Workshop #1: UTI: An Opportunity for Antimicrobial Stewardship

Workshop #1: UTI: An Opportunity for Antimicrobial Stewardship Robin Jump, MD, PhD VISN10 Geriatric Research Education and Clinical Center (GRECC) Louis Stokes Cleveland VA Medical Center Case Western Reserve University Robin.Jump@va.gov or robinjump@gmail.com Libby Dodds Ashley, PharmD, MHS DASON Libby.dodds@duke.edu

Disclaimer The opinions presented herein are my own and do not represent those of the Veterans Affairs system or the federal government.

Step I. Form Your Team: Antimicrobial Stewardship Collaboration Medical Director Advisory Team Microbiology lab Antibiogram and list of urine cultures Directors of other NH in the community Hospital Team members Treatment guidelines for UTI and Pneumonia Advisory Group Data Dispensing pharmacy In-house and a large dispensing pharmacy EIP CDI data LTCF Team Implementation of guidelines Antibiotic Reviews and feedback Urine culture testing and treatment review CDI NHSN reporting Implementa tion Education Hospital Team Diagnosis and Treatment guidelines Data summaries Education, pocket cards, posters Assistance with NHSN reporting

Step II. Measuring Antimicrobial Use

LTCF1-Top 12 Indications

Number of Residents LTCF1-12 Top Indications by Number of UTI/PNEUMONIA Residents PEMPHIGOID OTHER GI INFECTION UNSPECIFIED ABSCESS UTI PROPHYLAXIS HEENT INFECTION C. DIFF BRONCHITIS DENTAL/SURGICAL PROPHYLAXIS PNEUMONIA SKIN/SOFT TISSUE INFECTION UTI 0 20 40 60 80 100 120

Most Common Agents Used for UTI

# of isolates Ampicillin Ampicillin-Sulbactam Aztreonam Cefazolin Cefepime Ciprofloxacin Gentamicin Imipenem Levofloxacin Piperacillin-Tazaobactam Tobramycin Trimethprim- Sulfamethoxazole Nitrofurantoin Nursing home A- 2013 UTI Antibiogram Urine Isolates: % Susceptible Organism GRAM-NEGATIVE ORGANISMS Escherichia coli 50 50 54 94 76 96 62 82 100 50 90 80 76 94 Klebsiella pneumoniae 11 0 82 82 82 82 82 82 100 100 100 82 100 45 Proteus mirabilis 18 88 * 100 89 100 67 94 * 78 94 94 83 0 *Limitations prevent the testing and reporting of ampicillin-sulbactam and imipenem for P. mirabilis. &Differences in the % susceptibility for an organism represented by <30 isolates may not be statistically significant from year to year.

Step III. Action Improve Antibiotic use for Urinary Tract Infections Modified CDC assessment of appropriateness of antibiotics for UTI form: http://www.cdc.gov/getsmart/healthcare/implementation.html

Step IV. Education- Medical Providers Small group sessions Presentation of facility antibiotic use, CDI and UTI review data Review appropriate testing and treatment of UTI Review antibiogram Review locally created treatment guidelines Provided pocket treatment cards Recommended Improvement of the documentation of signs and symptoms Clinical evaluation for every antibiotic prescription and at 48 hours, i.e. antibiotic time out

Case 1 An 86-year old male with a peripheral vascular disease (PVD) and chronic indwelling urinary catheter for urinary retention was admitted yesterday with a severe foot infection. Vascular surgery took him for a below-knee amputation last night. Post-op, no antibiotics were given. 12

Case 1, continued This morning, the vascular surgeon asks what antibiotics to give in response to the following urinalysis: Urine ph 5.00 Color Yellow Clarity Hazy Protein Trace Glucose Negative Bilirubin Negative Blood Esterase Nitrite RBC/HPF 4 WBC/HPF 97 Small Large Positive Bacteria 1+ Mucus Present 13

Question Case 1 Question 1 Case Summary Culture results are not back yet. How do you respond to this urinalysis? A. No antibiotics B. Nitrofurantoin C. Sulfamethoxazole/Trimet hoprim D. Ciprofloxacin E. Piperacillin/tazobactam 86 yo male with PVD and BPH for which he has a chronic urinary catheter. Post-op day 1 from below-knee amputation. Pre-operative UA shows + blood + leuk esterase - nitrites 1+ bacteria + mucous 14

Case 1 Polling Slide A. No antibiotics B. Nitrofurantoin C. Sulfamethoxazole/Trimethoprim D. Ciprofloxacin E. Piperacillin/tazobactam 15

Case 1 Answer A. No antibiotics. This is asymptomatic bacteriuria (ASB). Expect mild to moderate pyuria with ASB. Bacteria in the bladder leads to mild inflammation (so this is not quite the same as colonization but conceptually very similar). 16

Case 1 Follow-Up Questions Does this change if the patient does not have an indwelling urinary catheter? No. Up to ~20% of older men living in the community have asymptomatic bacturiuria. Should the patient s primary care provider recheck a urinalysis or urine culture as an outpatient? No. In the absence of symptoms, there is no reason to repeat a UA/culture to look for infection. 17

Case 2 An 83-year old male is admitted to the hospital with hypotension (92/58) and fever (100.3 F). He is too confused to answer questions. On exam, he resists pressure to his bladder and attempts to push your hand away. Janice Haney Carr Public Health Image Library His WBC is 4 with 64% neutrophils. His Creatinine is 2.3 (baseline 0.8). His chest film shows no acute changes. 18

Case 2, continued He is started on vancomycin and piperacillin/tazobactam for presumed urosepsis. His urinalysis shows: Janice Haney Carr Public Health Image Library Urine ph 5.50 Color Yellow Clarity Turbid Protein 100 Glucose Negative Bilirubin Negative Blood Small Esterase Large Nitrite Negative RBC/HPF 13 WBC/HPF 2312 Bacteria 3+ Mucus Present Hyaline Casts >20 19

Case 2, continued On hospital day 1, his Cr is 1.6. He is somulent and appears comfortable. The microbiology laboratory reports: >100,000 CFU/mL of Gram negative rods His vancomycin is stopped. He remains on piperacillin-tazobactam On hospital day 2, his Cr is 1.0. He is feeding himself breakfast. The microbiology laboratory reports: >100,000 CFU/mL of lactose fermenting Gram negative rods Janice Haney Carr Public Health Image Library 20

Case 2, continued On hospital day 3, his Cr is 0.9. He is sitting up on the side of the bed. The microbiology laboratory reports: >100,000 CFU/ML ESCHERICHIA COLI INTP AMPICILLIN S MCG/ML CEFAZOLIN S MCG/ML CIPROFLOXACIN S MCG/ML TRIMETH/SULFA S MCG/M NITROFURANTOIN S MCG/ML AMPICILLIN/SULB S MCG/ML Janice Haney Carr Public Health Image Library 21

Question Which antibiotic should we choose? Case 2 Question 1 Case Summary 83 yo male with urosepsis (fever, leukocytosis). Urine culture with Escherichia coli susceptible to: A. Ampicillin B. Cefazolin Ampicillin C. Ciprofloxacin Cefazolin Ciprofloxacin D. Sulfamethoxazole/Trimet Tmp/Sulfa hoprim Nitrofurantoin Ampicillin/ E. Nitrofurantoin Sulbactam F. Ampicillin/Sulbactam 22

Case 2 Polling Slide Which antibiotic should we choose? A. Ampicillin B. Cefazolin C. Ciprofloxacin D. Sulfamethoxazole/Trimethoprim E. Nitrofurantoin F. Ampicillin/Sulbactam 23

Case 2 Answer A. Ampicillin preferred B. Cefazolin preferred C. Ciprofloxacin (too broad) D. Sulfamethoxazole/ Trimethoprim ok if good renal function E. Nitrofurantoin ok if good renal function F. Ampicillin/Sulbactam (too broad) The idea is to narrow therapy. Janice Haney Carr Public Health Image Library 24

Interpreting Urine Culture Results >100,000 CFU/ML ESCHERICHIA COLI INTP AMPICILLIN 4 S MCG/ML CEFAZOLIN <=4 S MCG/ML CIPROFLOXACIN <=0.25 S MCG/ML TRIMETH/SULFA <=20 S MCG/M NITROFURANTOIN <=16 S MCG/ML AMPICILLIN/SULB <=2 S MCG/ML CDC/James Gathany Public Health Image Library

Case 2 Follow-Up Questions How long should he receive antibiotics? In patients with a catheter: 7 days if prompt symptom resolution 10-14 days if a delayed response If no catheter. I favor 7 days if prompt symptom resolution Janice Haney Carr Public Health Image Library Please use calendar states to indicate stop dates (i.e. 9/26/2017). 27

Case 2, continued On hospital day 5, he is discharged. The next day, the microbiology laboratory reports a second bacterial species (in addition to the E. coli): >50,000 - <75,000 CFU/ML STENOTROPHOMONAS MALTOPHILIA INTP TRIMETH/SULFA <=20 S MCG/ML Does this change our decision to discharge or our choice of antibiotics? Janice Haney Carr Public Health Image Library 28

Case 3, Saturday 84 yo female w/ worsening dementia. Resident for 9 months following stroke with left-sided hemiparesis. Requires assistance with bathing, dressing and toileting. She would not answer her son s questions. He requested that she be checked for a UTI. Public Health Image Library Case courtesy of Dr. C. Muehrcke

Case 3, Saturday continued T 98.4 HR 88 BP 114/76 Assessment unremarkable Urinalysis positive for leukocyte esterase and nitrites. The on-call provider, who is from an agency, prescribes a 10-day course of ciprofloxacin. Public Health Image Library Case courtesy of Dr. C. Muehrcke

Culture Results: Case 3, Wednesday Urine Culture Results 1. >100,000 ESCHERICHI COLI 2. >100,000 PROVIDENCIA STUARTII ANTIBIOTIC SUSCEPTIBILITY TEST RESULTS: 1. ESCHERICHIA COLI 2. PROVIDENCIA STUARTII : : SUSC INTP SUSC INTP AMPICILLIN 4 S >=32 R MCG/ML CEFAZOLIN <=4 S >=64 R MCG/ML CIPROFLOXACIN 4 R >=4 R MCG/ML TRIMETH/SULFA >=320 R <=20 S MCG/ML NITROFURANTOIN <=16 R 256 R AMPICILLIN/SUL <=2 S R R MCG/ML

Case 3, continued The nurse manager calls and want to know how to respond to the urine culture results. She assessed the resident before calling you and notes that she is at her baseline Together, you decide to stop the antibiotics. Public Health Image Library Case courtesy of Dr. C. Muehrcke

Case 3, continued You round at the nursing home and see the resident. She is asymptomatic and does not recall feeling sick. There is nothing in the chart to indicate any signs or symptoms of infection. She tells you exactly what happened on Saturday..

Case 3 Question 1 Question There are several possible interventions to reduce the changes of a similar event in the future. Where would you start? (No right/wrong answers just your opinion) A. Review protocols for collecting urine samples B. Educate staff about criteria for testing urine C. Educate families about risks of antibiotics D. Develop a protocol that includes non-antibiotic management of residents with concerns for UTI 34

Case 3 Polling Slide To reduce the risk of this happening again, where would you start? A. Review protocols for collecting urine samples B. Educate staff about criteria for testing urine C. Educate families about risks of antibiotics D. Develop a protocol that includes non-antibiotic management of residents with concerns for UTI 35

Clean Catch? Sit down Cleanse Cleanse again Hold labia apart Start to pee Stop peeing Position container Start to pee again and collect urine Put lid onto container without touching sides or lid Public Health Image Library

Specimen Handling Sample collected Saturday afternoon Sample received in the laboratory on Monday morning What happened in the meantime? Public Health Image Library

Recommendations for Urine Collection Suggest shower or bath before attempting clean catch. For men, short-term condom catheter. Check bag every 30 minutes. For women, in/out catheterization, unfortunately. If urinary catheter, then must change entire collection system before collecting sample. Samples must be stored in the refrigerator until transported to the lab. Public Health Image Library

Establish Criteria for Testing Urine Diagnoses Urine Culture Clinical Symptoms Acute, uncomplicated urinary tract infection >100,000 bacteria, No more than 2 species of bacteria Dysuria OR Fever AND 1 of the following: -Frequency -Urgency -Suprapubic pain -Incontinence* -Gross Hematuria** Asymptomatic Bacteriuria >100,000 bacteria, No more than 2 species of bacteria No signs or symptoms referable to the urinary tract CDC/James Gathany Public Health Image Library Stone et al. Infec Control Hosp Epi 2012; *New or worsening of baseline incontinence **I have never known hematuria to a sign of infection in an older adult. Rather, it seems to indicate trauma to the mucosa, which can lead to urinary tract infection or urosepsis.

Establish Criteria for Testing Urine Diagnoses Urine Culture Clinical Symptoms Acute, uncomplicated urinary tract infection >100,000 bacteria, No more than 2 species of bacteria Asymptomatic Bacteriuria >100,000 bacteria, No more than 2 species of bacteria CDC/James Gathany Public Health Image Library Stone et al. Infec Control Hosp Epi 2012; *New or worsening of baseline incontinence **I have never known hematuria to a sign of infection in an older adult. Rather, it seems to indicate trauma to the mucosa, which can lead to urinary tract infection or urosepsis.

Catheter-Associated UTIs (CAUTIs) 10 3 cfu/ml of 1 bacterial species & a symptom: Clinical Symptoms Fever Rigors Change in mental status Malaise Lethargy Flank pain Costovertebral angle tenderness *Acute hematuria Pelvic Discomfort Dysuria Urgency or Frequency Suprapubic pain or tenderness Context for Interpretation With no other identified cause Signs or symptoms referable to the urinary tract Within 48 hours of catheter removal Janice Carr Public Health Image Library Hooton et al. CID 2010:50 625 (www.idsociety.org) *I have never known hematuria to a sign of infection in an older adult. Rather, it seems to indicate trauma to the mucosa, which can lead to urinary tract infection or urosepsis.

2009 NHSN criteria for CAUTI Laboratory Urine culture with 10 5 cfu/ml of 1-2 bacterial species OR Urine culture with 10 3 and <10 5 cfu/ml, pyuria ( 10) and positive leukocyte esterase or postive nitrite Symptoms Fever (>38 C), suprapubic tenderness or CVA tenderness If catheter removed with 48 hours urgency, frequency, dysuria Janice NIAID Carr Public Health Image Library Leekha et al. ICHE Oct 2015 v36(10) 1236. *NHSN = National Healthcare Safety Network

Clinical & NHSN-defined CAUTIs are not always the same thing 85 patients in hospital met 2009 NHSN surveillance definition. All had a fever 42 (49%) with clinical CAUTI the patient was given a diagnosis and treated for UTI 46 (54%) with alternate source of fever (e.g., other infection, DVT) Janice Carr Public Health Image Library Leekha et al. ICHE Oct 2015 v36(10) 1236. *NHSN = National Healthcare Safety Network

Antimicrobials for UTI in Residents with Severe Dementia 196 episodes of suspected UTI in 110 residents Over 80% female and white Extremely impaired cognitive & functional status 55 (28%) episodes with fever 118 (80%) positive UA & culture 31 (16%) met minimum criteria to start antimicrobials Janice Haney Carr Public Health Image Library Dufour et al., JAGS Dec 2015 v63(12) 2472.

Probability of Survival 1.0 0.8 0.6 0.4 0.2 IM, n =18 No Influence on Survival No Abx, n = 49 Oral, n = 117 IV/Hospital, n = 22 0 0 100 200 300 Days (from suspected UTI) Dufour et al., JAGS Dec 2015 v63(12) 2472.

Watchful Waiting Evidence for residents & families members that it s ok to wait to start antibiotics. Evidence (in young women) with recurrent UTIs that unnecessary treatment* leads to more symptomatic UTIs higher prevalence of antibiotic-resistant bacteria Janice Haney Carr Public Health Image Library *Treatment of asymptomatic bacteriuria Dufour et al., JAGS Dec 2015 v63(12) 2472. Cai et al., CID 2012 v55:771 and Cai et al., CID 2015 61:1655.

Watchful Waiting This is an active process More frequent vital signs Oral hydration Assess for pain, changes in medicine, other reasons like a bad night s sleep or no stuffed cabbage CDC/James Gathany Public Health Image Library

Careful Observation Order Set Nace et al., JAMDA 2014;15:133-139

Manage Family Members Set expectations with family members before the crisis

Potential Policies & Procedures NIAID Public Health Image Library Concerns about stinky or cloudy urine should lead to increased hydration and perhaps, watchful waiting/careful observation. Automatic review of all medication changes by outside providers. Send residents to the Emergency Room with a note clearly stating what you are (and are not) worried about.

Potential Policies & Procedures NIAID Public Health Image Library Clear criteria for collecting a urine sample Documented protocol for proper sample collection and handling Communication tools when nurses call a covering provider Proactively talk to residents and their family members on admission and during change of status

Take Home Messages A positive culture infection No tests of cure (Don t borrow trouble!) Asymptomatic bacteriuria (ASB) is common; expect pyuria Try watchful waiting/careful observation and hydration 7 days of antibiotics is usually plenty Public Health Image Library 54

IV. Education- Medical Providers Small group sessions Presentation of facility antibiotic use, CDI and UTI review data Review appropriate testing and treatment of UTI Review antibiogram Review locally created treatment guidelines Provided pocket treatment cards Recommended Improvement of the documentation of signs and symptoms Clinical evaluation for every antibiotic prescription and at 48 hours, i.e. antibiotic time out

Small group sessions Education- Nursing Staff Review CDI and UTI review data Review appropriateness of urine testing and treatment Recommended the use of an on-line education program Recommended the use of the SBAR Emphasized the importance of documentation of signs and symptoms Created posters

Education- Family Created a brochure on appropriate treatment of UTI Created a newsletter for distribution to residents and families Recommended coaching of nursing staff on best method to deliver the brochure information to families

V. Feedback of Data

LTCF1. Rate of Antibiotic Starts for UTI and Urine Culture Rate

LTCF1. Change in Ciprofloxacin DOT for UTI

Example How Data Was Used for Action Goal to capture all urine cultures and UTI treatment Worked with micro lab to get list of tested residents We used to work in silos, now we talk to each other Worked with pharmacy to get new antibiotic starts for UTI Uncovered the limitation of the 24 hour report Performed monthly assessments of tested and treated residents for signs and symptoms of UTI Feedback to nurses and in house medical providers on the appropriateness of testing and treatment

Thank you! Free On-Line Course for Nursing Staff Free Nursing Contact Hours https://robinjump.coursesites.com/ Public Health Image Library Robin.Jump@va.gov or robinjump@gmail.com

Loeb Minimum Criteria for Initiating Antibiotics Public Health Image Library Positive urine culture (>10 5 CFU/mL) and dysuria OR Positive urine culture (>10 5 CFU/mL) and 2 or more of the following: Fever and/or shaking chills Urgency Flank pain or suprapubic pain New or worsening incontinence Gross hematuria Loeb et al. BMJ 2005;331:669

Resources CDC: Core Elements of Antibiotic Stewardship for Nursing Homes http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html Choosing Wisely Campaign from the American Board of Internal Medicine (ABIM) AMDA The Society for Post-Acute and Long-Term Care https://www.amda.com/tools/choosingwisely_5things.pdf American Geriatrics Society (AGS) http://www.choosingwisely.org/societies/american-geriatrics-society/ Loeb Criteria Communication & Order Form www.reginfo.gov/public/do/downloaddocument?objectid=22963901 INTERACT: Interventions to Reduce Acute Care Transfers http://interact2.net/

Resources Agency for Healthcare Research & Quality (AHRQ) http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/module1/index.html http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/module1/toolkit1/utisbar-form.html http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/module1/toolkit1/uti-clinletter.html http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/module1/toolkit1/uticare-slides.html

Additional References 1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clinical Infectious Diseases 2005; 40:643 654. 2. 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; 50:625 663. 3. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60:616 631. 66