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ANTIBIOTIC STEWARDSHIP IN THE ELDERLY:
Decreasing Misdiagnosis of UTI In the Emergency Department
July 10, 2014
Shira Doron, MD
Associate Professor of Medicine
Division of Geographic Medicine and Infectious Diseases
Tufts Medical Center
Boston, MA
Daniel J. Pallin, MD, MPH
Director of Research
Brigham and Women’s Emergency Medicine
Boston, MA
SUMMARY OF FACULTY DISCLOSURE INFORMATION
Antibiotic Stewardship in the Elderly: Decreasing Misdiagnosis of UTI in the Emergency Department
July 10, 2014
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Daniel J Pallin, MD, MPH
Shira Doran, MD
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For more information about faculty and planner disclosures, contact Ashley Harris at [email protected].
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Frederick Buckley, Jr., MD
Ashley Harris
Phyllis Kaplan, RN, BSN
Kathy Killilea, RN, BSN
Denise Rebilas, RN, MSN
Cynthia Sacco, MD
Mary Scott, LPN
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The CME/CE Committee of Masspro has reviewed the appropriate documentation provided by the above individuals who are
speaking at this education activity. The Committee has determined that any potential relevant conflict of interest has been
resolved. For more information about faculty and planner disclosures, contact Ashley Harris at [email protected].
3
The Antibiotic
Resistance Crisis:
Overuse and Misuse in
the Elderly
Shira Doron, MD
Associate Professor of Medicine
Division of Geographic Medicine and Infectious Diseases
Tufts Medical Center
Boston, MA
Consultant to Massachusetts Partnership Collaborative:
Improving Antibiotic Stewardship for UTI
4
Antibiotics in Long Term Care and
the Elderly
• Antibiotics are among the most commonly
prescribed classes of medications in long-term
care facilities
• Up to 70% of residents in long-term care
facilities per year receive an antibiotic
• As much as half of antibiotic use in long term
care may be inappropriate or unnecessary
5
The importance of prudent use of
antibiotics
6
Bad Bugs No Drugs
7
The drug development pipeline for
antibacterials
8
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Antimicrobial Therapy
Appropriate initial
antibiotic while improving
patient outcomes and
healthcare
Unnecessary
Antibiotics, adverse
patient outcomes and
increased cost
A Balancing Act
10
What is Antimicrobial
Stewardship?
• Antimicrobial stewardship involves the
optimal selection, dose and duration of an
antibiotic resulting in the cure or prevention
of infection with minimal unintended
consequences to the patient including
emergence of resistance, adverse drug
events, and cost.
Ultimate goal is improved patient
care and healthcare outcomes
Dellit TH, et al. CID 2007;44:159-77,
Hand K, et al. Hospital Pharmacist 2004;11:459-64
Paskovaty A, et al IJAA 2005;25:1-10
Simonsen GS, et al Bull WHO 2004;82:928-34
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Why focus on long term care and
the elderly?
• Many long-term care residents are colonized
with bacteria that live in an on the patient
without causing harm
• Protocols are not readily available or
consistently used in long term care facilities to
distinguish between colonization and true
infection
• So, patients are regularly treated for infection
when they have none
– 30-50% of elderly long-term care residents have a
positive urine culture in the absence of infection
12
Why focus on long term care and
the elderly?
• When patients are transferred from acute
to long-term care, potential for
miscommunication can lead to
inappropriate antibiotic use
• Elderly or debilitated long-term care
residents are at particularly high risk for
complications due to the adverse effects
of antibiotics, including Clostridium
difficile infection
13
Antibiotic misuse adversely
impacts patients
Getting an antibiotic
increases a patient’s
chance of becoming
colonized or infected with
a resistant organism.
14
Case
• An 82-year-old long-term care resident is
brought to the ED after a pre-syncopal
event. He has had fever and a productive
cough for 3 days.
• He has no urinary or other symptoms,
and a chronic venous stasis ulcer on the
lower extremity is unchanged.
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Case
• A “pan-culture” is initiated in which urine
is sent for UA and culture, sputum and
blood are sent for culture, and the ulcer
on the leg is swabbed.
• He is admitted and started on broadspectrum antibiotics
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• CXR is negative
• The urinalysis has 3 white blood cells
• Urine culture is positive for >100,000
CFU of E coli
• Sputum gram stain has no PMNs, no
organisms
• Sputum culture grows 1+ Candida
albicans
• Wound culture grows VRE
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• The patient is started on cipro for the E
coli in the urine, linezolid for the VRE in
the wound, and fluconazole for the
Candida in the sputum
• Two weeks later the patient has diarrhea
and C. diff toxin assay is positive
18
• The only infection this patient ever had
was a viral URI
• He was pre-syncopal due to dehydration
19
Colonized or Infected:
What is the
Difference?
• People who carry bacteria or fungi without
evidence of infection are colonized
• If an infection develops, it is usually from
bacteria or fungi that colonize patients
• There is no need to treat for colonization
20
The Iceberg Effect
Infected
Colonized
21
What could have been done
differently?
• Understanding the difference between
colonization and infection
– No (or few) WBCs in a UA= no UTI
– In the absence of dyspnea, hypoxia and CXR
changes, pneumonia is unlikely
– Candida is an exceedingly rare cause of
pneumonia
– Wounds will grow organisms when culturedinfection can only be determined clinically
22
Take Home Points
• Antibiotics are a shared
resource… and becoming a
scare resource
• Appropriate antibiotic use is a
patient safety priority
• Know the difference between
colonization and infection
23
When it comes to resistance
Think globally, act locally
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Antibiotic Stewardship
and the
Misdiagnosis of UTI
Daniel J. Pallin, MD, MPH
Director of Research, Department of Emergency Medicine
Chairman, Clinical Investigation Committee
Brigham and Women’s Hospital
Assistant Professor, Medicine and Pediatrics
Harvard Medical School
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Under normal conditions…
the skin surface is not sterile…
the mouth is not sterile…
the colon is not sterile…
and in many patients,
the bladder is not sterile.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Asymptomatic Bacteriuria
the culture is positive
but no infection is present
Positive culture is:
≥105 CFU (midstream clean-catch)
or
≥102 CFU (cath)
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Therefore,
without UTI symptoms,
urine testing leads to
false diagnosis of UTI
• Unnecessary antibiotics
• Missing the real diagnosis
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Population
Prevalence
Long-term care facility, age ≥70
Women
Men
25-50%
15-40%
Community, age ≥70
Women
Men
Healthy pre-menopausal women
11-16%
4-19%
1-5%
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Infectious Disease Society of America:
“Do not test, do not treat”
Population
Quality
Elderly, institutionalized
Pre-menopausal, non-pregnant
women
A-I
Diabetic women
Older people in the community
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
A-I
A-I
A - II
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Asymptomatic Bacteriuria
 Positive urine culture, but
no need for antibiotic treatment
Exceptions:
–Pregnancy
–Urological surgery
Our Goal:
Give you a new perspective on
urine microbiology
 Faster care
 Lower expenses
 More accurate testing & treatment
 and fewer unnecessary antibiotics!
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Example of evidence
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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 Patients with asymptomatic bacteriuria
more likely to get prosthesis infections
 But treatment made no difference
 They are just sicker patients!
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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IDSA: let’s say it again:
 Bacteria in the urine should not lead to
antibiotic treatment in adults except
during pregnancy or before urologic
surgery.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Case Vignette
 75 year old female, “Hip pain”
 Slipped on wet floor at her nursing home
 Exam reveals shortened & externally
rotated leg
 Xray: hip fracture
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Case Vignette
 Tests that are done:
– CBC, Chem 7, PT/PTT, Type and Screen
– Chest xray
– EKG
– Urine dip
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Challenges
 Can this lady do a midstream cleancatch?
 Did the clinician specify how the
specimen should be collected?
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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But the real
challenge is…
 Why is the urine being tested in
the first place?!
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Was it done “because of her age?”
Was it done “because we always do that?”
Was the test ordered by a physician, NP, or
PA?
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Reminder
Population
Prevalence
Long-term care facility, age ≥70
Women
Men
25-50%
15-40%
Community, age ≥70
Women
Men
Healthy pre-menopausal women
11-16%
4-19%
1-5%
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Antibiotics in long-term care
 2/3 elderly long-term care residents
receive antibiotics every year.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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UTI ASB
FPUA
How do they overlap?
 Urinary tract infection
 Asymptomatic bacteriuria
 False-positive urinalysis
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Overlapping Sets
 When there are no symptoms:
– Positive urine dip is meaningless.
– Positive urinalysis is meaningless.
– Positive urine culture is just ASB.
 When symptoms are present:
– Only urine culture can rule out UTI.
 Regardless of symptoms:
– Poor urine collection technique causes falsepositive urinalysis.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Is it really so complicated?
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Let’s review the ways of getting
the sample:
 Suprapubic aspiration
 Catheter
 Midstream clean-catch
 First-void non-clean-catch
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Needle aspiration and
catheterization:
 Safe, but uncomfortable
 Highly accurate, but only for the
presence of bacteria, not the presence of
infection
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Midstream Clean-Catch
 Methods vary wildly
– Textbook to textbook
– Hospital to hospital
– Nurse to nurse
– Doctor to doctor
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Midstream Clean-Catch
 Difficult for the elderly
–Cognitive limitations
–Short-term memory limitations
–Physical limitations
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Midstream Clean-Catch
 Best-case scenario for accuracy:
– False positive: 22%
– False negative: 23%
 For the presence of bacteria only!
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Facts about
Midstream Clean-Catch samples
 No symptoms + no pyuria = no infection
 Pyuria without symptoms ≠ infection
 Symptoms with negative dipstick ≠ no infection
(poor sensitivity)
 Squamous epithelial cells ≠ contamination.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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First-void non-clean-catch
(the “dirty catch”)
 Necessary for PCR
– Best test for gonorrhea and chlamydia
 Must not have voided x 1 hour
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Mid-stream and first-void?
 Difficult to explain & coordinate
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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 No instructions received by patient: 57%
 Correct collection technique achieved: 6%
 Antibiotic prescriptions were NOT related to
clinical findings.
 Antibiotic prescriptions WERE related to test
results.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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How can we function with
such complexity?
 Clinical judgment
 Communication
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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conceptual framework:
Spectrum of Appropriateness
for urine testing & treatment
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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http://www.yourerdoc.com/weak-and-dizzy-symptoms/
http://bestdiytips.blogspot.com/2011/03/what-causes-painful-urination.html
Spectrum of Appropriateness
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
http://www.yourerdoc.com/weak-and-dizzy-symptoms/
http://bestdiytips.blogspot.com/2011/03/what-causes-painful-urination.html
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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The Gray Zone
 Weak and dizzy
 Altered mental status
 Decreased appetite
 Decreased mobility
 Fever without a focus
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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The Gray Zone – Evidence?
Can J Emerg Med 2007;9(2):87-92
 Ducharme et al. studied
200 ED patients aged ≥65
 100 with vague symptoms, possibly UTI
 100 with no urinary symptoms
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Study Definitions
Vague Symptoms
No UTI Symptoms
Confusion
Cast check
Weakness
Minor trauma
Fever without focus
etc.
(No fever allowed in “no symptoms” group.)
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Positive
Urine Culture
No symptoms
Vague symptoms
14%
19%
 Ducharme, Can J Emerg Med 2007;9(2):87-92
The gray zone patient
probably does NOT have UTI!
(p value = 0.34)
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Why is this important?
1. Antibiotic stewardship
2. Efficiency of clinical care
3. Patient safety
(avoid premature closure)
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Antibiotic Stewardship
 Individual patient
– C. difficile
– Other diarrhea
– Allergy
– Drug interactions
 Society
– Widespread antibiotic resistance
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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We are already in stewardship
mode for:
 Rhinitis
 Viral pharyngitis
 Bronchitis
 Acute gastroenteritis
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Efficiency
 Prescriber’s bandwidth is finite.
 Nurse’s time is finite.
 We all need to avoid distractions.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Financial Implications
 We cannot afford to spend time and money
chasing red herrings.
 Affordability is a national priority
 What could help affordability more than
eliminating unnecessary costs?
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
75
Premature Closure/
Patient Safety
 UTI is blamed, while the real criminal
goes free.
– Hyponatremia
– Dehydration
– Ischemia
– Medication adverse events
– Etc.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Case Vignette 2
 45 year old man has new-onset dysuria
 Challenges:
– What tests?
– Collection method?
– Is urine dip accurate?
– Is urinalysis accurate?
– Is urine culture accurate?
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Case Vignette 2
 45 year old man has new-onset dysuria
 Challenges:
– What tests?
– Collection method?
– Is urine dip accurate?
– Is urinalysis accurate?
– Is urine culture accurate?
UA and PCR
dirty and clean
Lots of false pos & neg
Lots of false pos & neg
UTI, yes; STD, no
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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What to do about collection?
 Communication is key!
– Between RNs and prescribers
– Explain to patients what is needed
– Ask patients what they did
 Always consider cath, or repeat void, if
the original specimen is dirty, especially
in females.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
79
With a “positive” result in hand…can
I defer antibiotics?
More communication!
 Talk to the team that will care for the
patient next.
– Inpatient
– Nursing home
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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General Take-Home Messages
 Prescribers
 Nurses
 Leadership
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Prescribers
1. Use the conceptual framework
2. Beware premature closure
3. Formal, written orders only
4. Specify collection method
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Nurses and Assistants
1. No urine testing (except hCG) without
prescriber’s order
2. Improve communication
– ASK: what sample do we need?
– EXPLAIN: what the patient has to do.
– RECORD: what sample did we get?
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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Leadership
Educate!
– Asymptomatic bacteriuria is very common.
For your prescribers:
– No non-indicated orders.
For your nurses:
– No non-ordered urine tests (except hCG).
For your QI staff:
– Separate surveillance from clinical practice.
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
84
Conclusion
 Urine testing is more complicated than it seems.
 Like other medical tests, it should be done:
– With an appropriate cognitive framework.
– With appropriate technique.
– With appropriate credentials.
 Primum non nocere: first do no harm.
– Avoid unnecessary antibiotics and wrong
diagnoses!
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
85
Thank you!
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
86
If we remember one thing…
Population
Prevalence
Long-term care facility, age ≥70
Women
Men
25-50%
15-40%
Community, age ≥70
Women
Men
Healthy pre-menopausal women
11-16%
4-19%
1-5%
Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School
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INFORMATION AND
PROGRAM MATERIALS
UTI in the Elderly Educational and Practice Support Tools
www.macoalition.org/uti-elderly-tools
Questions? Please email
[email protected]
88
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