Less is More - Health Unithealthunit.org/wp-content/uploads/ASP_in_LTC_Education_Day.pdf · Less is...

Less is More Antimicrobial Stewardship in Long-term Care (LTC)

Brad Langford BScPhm, ACPR, PharmD, BCPS

Valerie Leung BScPhm, ACPR, MBA

[email protected]

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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http://www.publichealthontario.ca/

PublicHealthOntario.ca 4



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.



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



Top 3 Reasons for Antibiotic Use in LTCH

• #3 Skin/Soft Tissue

• #2 Respiratory

• #1 Urinary

8 Image credit: Public Health Ontario, 2013



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.



Drivers of Antibiotic Prescribing in LTCH

Knowledge

Social Influences

Environmental context

Risk-Benefit Assessment

10 Image credit: PeopleImages.com, Kaan Ates/Getty Images



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



Consequences of Antibiotic Use

↑ Adverse effects

↑ C. difficile infection

↑ Antimicrobial resistance

↑ Cost to health care system

↑ Mortality

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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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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



Why should we care about antibiotic overuse?

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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

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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



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



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.




21 Image credit: PeopleImages.com/Getty Images



www.publichealthontario.ca/ASP




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



Bacteriuria is common in LTCH residents

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bacteriuria




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bacteriuria

UTI



“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



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:



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



www.PublicHealthOntario.ca/ASP



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?



Reduce Duration of Antibiotic Therapy

35 Image credit: PeopleImages.com/Getty Images



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



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



Thank You!

Questions?

Image credit: OJO Images/Getty Images

www.PublicHealthOntario.ca/ASP [email protected]


http://www.publichealthontario.ca/ASP


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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