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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 As a sponsor accredited by the Massachusetts Medical Society, Masspro follows the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support SM to ensure balance, independence, objectivity, and scientific rigor in all its individually sponsored and jointly sponsored educational activities. All faculty participating in a sponsored activity are expected to disclose to the activity audience any discussion of off-label use or investigational use of a product, and any relevant financial interests or other relationships which they have, or their spouse/significant other have (a) with the manufacture(s) of any commercial product(s), (b) provider(s) of commercial services discussed in an educational presentation or (c) with any commercial supporters of the activity. (Relevant financial interests or other relationships can include such things as receiving grants or research support, or being an employee, consultant, major stockholder, member of speaker’s bureau, etc.). The intent of this disclosure is not to prevent a speaker with a relevant financial or other relationship from making a presentation, but rather to provide listeners with information on which they can make their own judgments. FINANCIAL INTERESTS OR RELATIONSHIPS The following faculty members have indicated their financial interests and/or relationships with commercial manufacturer(s) (and/or those of their spouse/partner) below. Faculty with no relevant financial relationships are listed with N/A. Faculty Daniel J Pallin, MD, MPH Shira Doran, MD Name of Organization N/A Forest Labs Optimer Pharmaceuticals Cubist Pharmaceuticals Merck Durata Consultant Grant Research/ Support X Speaker's Bureau Major Stockholder Other Financial or Material Interest X X X X X The speaker must disclose any discussion of off-label use and/or investigational products to the audience during the presentation. 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]. 2 FINANCIAL INTERESTS OR RELATIONSHIPS The following CME/CE program planners have indicated their financial interests and/or relationships with commercial manufacturer(s) (and/or those of their spouse/partner) below. Planners with no relevant financial relationships are listed with N/A Consultant Program Planner Frederick Buckley, Jr., MD Ashley Harris Phyllis Kaplan, RN, BSN Kathy Killilea, RN, BSN Denise Rebilas, RN, MSN Cynthia Sacco, MD Mary Scott, LPN Name of Organization Grant Research/ Support Speaker's Bureau Major Stockholder Other Financial or Material Interest N/A N/A N/A N/A N/A N/A N/A 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 9 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 11 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. 15 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 16 • 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 17 • 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 24 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 25 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 26 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 27 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 28 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 29 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 30 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 32 Example of evidence Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 33 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 34 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 35 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 36 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 37 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 38 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 39 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 40 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 41 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 42 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 43 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 44 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 45 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 46 Is it really so complicated? Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 47 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 48 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 49 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 50 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 51 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 52 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 53 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 54 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 55 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 56 Mid-stream and first-void? Difficult to explain & coordinate Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 57 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 58 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 59 How can we function with such complexity? Clinical judgment Communication Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 60 conceptual framework: Spectrum of Appropriateness for urine testing & treatment Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 61 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 62 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 63 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 64 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 65 Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 66 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 67 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 68 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 69 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 70 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 71 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 72 We are already in stewardship mode for: Rhinitis Viral pharyngitis Bronchitis Acute gastroenteritis Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 73 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 74 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 76 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 77 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 78 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 80 General Take-Home Messages Prescribers Nurses Leadership Danny Pallin – Brigham and Women‘s Hospital – Harvard Medical School 81 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 82 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 83 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 87 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 Continuing Education Credits Survey for Nursing CEU credit https://www.surveymonkey.com/s/2014EDWebinar Physician, Nursing Home Administrator, or Pharmacist CME credit please email [email protected] for your survey 89