ANTIMICROBIAL STEWARDSHIP COLLABORATIVE COLORADO … · ANTIMICROBIAL STEWARDSHIP IN LONG TERM CARE...
Transcript of ANTIMICROBIAL STEWARDSHIP COLLABORATIVE COLORADO … · ANTIMICROBIAL STEWARDSHIP IN LONG TERM CARE...
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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LTCF Pseudomonal Susceptibility Trending 2011 - 2015 2011
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ays LTCF Antipseudomonal Usage Trending 2011-2014
(Jan-Jun) 2011
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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
020406080
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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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VRE % of Enterococcus Acute + LTCF 2014
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 [email protected] Please feel free to contact me for copies of forms or education PowerPoints, etc.