Antibiotics in Long Term Care David Gary Smith, MD, FACP Abington Memorial Hospital.
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Transcript of Antibiotics in Long Term Care David Gary Smith, MD, FACP Abington Memorial Hospital.
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Antibiotics in Long Term Care
David Gary Smith, MD, FACP
Abington Memorial Hospital
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Audience Response System
• Keypads- must return them
• Real time polling of audience
• Anonymity
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Do you really want to hear a talk about antibiotics and LTC?
Yes
- and
als
o driv
e nai
..
No- I
woul
d rath
er li
st..
49%
51%1. Yes- and also
drive nails into my fingers
2. No- I would rather listen to elevator music
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What is your profession?
Nurs
e
MD/D
O
Soci
al W
ork
Adm
inis
trato
r
Oth
er c
linic
al
31%
27%
0%
13%
29%
1. Nurse
2. MD/DO
3. Social Work
4. Administrator
5. Other clinical
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Goals
• Outline of the antibiotic “problem”
• Guidelines for antibiotic use– address over utilization
• Antibiotics and the “Goals of Care” dilemma
• Existential model for patient centeredness at the bedside
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Patterns of Antimicrobial Use in NH Residents with Advanced Dementia• Approximately 1 year of f/u
• 66% (n=142) received at least one course of antimicrobial therapy
• 540 prescribed courses
• 42% (n=42) of decedents received antibiotics within two weeks of their death and 41courses were administered parenterally
D’Agata E, Mithcell S, Arch Int Med 2008;168:357-361
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Antibiotic Therapy in the Demented Elderly Population:
Redefining the Ethical Dilemma• Low likelihood of benefit
• Emerging resistance
• Avoidance of “goals of therapy” discussion
• Easier to treat than to raise the “D” word
• Costs
Schaber M, Cormelli Y, Arch Int Med 2008;168:349-350
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2 Studies on Benefit of Educational Program on Antibiotic Use in LTCF• Reported frequency of suboptimal
antibiotic use- 25-75%
• Educational interventions reduced errors by approximately 20%
• Post intervention adherence to protocol rates- 40-77%
Scwartz D , et.al. JAGS, 2007;.55:1236-1242Monette J, et.al. JAGS, 2007; 55:1231-1235
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Case
• 88 y.o. with indwelling foley and dementia. The clinical attendant calls because the urine is dark and the culture revealed >100,000 colonies E. Coli. She wants to know what antibiotic do you want to use. No allergies. No fever.
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What is your opinion?
TM
P/Sulfa
Am
oxaci
llin
Lev
aflo
xaci
n
Tra
nsfer
for I
V antib
i...
No tr
eatm
ent
26%
19%
11%
28%
17%
1. TMP/Sulfa
2. Amoxacillin
3. Levafloxacin
4. Transfer for IV antibiotics
5. No treatment
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Minnesota Guidelines
• No indwelling catheter– Acute dysuria or– Fever >38.9 (102 F) and at least one of the following:– Urgency– Frequency– Suprapubic pain– Hematuria– CVA tenderness– New onset urinary incontinence
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Minnesota Guidelines
• Indwelling Foley
• Need at least one of the following:
• Fever >38.9 (102)
• New CVA tenderness
• Rigors
• New onset of delirium
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Another call from same NH
• 78 yo patient with COPD and has new cough with yellow sputum. Temp is normal. Pulse is 80. Respiratory rate is 15. No delirium, rigors.
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What is your opinion?
PO
Lev
oflo
xaci
n
PO
Azit
hrom
ycin
Oth
er P
O a
ntibio
tic
Tra
nsfer
to h
ospita
l fo...
No a
ntibio
tics
needed
30%
16%
9%
16%
28%
1. PO Levofloxacin2. PO Azithromycin3. Other PO
antibiotic4. Transfer to
hospital for IV antibiotics
5. No antibiotics needed
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Minnesota Guidelines
• Fever > 38.9 (102 F) and one of the following:– Respiratory Rate>25– Productive cough
• Or• Fever > 37.9 (100 F) and cough and at least one
of the following:– Pulse >100– Delirium– Rigors– Respiratory Rate >25
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Minnesota Guidelines
• Or
• COPD history and purulent cough*
• Or
• New infiltrate on chest xray and at least one of the following:– Respiratory rate > 25– Productive cough– Fever > 37.9 (100 F)
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Same nurse calls you about another case
• 83 yo with dementia has a fever of 37.9 (100 F) and some aspects of a delirium. You are on call for this patient who is followed by your partner. She has no other focal symptoms or signs. Do you want to start antibiotics?
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What is your opinion?
Wat
chfu
l wai
ting
Sen
d her
to th
e hosp
ital
PO
Lev
aflo
xaci
n
Cal
l her
prim
ary
car..
.
28%
15%
32%
26%
1. Watchful waiting
2. Send her to the hospital
3. PO Levafloxacin
4. Call her primary care physician in AM
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Minnesota Guidelines
• Fever with unknown focus of infection
• Fever > 37.9 (100 F) and at least one of the following:
• New Delirium
• Rigors
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Do you think that antibiotics are over-utilized?
Yes N
o
0%
100%1. Yes
2. No
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Do you have protocols in place to guide management?
Yes N
o
0%
100%1. Yes
2. No
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Contributors to unnecessary antibiotic use
• Antibiotics are overused in LTCFs? (% agree)– MD 82– Nurse Practitioner 91– Director of Nursing 66– Infection Control 80
• Established protocols– Facilities 31– Providers 16
Gahr P et.al. J Amer Ger Soc 2007;55:471-474
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What do you think the most important factor is in this overuse?
Fam
ily p
ress
ure
Nurs
e pre
ssure
Cogni
tive
impai
rmen
t
Lac
k of c
lear
guid
elin
es
Oth
er
28%
20%
7%
22%23%
1. Family pressure
2. Nurse pressure
3. Cognitive impairment
4. Lack of clear guidelines
5. Other
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Contributors to unnecessary antibiotic use
• Factors which contribute to unnecessary use of antibiotics– Pressure from nurse- 54-56%– Pressure from family- 21-28%– Resident cognitive impair.- 57-58%
• Need for:– Education for nurses- 62-73%– Education for MDs/NPs- 35-57%– Nursing guidelines- 60-70%
Gahr P et.al. J Amer Ger Soc 2007;55:471-474
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Lessons so far…
• We suck (my teenagers classification) at making decisions about antibiotics
• Part of the reason we suck is the lack of clear guidelines, protocols, reminders, systems of accountability….
• We all tend to avoid or butcher the “goals of treatment” discussion– Overestimate benefit of Abs etc.– Avoid the “D” word
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Good News
• We can do something about “it”, if we care to do something about it.
• Antibiotic Protocol champion that has stature and power!!!!
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"If you want the truth to stand clearbefore you, never be for or against.
The struggle between "for" and against"is the mind's worst disease.
- Sent-Ts'an (aka Seng Tsan) c. 700 C.E.1
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Existential Issues
• Talk about a patient who challenged us recently on service.
• The details of the case have been changed to protect the identity of all participants except for me.
• Goals of case– Talk about barriers to genuine patient
centered care– Discuss a way of overcoming those barriers
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Case
• 39 y.o. Persistent Vegetative State patient is admitted for her 5th presentation for a suspected pneumonia. She has been at home with her family in this state for 8 months. The family noted a change in her breathing and slight increase in her secretions.
• Subintern (fourth year medical student) on service is sent in to see patient but she is clearly terrified by the assignment. Why?
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View from subintern and attending
• How do I approach a patient in a PVS? The family? My feelings of hopelessness? My inability to form a relationship with the patient? How do I determine the goals of care? Can I even see the patient?
• Coping style- pretend that there is no patient as person but just a biological preparation (a petri dish) with bacteria that need antibiotics.
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View from subintern and attending
• Additional feelings deal with the resource utilization; distracting the clinicians from someone who really needs our attention; the absurdity of the whole situation.
• These feelings underlie a lot of the ethics consults concerning patient futility received by ethics committees.
• Tension- between a family that demands care and the clinicians who see no purpose in providing that care
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How do you feel about caring for such a patient?
Ver
y Sad
Angry
abou
t the
was
t...
No fe
elin
g at a
ll
Oth
er
27%
22%
28%
23%
1. Very Sad
2. Angry about the waste of resources
3. No feeling at all
4. Other
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What would you recommend to the family?
IV a
ntibio
tics
With
hold a
ntibio
tics
Pal
liativ
e ca
re c
onsult
Oth
er
0%
100%
0%0%
1. IV antibiotics
2. Withhold antibiotics
3. Palliative care consult
4. Other
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Feeling and Impact on Care
• Elkman- “Your face is the mirror of everything inside”
• The family could sense a clinical disdain by the hospital staff in the past toward them for wanting to continue care
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Do you think you can “fake” that you care?
1. Absolutely
2. Definitely not
3. Never thought about it
4. Other
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The medical student and I walked through the ER curtain and beheld a scene of great devotion by the husband and the daughterfor the patient that was transformative for us.
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This case
• Any prior thought, conceptions, feelings were totally washed away.
• We just stood there and beheld a scene of biblical proportion.
• Our direction was given us from within the scene at the bedside.
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An Approach
• Suspension of Values
• Interiorization
• Letting go and the insight will emerge
Senge P, et.al. Presence: An Exploration of Profound Change in People, Organizations and Society. 2004
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Generalizability
• Can everyone do this?
• Does it take much time?
• How will it ultimately affect me?
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Downside
• None
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Patient Centered
• There is no better model out there for a truly patient centered experience!
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Summary
• We can certainly do a better job prescribing antibiotics or any other type of treatments for our patients
• We have to embrace this whole area as primarily important especially given all the other very important initiatives that we should embrace
• We have to avoid yielding to the forces within medicine that obliterates all of our humanities
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