ANTIMICROBIAL STEWARDSHIP IN LONG TERM CARE FACILITIES ANTIMICROBIAL STEWARDSHIP COLLABORATIVE COLORADO HOSPITAL ASSOCIATION MARCH 23, 2016

Bridget Olson, RPh Infectious Disease Pharmacist, Sharp Coronado Hospital & Villa Long Term Care Facility

Raymond Chinn, MD Medical Director of Infection Prevention, Sharp Memorial Hospital

OBJECTIVES:

• Identify challenges with antimicrobial prescribing in long-term care facilities (LTCFs)

• Review a practical application of an ASP in LTCFs

• Demonstrate the impact of reducing antimicrobial use on antimicrobial

resistance • Benefits of LTCF ASP to associated acute care hospitals

CHALLENGES OF A CHANGING LTCF POPULATION:

• Presence of more invasive devices and procedures

• Multiple co-morbidities and advanced age

• Colonization and infection with multi-drug resistant organisms (MDROs)

• Missed opportunities to

provide the staff of LTCFs with education to better care for their patients

Trivedi, K. Approaches to Antimicrobial Stewardship in LTC facilities. IDAC Symposium 2011

BACKGROUND: (my beginning in ASP) 1998 - An ‘Antimicrobial Surveillance Team’ (AST) was formed at Sharp Cabrillo Hospital in San Diego and included:

• Pharmacist • Infection Control RN • Infectious Disease Physician

Acute care services were later relocated but the importance of continued AST was recognized when the facility was converted to all LTC. Administration showed great foresight in retaining the ASP for the LTCF

OUR LTCF ISSUES WITH TREATMENT OF INFECTIONS Frequent colonization with multi-drug resistant organisms that

can result in infection

Incomplete reporting of patient’s symptoms to physicians

Patient evaluation and diagnosis are difficult

Physicians were unsure of best empiric treatment choices

Antimicrobials are ordered by phone without proper patient assessment

Treatment of culture results, with inadequate assessment of patient signs and symptoms of infection

Suboptimal follow-up of culture results to de-escalate or to stop antimicrobial agents

Consequent overuse of antimicrobial agents resulting in development of antimicrobial resistance

Sputum culture with 1 GNR

LTCF patient sputum culture

STRATEGIES FOR OUR 181-BED COMMUNITY HOSPITAL: 59 ACUTE-CARE & 122 LTC BEDS

Establish an Antimicrobial Stewardship Program with ID oversight Use modified McGeer Criteria* as a guideline for initiation of antimicrobials in LTCF

Develop comprehensive patient assessment forms

Establish a LTCF Fever/Suspected Infection Protocol Implement initiatives to reduce C.difficile infections

Provide nursing education

Ensure physician acceptance

*Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 ;33(10):965-977

CONTRIBUTORS TO THE ANTIMICROBIAL STEWARDSHIP PROGRAM Administrative Support

ID Pharmacist

ID Physician

Microbiologist

Lead Nursing Educator

Infection Preventionist

Information systems

MCGEER CRITERIA (OCTOBER 2012 UPDATE BY STONE, ET.AL.)

Identification of infection should not be based on a single piece of evidence, but should always consider the clinical presentation in addition to microbiological or radiological information available

Goal: to standardize identifying factors for infections in LTCF patients often difficult to assess: Symptoms not expressed or misinterpreted Co-morbidities can obscure signs symptoms of infection

Criteria for antibiotic initiation in 4 main categories: UTI Respiratory Infection Skin & soft Tissue Infection Fever of Unknown Origin

Nicolle, LE et al. Antimicrobial Use in LTCFs, Infect Control Hosp Epidemiol 2000; 21: 537-545 Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 October; 33(10):965-977

MICROBIOLOGY DATA 2015: RESPIRATORY ORGANISMS CULTURED FROM LTCF PATIENTS

2015, Sharp Coronado Hospital & Villa LTCF (n=109)

H. influenzae, 10% (all B-lactamase positive)

S.aureus 11% (MRSA, 72%)

Proteus sp., 42%

Pseudomonas aeruginosa, 54% (of which 5% MDRO)

Strep Grp G, 8%

Others*, 19%

*Others = Acinetobacter, Chryseobacterium, Corynbacterium, E. cloacae, Klebsiella, Moraxella spp, Mycobacterium, Serratia, grp B Strep, S. pnemo, E. coli

DECREASED PIP/TAZO, QUINOLONE, CARBAPENEM, AZTREONAM USE INCREASED PSEUDOMONAS AERUGINOSA (PSA) SUSCEPTIBILITY

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22012- no outside admissions x 6 months

MCGEER CRITERIA FLOW-CHARTS: RESPIRATORY

Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 October; 33(10):965-977

MICROBIOLOGY DATA 2015: URINARY ORGANISMS CULTURED FROM LTCF PATIENTS

2015, Sharp Coronado Hospital & Villa LTCF (n=93)

E. coli, 28% (46% MDRO)

E. faecalis**, 16%

E. faecium**, 2% Klebsiella

pneumoniae, 7% Proteus

mirabilis, 30%

Providencia stuartii, 5%

Pseudomonas aeruginosa, 19%

Others*, 17%

*Others = Acinetobacter, Citrobacter, Enterobacter, Moraxella, Serratia, Staph, Strep, MRSA **31% of Enterococcus were from urine cultures with > 3 organisms

URINARY E.coli SUSCEPTIBILITIES TRENDED

#isolates 2010 50 2011 49 2012 26 2013 22 2014 10

While 74% of urine ESBL E.coli isolates are covered by Tobramycin, it covers 90% of all E.coli isolates in the LTCF

ASP EFFECTS ON RESISTANCE DECREASED FLUOROQUINOLONE USE INCREASED E.COLI SUSCEPTIBILITY

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MCGEER CRITERIA FLOW-CHARTS: URINARY

Stone, ND, Ashraf, MS et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 October; 33(10):965-977

LTCF FEVER/SUSPECTED INFECTION PROTOCOL

Provides a multi-disciplinary approach Ensures comprehensive patient assessments in a

checklist format, based on modified McGeer criteria Involves pharmacists, working with nurses in

assessing need for initiation of antimicrobial agents

Utilizes computer-based “Powerplans” to aid in ordering labs, IV fluids, cultures and appropriate ID-recommended empiric therapy

NURSING EDUCATION AND INVOLVEMENT:

• Nurses play a major role in whether antimicrobials are initiated, based on their assessments and reporting.

• They are the eyes and ears for the physicians

• Education of all levels of nursing

(RN, LVN, CNA) is essential, both initially and on-going.

First slide of Nursing Education PowerPoint

COMPONENTS OF NURSING EDUCATION:

Patient assessment

Difference between colonization vs. infection

Use of empiric vs. targeted antibiotics

Why bacterial resistance develops

Importance of limiting unnecessary antimicrobials

Format for physician calls

Strategies to decrease C.difficile infection

MRSA screening and usefulness in de-escalation of therapy

PATIENT ASSESSMENT FORMS • A comprehensive checklist format, based on the modified McGeer Criteria

• Symptoms are grouped by association with the 4 basic categories of infection (UTI, respiratory, SSTI and fever of unknown origin)

• Reviewed by pharmacist who assesses with criteria for antimicrobial use and history of resistant organisms.

3 COMPUTER POWERPLANS FOR ORDERING • Protocol order-sets for ease of

ordering labs, cultures, fluids and antibiotics:

REDUCTION OF CLOSTRIDIUM DIFFICILE INFECTION (CDI) INITIATIVES

1. Incorporate Antimicrobial Stewardship 2. Change in intensity of GI prophylaxis 3. Initiate probiotic therapy with antimicrobials

ANTIBIOTIC PRESSURE PRIOR TO C.DIFFICILE INFECTIONS

other (<2% each) 9%

azithromycin 4%

amox/clavanulate 4%

aminoglycosides 4% No abx

7% carbapenems

11% extended-spectrum

PCNs 12%

3rd-4th gen. Cephalosporins

23% Quinolones

26%

Antimicrobials used prior to C.difficile infections 2009-2014

Other (<2% each): 1st-gen cephs, linezolid, clindamycin, cefuroxime, doxycycline, & colistin

DAYS OF ANTIMICROBIAL THERAPY (DOT) TRENDING (PER 1000 PATIENT DAYS) CORONADO HOSPITAL LTCF JAN 2010-->DEC 2014

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2012 LTCF Fever Protocol started

Started LTC Prospective reviews with intervention

No outside admissions x 6 months

Information Systems runs a DOT report to track antimicrobial usage

REDUCTION IN ACID SUPPRESSION: (DUE TO ASSOCIATION WITH CDI)

May 2010: Long-term care facility (LTCF) patients on GI prophylaxis with proton pump inhibitors (PPI) were converted to H2 receptor antagonists

Physicians noted drop in CDI rates, and began to avoid PPIs in both acute care and LTC

2012: PPIs removed from treatment Powerplans of hospital system

PROBIOTIC THERAPY Probiotics are promoted to help re-establish GI micro-flora after disruption from antimicrobials +/- acid suppression Probiotics recommended for all patients on broad spectrum antimicrobials + 1

additional week1

Products: Lactobacillus acidophilus and L.casei, L. rhamnosus, (Biok-plus) 2 capsules orally daily OR Liquid probiotic yogurt 1 bottle per FT BID Contraindications: 1) immunosuppressed patients if neutropenic 2) post-pyloric feeding tube (J-tube) administration 3) NPO w/o enteral feedings

1Johnston BC, Ma SY, Goldenberg JZ, et al. Probiotics for the Prevention of Clostridium difficile-Associated Diarrhea. Ann Intern Med. 2012; 157:878-888.

RESULTS: CDI REDUCTION LTCF CDI rate per 10,000 patient days was reduced from 6.1 (average rate 2008-2010) to 1.1 (average rate 2011-2014)

Olson, B, et.al. A Multipronged Approach to Decrease the Risk of Clostridium difficile Infection at a Community Hospital and Long-Term Care Facility. J Clin Outcome Manag 2015; 22(9): 398-406

ASP INTERVENTIONS:

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LTC Care Interventions (94% acceptance)

portion not corrected

interventions

Jan-Jun 2015; n=110

Goals: Patient Safety, Antibiotic resistance, cost

MRSA SCREENING

• Colonization with S aureus precedes most invasive diseases caused by S.aureus

• MRSA screening- molecular amp (nares)

o upon admission

o prior to initiation of antibiotics if there is a risk for staph infections: • respiratory infections

• skin & soft tissue infections

• Results available: MRSA molecular amp: 24 hours vs. cultures : 2-3 days

• Negative result has a 99% negative predictive value for MRSA pneumonia1

More rapid de-escalation of vancomycin or other anti-MRSA therapy is possible

• Fever protocol allows automatic discontinuation of vanco if MRSA nares negative

1Dangerfield B, et.al. Predictive value of methicillin-resistant Staphylococcus aureus(MRSA) nasal swab PCR assay for MRSA pneumonia. Antimicrob Agents Chemother. 2014;58(2):859-64

ASP EFFECTS ON RESISTANCE DECREASED VANCOMYCIN AND OVERALL ABX USE DECREASING VRE

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Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

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BENEFITS OF LTCF ASP TO ASSOCIATED ACUTE CARE HOSPITALS

Improves quality of patient care through: Decreased horizontal transfer of resistant organisms (less MDRO,

XDRO)

Decreased re-admissions

Decreased antibiotic expenditures

Decreased C.difficile infections

New legislation in California requiring LTCF ASP (SB 361, Oct 2015): may allow for increased resources and support for ASPs1

1K. Trivedi. Pew Charitable Trusts: Inpatient Antibiotic Stewardship Program Case Studies, 2015

SUMMARY

A multi-disciplinary ASP can result in decreasing transmission of multi-drug resistant organisms such as ESBL E.coli, VRE, MDRO Pseudomonas and C.difficile by improving antimicrobial use in a LTCF.

With a robust ASP, these benefits can be sustained over time

Full engagement and ongoing interdisciplinary cooperation among nursing, physicians and pharmacists is necessary for ASP success.

Looking forward, additional studies on the growing population of LTCF patients with their particular susceptibility to infections would be impactful in improving treatment.

Resources are available for education

THANK YOU! QUESTIONS? CONTACT INFORMATION: Bridget Olson, ID/ASP Pharmacist Sharp Coronado Hospital Coronado, California Bridget.Olson@sharp.com Please feel free to contact me for copies of forms or education PowerPoints, etc.