Download OHCA District II ABT July 2016

OHCA District II
July 26, 2016
Move over Antipsychotics:
A Look at the Increased Scrutiny
of Antibiotic Use in LTC
1 | © 2015 Remedi Senior Care™
Disclosure / Contact
• Rob Shulman has no significant disclosures at this time.
• William Vaughan is a contractor to CMS (QAPI) and a
member of the Institute for Safe Medication Practices
clinical advisory board (Long-Term Care Advise ERR)
• Contact :
• [email protected]
• [email protected]
2 | © 2015 Remedi Senior Care™
“Welcome to the ISMP Long-Term Care AdviseERR, a medication safety newsletter designed
specifically to meet the needs of administrators,
nursing directors, and nurses who transcribe
medication orders, administer medications, monitor
the effects of medications on residents, and/or
supervise those who carry out these important
tasks.”
http://www.ismp.org/Newsletters/longtermcare/default.aspx
Objectives
• Discuss current and proposed federal regulations
which impact the use of antibiotics in LTC.
• Identify three clinical practices which maximize
the benefits and minimize the risks associated
with the use of antibiotics in long term care
residents.
• Describe the concept of antibiotic stewardship
and identify four core elements of an antibiotic
stewardship program.
Regulatory “Priorities”
Antibiotics
“However, with the recent emergence of
resistant organisms, pediatric organizations
have strongly recommended initial antibiotics
only for certain children”
- Merck Manual
“90% – 98% of rhinosinusitis cases are viral,
and antibiotics are not guaranteed to help
even if the causative agent is bacterial.”
- CDC
“Although warranted in some cases, antibiotics
are greatly overused.”
- American Academy of Family Physicians
Nursing Homes
• ~ 4 million admissions / year
• ABT use common (up to 70% / year)
• Inappropriate prescribing (up to 75%)
– Unnecessary
– Wrong drug, dose or duration
• Colonization common
Source: CDC (http://www.cdc.gov/media/releases/2015/p0915-nursing-home-antibiotics.html)
In the Crosshairs:
Urinary Tract “Infections”
• Generalized change in condition (falls, mental
status, etc.)
– Adverse drug reaction ("Any symptom in an
elderly patient should be considered a drug side
effect until proven otherwise.”– Gurwitz et al)
– Fluid / electrolyte imbalance
– Infection
• + urine culture  Antibiotics
colonization
In the Crosshairs:
Urinary Tract “Infections”
• “Don’t obtain a urine culture unless there are
clear signs and symptoms that localize to the
urinary tract.”
– AMDA
• “Don’t use antimicrobials to treat bacteriuria
in older adults unless specific urinary tract
symptoms are present.”
– AGS
Guidance to Surveyors – F 315 (Incont)
(what's old is new again)
“In someone with nonspecific symptoms such as a
change in function or mental status, bacteriuria
alone does not necessarily warrant antibiotic
treatment … In the absence of fever, hematuria,
pyuria, or local urinary tract symptoms, other
potential causes of nonspecific general symptoms,
such as fluid and electrolyte imbalance or adverse
drug reactions, should be considered instead of, or
in addition to, a UTI …”
In the Crosshairs:
Urinary Tract “Infections”
• A patient with advanced dementia may be
unable to report urinary symptoms … In this
situation, it is reasonable to obtain a urine
culture if there are signs of systemic infection
such as fever … leukocytosis, or a left shift or
chills in the absence of additional symptoms
(e.g., new cough) to suggest an alternative
source of infection.
– AMDA
Other High Risk Areas
Current Regulations
• F 281 (Profession standards of quality)
– “Standards published by professional
organizations”
• F 329 (Unnecessary Drugs)
– Indication
– Dose
– Duration
– Monitoring
– Adverse consequences (c. diff)
Current Regulations
• F 281 (Profession standards of quality)
– “Standards published by professional
organizations”
• F 329 (Unnecessary Drugs)
– Indication
Inappropriate prescribing (up to 75%)
Unnecessary
– Dose
Wrong drug, dose or duration
– Duration
- CDC on ABT (2015)
– Monitoring
– Adverse consequences (c. diff)
No Absolutes
Rationale for Care Based on:
• Evidence
• Thoughtful risk / benefit analysis
• Resident / surrogate involvement
 Document especially in high risk situations
76 year old Female : SDAT, HTN , DM, CHF
July 26, 2016:
“Cipro 500 mgs. PO q day x 7 days UTI”
- VO Dr. Smith
Actions to Consider
• Engage Medical Directors / Consultant
Pharmacists
• Educate
– Prescribers
– Nursing staff
– Residents / surrogates /families
• “But what if your wrong?”
• Discuss / document goals of care
Actions to Consider
• Don’t succumb to perceived regulatory
pressure to “do something”
– Watchful waiting
– Antibiotic “time out”
• Quality assurance
– Consistency of prescribing practices
– Type of antibiotic (broad spectrum)
– Duration of therapy
• Choosing Wisely (www.choosingwisely.org)
Proposed Regulations
• Infection and Prevention Control Officer
• Infection Prevention and Control Program
– Antibiotic stewardship
• Quality Assurance Performance Improvement
QAPI/Resistance: Think Like a Squirrel
QAPI/Resistance: Think Like a Squirrel
QAPI/Resistance: Think Like a Squirrel
Key Components of an Infection Prevention and Control
Program: F-Tag 441: 2009 Updates
 Policies, procedures, and practices consistent with
evidence-based infection control practices
 Interdisciplinary involvement
 “Infection Preventionist” – a person designated to serve as
coordinator of the infection prevention and control program
 Surveillance of both process and outcome, including
monitoring effectiveness of the program and the condition of
any resident with an infection; documentation and analysis of
surveillance data; and reporting communicable diseases to
state and federal authorities
 Education and training - Antibiotic review to monitor the
appropriate use of antibiotics in the resident population
http://www.ascp.com/resources/nhsurvey/upload/FTag%20441%20summary.pdf
http://www.ascp.com/resources/nhsurvey/upload/FTag%20441%20summary.pdf
Antibiotics- Some Facts
Each Year in the US:
• ~2 million people become infected with resistant bacteria
• At least 23,000 people die each year as a direct result of these
infections
• 250,000 patients (hospitalization) get Clostridium difficile each
year,
• C. difficile kills at least 14,000 people each year
Resistance Develops….Survival of the Fittest
Antibiotic Resistance Spreads…..
Fast-paced resistance
Resistance develops quickly:
• Methicillin:
o developed in 1960
o resistance by 1962
• Linezolid
o developed in 2000
o resistance by 2001
Adverse Drug Reactions:
Antibiotic Overuse
Systemic Adverse Effects of Common Antibiotics
Antibiotic Class
• Adverse Drug Events





N/V/D
Myalgias
Blood dyscrasias
Candidiasis
C. Difficile
Most Common Side Effects
Penicillins
rash, diarrhea, abdominal pain, nausea/vomiting, hypersensitivity reactions
Cephalosporins
rash, diarrhea, nausea/vomiting (rare), hypersensitivity reactions, vaginal
candidiasis
Aminoglycosides
renal toxicity, ototoxicity, dizziness, nausea/vomiting, nystagmus
Carbapenems
diarrhea, nausea/vomiting, headache, rash, liver toxicity, eosinophilia
Vancomycin
flushing, hypotension, itching, phlebitis, taste alteration, nausea/vomiting,
headache, dizziness
Macrolides
abdominal pain, diarrhea, anorexia, nausea/vomiting, taste alterations
Sulfonamides
nausea/vomiting, diarrhea, anorexia, abdominal pain, rash, photosensitivity,
headache, dizziness
Tetracyclines
nausea/vomiting, diarrhea, anorexia, abdominal pain, liver toxicity
Quinolones
myalgias, tendonitis, nausea/vomiting, diarrhea, abdominal pain, headache,
lethargy, insomnia, photosensitivity
Lincosamide
colitis,diarrhea, nausea/vomiting, rash, hypersensitivity, jaundice
Additional Problems:
Clostridium Difficile
Clostridium Difficile
C.Difficile - Treatment
Drug Treatment:
• Metronidazole $
• Vancomycin $$-$$$
• Fidaxomicin (Dificid) $$$$
Recurrence -can occur in up to 25% of patients (another episode
of C. difficile within 8 weeks)
• Relapse of the initial infection
• Re-infection with a new strain
Recurrence Treatment:
• First recurrence- the same medication
• Second recurrence, a tapered or pulsed oral vancomycin
• Third recurrence fecal transplant should be considered
Long-term care facility residents are particularly at risk for C. Difficile complications
CDC: What Can the Health Care Community Do?
CDC: What Can the Health Care Community Do?
Antimicrobial Stewardship
Coordinated interventions designed to improve and measure the
appropriate use of antimicrobial agents by promoting the
selection of the optimal antimicrobial drug regimen
Patients receive the right antibiotic, at the right dose, at the right
time, and for the right duration
Antibiotic Stewardship Programs are a
“win‐win” for all involved!
Antibiotic Stewardship will:
–
–
–
–
Decrease antibiotic resistance
Decrease C. difficile infections
Decrease costs
Increase good patient outcomes
http://www.cdc.gov/getsmart/healthcare/factsheets/antibiotic-use.html
LTC Core Elements for Antibiotic
Stewardship
http://www.cdc.gov/longtermcare/prevention/antibi
otic-stewardship.html
Leadership Commitment
• Write statements in support of improving antibiotic use to be
shared with staff, residents and families
• Include stewardship-related duties in position descriptions:
o
o
o
Medical Director
Clinical nurse leads, DON
Consultant pharmacist
• Communicate with nursing staff, prescribing clinicians
o Expectations about use of antibiotics
o Monitoring and enforcement of stewardship policies
• Create a culture which promotes antibiotic stewardship
o
o
o
Messaging
Education
Celebrating improvement
Accountability
• Medical Director: set standards for antibiotic prescribing practices for all
clinical providers
• Director of Nursing: set the practice standards for assessing, monitoring and
communicating changes in a resident’s condition by front-line nursing staff.
• Infection prevention program coordinator:
o Track antibiotic starts
o Monitor adherence to evidence-based published criteria
o Review antibiotic resistance patterns in the facility
• Consultant pharmacist : support antibiotic stewardship oversight through
quality assurance activities
• Laboratory Services:
o Alerting facility if certain antibiotic-resistant organisms are identified,
o Educate staff on the differences in diagnostic tests available
o Antibiogram
Drug Expertise
• Partner with antibiotic stewardship program leads at
the hospitals within your referral network
• Infectious Disease practitioners and consultants in
your community
• Consultant Pharmacists
Action Through Policy/Practice Change
Policies that support optimal antibiotic use
o Require dose, duration, indication for every order
o Viewing culture data
Broad interventions to improve antibiotic use
o Improving the evaluation and communication of clinical signs/symptoms
o “Communication Tool”
o INTERACT Tools
o “Antibiotic time-out”
o Developing antibiotic monitoring and infection management guidance
Infection and syndrome specific interventions to improve
antibiotic use
o Asymptomatic bacteriuria (ASB)
o Urinary tract infection prophylaxis
o Lower Respiratory Tract Infections (Viral vs Bacterial)
Tools and Protocols:
INTERACT Programs
https://interact2.net/tools_v4.html
Tracking/Reporting: Use and Outcomes
• Process Measures:
o Completeness of clinical assessment documentation at the time of the
antibiotic prescription
o Completeness of antibiotic prescribing documentation
o Antibiotic selection is consistent with recommended agents for
specific indications
o Point prevalence of antibiotic use
o Antibiotic days of therapy (DOT)
o Post-prescription review of appropriateness
• Outcome Measures:
o
o
o
o
Track C. difficile and resistant organisms
Track adverse drug events related to antibiotic use
Antibiotic resistance
Track costs related to antibiotic use
Tools and Protocols:
Antibiotic Appropriateness Assessment - G+ Infections
Tools and Protocols:
Antibiotic Appropriateness Assessment- UTI
http://www.remedirx.com/site/wp-content/uploads/2016/02/2016-02-M.R.-UTI-Assess-Tool.pdf
Education
• Provide antibiotic stewardship education to clinicians, nursing staff,
residents and families
• Linking education with feedback on physician prescribing practices
• Interactive academic detailing (e.g., face-to-face interactive
workshops) has the strongest evidence for improving medication
prescribing practices
• Providing feedback on individual physician prescribing practices and
adherence to the guidelines over 12 months
Tools and Protocols:
Appropriate Antibiotic Use Summary
http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/adult-approp-summary.pdf
The First Steps:
• Ensure all orders have dose, duration, and indications
• Get cultures before starting antibiotics
• Take an “antibiotic timeout,” reassessing antibiotics after 48–72
hours
• Implement policies that encourage best practices
o Establishment of minimum criteria for prescribing antibiotics
o Review of antibiotic appropriateness/resistance patterns
o Nursing protocols for monitoring patients’ status for an evolving
condition if there is no specific indication for antibiotics
Small, Sustainable Changes
• Facility should not attempt to implement all of the
interventions at once.
• Interventions to implement should be tailored to the
areas that most need improvement at your facility
• Essential to monitor and measure
o Measurement Framework- various measures of antibiotic
use to assess effectiveness of improvements
http://www.remedirx.com/news-events/news/
Changing Prescribing Behaviors
Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing
Among Prescribers; Leeker et al.
Alternative:
EHR pop-up: presented electronic order sets
suggesting non-antibiotic treatments
22%  6%
Justification:
Required clinicians to enter free-text justification
when prescribing ABTs into EHR. “No justification”
populated if left blank
23%  5%
Comparison:
Sent e-mails to prescribers that compared their ABT
prescribing rates with those of “top performers”
(those with lowest inappropriate prescribing rates)
20%  4%
JAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275
Antibiotic Stewardship:
Are You Ready?
LTC Antibiotic Stewardship Tool
Core Elements Checklist
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf
LTC Antibiotic Stewardship Tool
Core Elements Checklist
LTC Antibiotic Stewardship Tool
Core Elements Checklist
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf
LTC Antibiotic Stewardship Tool
Core Elements Checklist
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf
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