have shown benefit in post-menopausal women in two randomized-control trials (RTCs), consider for women not taking oral estrogen who have 3 recurrent UTIs/year Cranberry Proposed mechanism: contain tannins called proanthocyanidins which exhibit in vitro anti-adhesion activity against E. coli Evidence: Conflicting, some studies have shown positive benefit Beerepoot MA, et al Mody L, et al. 2014

29 Patient Case E.M. is an 87y.o. female with hx of dementia, insomnia, and hypertension. Meds include: Aricept 10mg daily, Tylenol PM 2 tabs qhs (recently started for sleep), Lisinopril 10mg daily Allergies: penicillin (rash) Today the patient presents with increased confusion and disorientation. Her vitals are normal, she is afebrile, and she has no other complaints. Her daughter is concerned about a UTI and would like an antibiotic ordered.

30 Suspected UTI SBAR What additional information would you want before contacting the provider? Situation and Background Urinary symptoms, fever, pain, delirium Recent UA or culture results (w/in 10 days) Presence of Catheter, Incontinence Active diagnoses: Use to document any recent changes (new meds, new diagnosis, etc.) Medication allergies: Include reactions if known

31 Assessment and Recommendation

32 Next Steps Monitor patient for improvement Contact provider if worsening symptoms or no improvement Include daughter and/or other family in the care plan

33 Take Home Points Diagnosis of UTI is based on urinary symptoms, not presence of bacteria in urine Antibiotic treatment of ASB has no benefit to patient and carries significant risk Urine cultures drive inappropriate treatment of ASB All long-term catheterized patients have bacteriuria Communication with provider and resident/family are key to appropriate diagnosis and treatment of UTI

34 Take Home Messages Important to get an indication with all antibiotic orders All antibiotic orders should include total days of therapy When sending C&S facility staff should include most recent Serum Creatinine level Mandatory Staff Vaccinations Set expectations with families Avoid prophylaxis Convert IV antibiotics to oral agents as soon as possible

35 References 1. Core Elements of Antibiotic Stewardship for Nursing Homes. Accessed August Martin, C; Antibiotic Stewardship in Long-Term Care: A Call to Action; The Consultant Pharmacist July Telligen QIO; Nursing Home Quality Care Collaborative Clostridium Difficle Initiative 4. Barten, C Hogan, P; Antimicrobial Stewardship and Improved LTC Infection Control; IHCA Medical Director and Consultant Pharmacist Conference; July Agency for Healthcare Research and Quality; Nursing Home Antimicrobial Stewardship Modules; Accessed Sept Martin, Caren McHenry; Antibiotic Stewardship in Long-Term Care: A Call to Action; The Consultant Pharmacist, July 2016

36 References 1. Tsan L, Langberg R, Davis C, et al. Nursing home-associated infections in Department of Veterans Affairs community living centers. Am J Infect Control. 2010;38(6): Nicolle LE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev 1996;9: Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol. 2001;22: Stone ND, Ashraf MS, Calder J, et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012;33(10): Loeb M, et al. Development of minimum criteria for the initiation of antibiotics in residents of long term care facilities: results of a consensus conference. Infect Control Hosp Epidemiol. 2001;22(2): Juthani-Mehta M, Tinetti M, Perrelli E, et al. Diagnostic Accuracy of Criteria for Urinary Tract Infection in a Cohort of Nursing Home Residents. J Am Geriatr Soc. 2007;55: Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society o America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis. 2005;40: Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med May;42(5): Rotjanapan P, Dosa D, Thomas KS. Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes. Arch Intern Med. 2011;171: Hooton TM, Bradley SF, Cardenas, DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50: Beerepoot MA, Geerlings SE, van Haarst EP, et al. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials. J Urol Dec;190(6): Mody L, Juthani-Mehta M. Urinary Tract Infections in Older Women A Clinical Review. JAMA. 2014;311(8): Drekonja DM, Johnson JR. Urinary tract infections. Prim Care Jun;35(2):