Edward C. Oldfield, III, MD Virginia Medical Directors Association September 29, 2012

1. Update on Revised McGeer Criteria, Clostridium difficile Infections (CDI) and UTIs in the Long Term Care Facility Edward C. Oldfield, III, MD Virginia Medical Directors Association September 29, 2012

2. Ageing Population • By 2030, 20% of the U.S. population will be over 65 years old. • Currently, > 16,000 nursing homes/LTCFs with 1.5 million residents in the U.S.

3. Infections in the LTCF • Infections in LTCFs are more frequent than hospital acquired infections; about 2.5 million each year. • Infections cause 25-50% of all hospital transfers or 250,000 admissions each year. • 30-50% of all hospital admissions for those over 65 y.o. • Over 100,000 deaths in LTCFs each year at a cost of $1 billion.

4. Antibiotics and Nursing Homes • 54% of nursing home patients receive a course of antibiotics each year. • Most common indication is for urinary tract infections; 36% of all antibiotics. • 9% of all prescriptions are for asymptomatic bacteriuria, which is inappropriate. Warren J. J Am Geriatr Soc 1991;39:963-72.

5. Infection Control in LTCFs LTCFs pose multiple challenges to infection control: • High prevalence of infections. • High rates of colonization with antimicrobial resistant organisms. • Frequent and often inappropriate prescribing of antimicrobials. Moro M. Infect Control HospEpidemiol. 2012;33:978-80.

6. Infection Control in LTCFs • Frequent transfer of residents from the hospital. • Growing elderly populations with increasingly complex medical problems. • Scarce resources. • Absent/poor coordination of clinical and nursing care.

7. “The Perfect Storm of Antimicrobial Resistance”

8. Surveillance in LTCFs • Surveillance of infections is universally recommended as the core of infection control efforts. • Increases awareness of the problem. • Establishes an infection control “presence” in the facility. • Identifies critical areas for infection control. • Determines trends. • Identifies and prevents outbreaks in a timely fashion.

9. Mc Geer Criteria. Definitions of Infections in Long Term Care Facilities. Am J Infect Control 1991;10:1-7. Revisiting the McGeer Criteria. Surveillance Definitions of Infections in Long Term Care Facilities. SHEA/CDC Position Paper. Stone N. Infection Control Hosp Epidemiol. 2012;33:965-77.

10. Revised McGeer Criteria • Focus was to increase the specificity and PPV of the criteria to limit unnecessary interventions and curb misallocation of scarce resources. • Will be less sensitive than clinical diagnoses. • Revised criteria provide explicit definitions for fever, acute confusion or altered mental status and acute functional decline. • Attempt to harmonize the definitions used in acute and LTCFs (using > 2 days at the facility to define a HAI).

11. Revised McGeer Criteria • Criteria for systemic infections, common cold, conjunctivitis, ear infections, herpes simplex and zoster were left unchanged. • Influenza was modified only to track cases outside the influenza season, as a consequence of pandemic H1N1. • Criteria for gastrointestinal infections were unchanged, but specific criteria for norovirus and C. difficile were added. • Skin infection criteria were not substantially changed, but NHSN criteria for surgical site infections was added.

12. Revised McGeer Criteria • Major changes were made to the criteria for defining respiratory track and UTIs. • Original McGeer criteria did not include a positive urine culture to define a UTI. • More than half of residents suspected of having a UTI have negative cultures despite the high prevalence of asymptomatic bacteriuria. Juthani-Mehta M. J Am Geriatric Soc 2007;55:1072-7.

13. Revised McGeer Criteria • Urinary tract symptoms alone are not sufficient to identify cases of UTI with a high level of specificity. • Revised criteria require a positive urine culture as a necessary condition to diagnose a UTI.

14. Revised McGeer Criteria • Define which infections should have priority in LTCF infection control, either because they are avoidable or cause significant morbidity and mortality. Priorities include: • Viral respiratory, GI and conjunctivitis due to high transmissibility. • UTI, pneumonia, GI infections, SSTI (morbidity). • Infections that can lead to serious outbreaks (hepatitis, norovirus, scabies, influenza, group A streptococci). Even a single case should trigger a more intensive investigation.

15. HBV and Glucose Monitoring • 8 residents hospitalized, 6 died of acute HBV in a North Carolina assisted-living facility in 2010 related to facility staff assisting with blood glucose monitoring. • 16 outbreaks of HBV have been reported related to sharing of glucose monitoring equipment in assisted-living facilities since 2004. Moore Z. MMWR 2011;60:182

16. HBV and Glucose Monitoring • VDH was notified of acute HBV infections in residents from 4 assisted living facilities regulated by state agencies (not CMS) between 2/2009 and 11/2011. • All infections were among residents receiving assisted monitoring of blood glucose (AMBG). • Attack rates by facility among susceptible residents receiving AMBG ranged from 17-92%. • AMBG has been responsible for 27 of 29 (93%) HBV outbreaks in LTCFs since 1996. MMWR 2012;61:339.

17. HBV and Glucose Monitoring 3 of 4 facilities had lapses in infection prevention practices: • Shared use of penlet-style reusable finger stick devices (intended only for a single patient). • Failure to clean and disinfect shared glucometers. • Poor hand hygiene techniques.

18. Diabetes and HBV • 10/2011: ACIP recommended that adults 19-59 y.o. be vaccinated against HBV. • Adults >59 y.o. with DM may be vaccinated at the discretion of their physician.

20. Blood Glucose Meters • Whenever possible, blood glucose meters should not be shared. • If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer’s instructions. • If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

22. Fingerstick Devices • Fingerstick devices should never be used for more than one person. • Single-use, auto-disabling fingerstick devices: These are devices that are disposable and prevent reuse through an auto-disabling feature. • In settings where assisted monitoring of blood glucose is performed, single-use, auto-disabling fingerstick devices should be used.

24. Insulin Pens • Insulin pens containing multiple doses of insulin are meant for use on a single person only, and should never be used for more than one person, even when the needle is changed. • Insulin pens should be clearly labeled with the person’s name or other identifying information to ensure that the correct pen is used only on the correct individual.

25. Insulin Pens • Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices. • If reuse is identified, exposed persons should be promptly notified and offered appropriate follow-up, including bloodborne pathogen testing.

26. http://www.cdc.gov/nhsn/LTC/index.html CDC’s National Healthcare Safety Network (NHSN) web site provides LTCFs a customized system to track infections in a streamlined and systematic way. Site provides NHSN enrollment, forms, toolkits, protocols and training to report C. difficile, MRSA and other drug-resistant infections, UTIs, and prevention process measures, including hand hygiene adherence.

27. UTI New Case surveillance definition. Who to treat

28. New UTI Surveillance Definition For residents without an indwelling catheter (both criteria 1 and 2 must be present). Criteria 1: At least 1 of the following sign or symptom: • Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. • Fever or leukocytosis and at least 1 of the following localizing urinary tract symptoms (must be new or marked increase): acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, incontinence, urgency, frequency.

29. UTI Surveillance Definition In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract symptoms: • Suprapubic pain • Gross hematuria • New or marked increase in incontinence • New or marked increase in urgency • New or marked increase in frequency

30. UTI Surveillance Definition Criteria 2. One of the following microbiologic subcriteria: • At least 100,000 cfu/mL of no more than 2 species of microorganisms in a voided urine sample. • At least 100 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter • Urine specimens for culture should be processed as soon as possible, preferably within 1–2 h. • If urine specimens cannot be processed within 30 min of collection, they should be refrigerated. Refrigerated specimens should be cultured within 24 h.

31. UTI Surveillance Definition • UTI should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture result. • A diagnosis of UTI can be made without localizing symptoms if a blood culture isolate is the same as the organism isolated from the urine and there is no alternate site of infection.

32. UTI Surveillance Definition • In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the noncatheterized resident or acute confusion in the catheterized resident will often be treated as UTI. • However, evidence suggests that most of these episodes are likely not due to infection of a urinary source.

33. UTI Surveillance Definition For residents with an indwelling catheter (both criteria 1 and 2 must be present): Criteria1 (at least 1 of the following signs/symptoms): • Fever, rigors, or new-onset hypotension, with no alternate site of infection. • Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis. • New-onset suprapubic pain or costovertebral angle pain or tenderness. • Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate

34. UTI Surveillance Definition Criteria 2. Urinary catheter specimen culture with at least: • 100,000 cfu/mL of any organism(s). • Recent catheter trauma, catheter obstruction, or new onset hematuria are useful localizing signs that are c/w UTI but are not necessary for diagnosis. • Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for >14 d).

35. UTI Surveillance Definition • Pyuria (>/= 10 WBC/hpf) does not differentiate symptomatic UTI from asymptomatic bacteriuria. • Absence of pyuria in diagnostic tests excludes symptomatic UTI in residents of long-term care facilities.

36. Acute Functional Decline A new 3-point increase in total ADL score (range, 0–28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence): • Bed mobility • Transfer • Locomotion within LTCF • Dressing • Toilet use • Personal hygiene • Eating

37. Acute Change in Mental Status Acute change in mental status from baseline (all criteria must be present): • Acute onset. • Fluctuating course. • Inattention. AND • Either disorganized thinking or altered level of consciousness.

38. Confusion Assessment Method Criteria Acute change in resident’s mental status from baseline • Fluctuating Behavior: coming and going or changing in severity during the assessment. • Inattention: difficulty focusing attention (eg, unable to keep track of discussion or easily distracted). • Disorganized thinking: thinking is incoherent (rambling conversation, unclear flow of ideas, unpredictable switches in subject). • Altered level of consciousness: level of consciousness is described as different from baseline (hyperalert, sleepy, drowsy, difficult to arouse, nonresponsive).

39. Treating Asymptomatic Bacteriuria Prospective randomized trials of screening for or treating asymptomatic bacteriuria have shown: • No decrease in the rate of symptomatic infection. • No improvement in survival. • No change in chronic genitourinary symptoms. Nicolle L. Am J Med 1987;83:27-33. Nicolle L. NEJM 1983;309:1420-5. Abrutyn E. Ann Intern Med 1994:120:827-33.

40. Asymptomatic UTI Nursing Home • 172 nursing home residents with an abnormal urinalysis and no Foley catheter. • 146 did not meet criteria for treatment, 76 were not treated. • None developed adverse consequences. • No deaths or hospitalizations attributed to worsening infection or sepsis occurred during the following 3 months. Rotjanapan P. Arch Int Med 2011;171:438-43.

41. Chronic Incontinence Ouslander et al Ann Int Med 122: 753 Randomized, placebo controlled trial of antibiotic therapy

42. Detrimental Effects of Treating Asymptomatic UTI • By 6-8 weeks after treating asymptomatic patients with bacteriuria, 60-80% will have recurrence with the same or a new infecting organism. Subjects who receive antimicrobial therapy for asymptomatic bacteriuria have: • Increased frequency of adverse events from the antibiotics. • Increased reinfection with resistant organisms. • Increased cost.

43. UTI and C. difficile • 172 nursing home residents with an abnormal urinalysis and no Foley catheter. • 85% did not meet criteria for treatment, but 41% of them were started on antibiotics. • 12% who received inappropriate antibiotics developed C. difficileinfection within 3 weeks. • Overall, those who received inappropriate antibiotics were 8-fold more likely to develop C. difficile within 3 months. Rotjanapan P. Arch Int Med 2011;171:438-43.

44. Antibiotics and Warfarin • Exposure to any antibiotic within 15d increased the chance of bleeding with hospitaliztion by 2-fold. • Azoles (eg fluconazole) increased risk by 4.5-fold, TMP SMZ 2.7, cephalosporins 2.5, penicillins 1.9, macrolides 1.9, quinolones 1.7. • Interference with metabolism (azoles, TMP SMZ) and disruption of bacteria that synthesize Vit K. • Monitor INR one week after starting antibiotics. Baillargeon J. Am J Med 2012;125:183-9.

45. Mortality, Elderly Men NEJM, 1983

46. Asymptomatic Bacteriuric: Elderly Women Amer J Med, 1987

47. Residents with Chronic Catheterization • Bacterial colonization of residents with chronic indwelling foley catheters approaches 100%, usually with 2-5 different organisms. • Indwelling catheters develop a biofilm on the interior of the catheters where the organisms reside. • Urine cultures in chronically catheterized residents often reflect the bacteriology of the catheter biofilm; not the bladder urine.

48. Treatment of Asymptomatic Bacteriuria in Chronically Catheterized Residents • Asymptomatic bacteriuria is universal in patients with long term indwelling catheters. • Antimicrobial therapy will not prevent bacteriuria or symptomatic infection. • Antimicrobial therapy will lead to side effects, increasing resistance and cost. • Asymptomatic bacteriuria should not be treated.

49. How do I decide which resident to treat for suspected UTI?

50. Is It a UTI ? No easy Answers. • For residents of LTCFs without a foley, 25-50% of women and 15-40% of men have significant bacteriuria, but no symptoms. • At the same time, UTI is also the most common cause of bacteremia in LTCF residents. • Common cause of transfer to acute care facilities. How do I separate the large number of asymptomatic patients with bacteria in their urine who don’t need treatment from those with serious infections that need treatment?