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Less is More Antimicrobial Stewardship in Long-term Care (LTC)
Brad Langford BScPhm, ACPR, PharmD, BCPS
Valerie Leung BScPhm, ACPR, MBA
ASP@oahpp.ca
Image credit: Public Health Ontario, 2016
@BRxAD
PublicHealthOntario.ca
Objectives
What is the problem?
What is the solution?
How can you take action?
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Duration of Antibiotic Therapy in LTCH
62.6% of courses are over 10 days
20.9% of courses are over 90 days
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Daneman N, Gruneir A, Newman A, Fischer HD, Bronskill SE, Rochon PA, Anderson GM, Bell CM. Antibiotic use in long-term care facilities. Journal of Antimicrobial Chemotherapy. 2011 Sep 27:dkr395.
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77,000 residents
4620 residents currently receiving antibiotics
2310 are receiving unnecessary or inappropriate therapy right now
30,000 receive unnecessary or inappropriate therapy every year
Antibiotic Use in Ontario LTC Homes (LTCH)
7 Image credit: JakeOlimb/Getty Images
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Top 3 Reasons for Antibiotic Use in LTCH
• #3 Skin/Soft Tissue
• #2 Respiratory
• #1 Urinary
8 Image credit: Public Health Ontario, 2013
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Extreme Variability of Antibiotic Use in LTCH
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Lowest Use Home in Ontario Highest Use Home in Ontario
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9 Daneman N, Bronskill SE, Gruneir A, Newman AM, Fischer HD, Rochon PA, Anderson GM, Bell CM. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Internal Medicine. 2015 Aug 1;175(8):1331-9.
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Drivers of Antibiotic Prescribing in LTCH
Knowledge
Social Influences
Environmental context
Risk-Benefit Assessment
10 Image credit: PeopleImages.com, Kaan Ates/Getty Images
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Antibiotic Resistance: “Not my problem”
Most clinicians have heard of antibiotic
resistance and believe it to be serious
However, most think it is caused by other countries or health
care settings
11 Image credit: Derek Latta/Getty Images
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Consequences of Antibiotic Use
↑ Adverse effects
↑ C. difficile infection
↑ Antimicrobial resistance
↑ Cost to health care system
↑ Mortality
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PublicHealthOntario.ca
Extreme Variability of Antibiotic Use in LTCH
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20
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Lowest Use Home in Ontario Highest Use Home in Ontario
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tib
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13 Daneman N, Bronskill SE, Gruneir A, Newman AM, Fischer HD, Rochon PA, Anderson GM, Bell CM. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Internal Medicine. 2015 Aug 1;175(8):1331-9.
24% Increased Risk of Harm C. difficile, adverse effects, diarrhea,
antibiotic resistant organsims
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Why should we care about antibiotic overuse?
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1983-1987 1988-1992 1993-1997 1998-2002 2003-2007 2008-2012
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What is the solution?
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Reduce Environmental Exposure
Reduce Patient Colonization
Reduce Patient Susceptibility
Environmental Cleaning
Infection Prevention and Control
Antimicrobial Stewardship
An
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What is antimicrobial stewardship?
Optimal Antibiotic Use
• Cure Infection
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Avoid
• Adverse Effects • C. difficile • Antibiotic Resistance
Image credit: nambitomo/Getty Images
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What is antimicrobial stewardship?
“coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration”
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Fishman N. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infection Control & Hospital Epidemiology. 2012 Apr 1;33(04):322-7.
Image credit: Public Health Ontario, 2016
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Accreditation Canada Required Organizational Practice in Acute Care
An antimicrobial stewardship program has been implemented. (major)
The program specifies who is accountable for implementing the program. (major)
The program is interdisciplinary, involving pharmacists, infectious diseases physicians, infection control specialists, physicians, microbiology staff, nursing staff, hospital administrators, and information system specialists, as available and appropriate. (major)
The program includes interventions to optimize antimicrobial use. (major)
The program is evaluated on an ongoing basis and results are shared with stakeholders in the organization. (minor)
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US Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in LTC
Leadership Support
Accountability
Drug Expertise
Actions to Improve Use
Tracking: Monitoring
antibiotic use and resistance
Reporting: information to
staff on antibiotic use and resistance
Education
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Centers for Disease Control and Prevention (CDC). The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2015.
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How can you take action?
21 Image credit: PeopleImages.com/Getty Images
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How can you take action?
Don’t treat non-infectious
conditions
Re-assess empiric therapy
Reduce duration of treatment
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Don’t treat non-infectious conditions
24 Image credit: Public Health Ontario, 2013
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Bacteriuria is common in LTCH residents
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Bacteriuria is common in LTCH residents
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bacteriuria
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Bacteriuria is common in LTCH residents
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bacteriuria
UTI
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“Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.”
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long‐term care facilities: 2008 update by the Infectious Diseases Society of America. Journal of the American Geriatrics Society. 2009 Mar 1;57(3):375-94. Image credit: Public Health Ontario, 2013
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Asymptomatic Bacteriuria – ASP Strategies
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• Do’s and Don'ts Key simple messages
• small group, interactive, case-based Education
• Pocket cards, algorithms, posters, Tools & Resources
• guidelines, Structured patient assessment Organizational Policies &
Procedures
• opinion leaders/champions, local consensus Locally-driven
• outcome metrics Measurement
Multi-pronged approach to reducing unnecessary urine cultures:
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The Do’s and Don’ts for Urine Samples in LTCH
Do Do NOT Obtain urine cultures only when residents have the indicated clinical signs and symptoms of a UTI. Obtain and store urine cultures properly. Prescribe antibiotics only when specified criteria have been met, and reassess once urine culture and susceptibility results have been received.
Do NOT use dipsticks to diagnose a UTI. Do NOT perform routine annual urine screening and screening at admission if residents do not have indicated clinical signs and symptoms of a UTI
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Re-Assess Initial Antibiotic Therapy
32 Image credit: Kwangmoozaa/Getty Images
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Re-Assess Initial Antibiotic Therapy
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Often antibiotics are started before all information is obtained
A “time-out” at 48-72 h is recommended to re-assess the situation
• Stop antibiotics?
• Streamline therapy?
• Escalate therapy?
• Re-assess duration?
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Reduce Duration of Antibiotic Therapy
35 Image credit: PeopleImages.com/Getty Images
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Reduce Duration of Antibiotic Therapy
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Another way to reduce patient exposure
Dispel the myth: shorter duration = more resistance
Wide variability in prescribing practices in Ontario, linked to prescriber rather than patient characteristics
Uncomplicated urinary tract infections (UTI) in elderly females can be treated for as short as 3 days
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Conclusion
• Antibiotic overuse is common in Ontario LTCHs
• Antibiotic use is a driver for antibiotic resistance, one of the world’s most pressing public health threats
• Antimicrobial stewardship can help to reduce the negative consequences of antibiotic use in LTCH
• 3 key messages for antibiotic stewardship in LTCH:
• Don’t treat non-infectious conditions
• Re-assess empiric antibiotic therapy after 2-3 days
• Reduce duration of antibiotic therapy
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Stay Tuned
• PHO’s Antibiotic Resistant Organism Survey for LTCHs
• Estimates the burden of AROs in LTCH
• Questions about IPAC practices
• Questions about antibiotic stewardship practices
• Coming in Spring 2017!
40 Image credit: BrianAJackson / Getty Images
PublicHealthOntario.ca 41
Thank You!
Questions?
Image credit: OJO Images/Getty Images
www.PublicHealthOntario.ca/ASP ASP@oahpp.ca
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References • Daneman N, Gruneir A, Newman A, Fischer HD, Bronskill SE,
Rochon PA, Anderson GM, Bell CM. Antibiotic use in long-term care facilities. Journal of Antimicrobial Chemotherapy. 2011 Sep 27:dkr395.
• Daneman N, Gruneir A, Bronskill SE, Newman A, Fischer HD, Rochon PA, Anderson GM, Bell CM. Prolonged antibiotic treatment in long-term care: role of the prescriber. JAMA internal medicine. 2013 Apr 22;173(8):673-82.
• Fleming A, Bradley C, Cullinan S, Byrne S. Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation. BMJ open. 2014 Nov 1;4(11):e006442.
• McCullough AR, Rathbone J, Parekh S, Hoffmann TC, Del Mar CB. Not in my backyard: a systematic review of clinicians' knowledge and beliefs about antibiotic resistance. Journal of antimicrobial chemotherapy. 2015 Jun 20:dkv164.
• Daneman N, Bronskill SE, Gruneir A, Newman AM, Fischer HD, Rochon PA, Anderson GM, Bell CM. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Internal Medicine. 2015 Aug 1;175(8):1331-9
• Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases. 2016 Apr 13:ciw118.
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• Centers for Disease Control and Prevention (CDC). The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2015.
• Beveridge LA, Davey PG, Phillips G, McMurdo ME. Optimal management of urinary tract infections in older people. Clin Interv Aging. 2011 Jan 1;6:173-80.
• Tsan L, Langberg R, Davis C, Phillips Y, Pierce J, Hojlo C, Gibert C, Gaynes R, Montgomery O, Bradley S, Danko L. Nursing home-associated infections in Department of Veterans Affairs community living centers. American journal of infection control. 2010 Aug 31;38(6):461-6.
• High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long‐term care facilities: 2008 update by the Infectious Diseases Society of America. Journal of the American Geriatrics Society. 2009 Mar 1;57(3):375-94.
• Zabarsky TF, Sethi AK, Donskey CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. American journal of infection control. 2008 Sep 30;36(7):476-80.
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