Antimicrobial Stewardship Guide for Nursing Homes

1. Nursing Home Antimicrobial Stewardship GuideDetermine Whether To TreatToolkit 2. Common Suspected Infections: Communication and Decision Making for Four Infections Tool 4. Tools To Improve Communication and Decision Making www.ahrq.gov/NH-ASPGuide ● May 2014 AHRQ Pub. No. AHRQ 14-0011-6-EF

2. Quality Improvement for Antibiotic Prescribing Problems with taking antibiotics Drug resistance and lack of new antibiotics Approaches to antimicrobial stewardship Description of the tools and how to use them Additional information about suspected infections

3. Problems with Taking Antibiotics • GI: Nausea, vomiting, diarrhea • Secondary infections: C difficile, yeast • Allergic reactions: rash, anaphylaxis • Drug interactions: coumadin, glipizide • If on fluoroquinolones  tendon rupture • Dehydration  falls • Photosensitivity skin reaction • Resistant bacteria

4. Antibiotic Resistance • Multi-drug resistance is increasingly common • Streptococcus pneumoniae • Staphylococcus aureus • Enterococcus, E coli, Pseudomonas aeruginosa • Acinetobacterbaumannii • Tuberculosis

5. Resistant Strains Spread Rapidly Percent of Isolates Source:  Infectious Diseases Society of America  http://www.idsociety.org/10x.20.htm

6. Few New Antibiotics Source:  Boucher, Talbot, Benjamin, et al.,10 × '20 Progress—Development of new drugs active against gram-negative bacilli: an update from the Infectious Diseases Society of America. Clin Infect Dis. 2013; 1-10.

7. Developing a New Drug is Expensive Cost in Billions of Dollars Adjusted for Inflation, expressed as 2000 dollars Source:  DiMasi JA, Hansen RW, Grabowski HG. The price of innovation: new estimates of drug development costs. Journal of Health Economics, 22:151-185, 2003. 

8. Consequences World Health Organization: “Antibiotic resistance is one of the three biggest threats to human health”

9. Indications of Overuse Journal of General Internal Medicine. 16(6): 376-383, 2001. • Between 25 to 75 percent of antibiotic prescriptions in nursing homes do not meet clinical guidelines for prescribing. • Example: One-third of residents receiving antibiotics for UTI are being treated for asymptomatic bacteriuria.

10. Approaches to Antimicrobial Stewardship • Encourage research into new classes of antibiotics • Reduce overuse in key areas • Populations with high prescription rates • Respiratory infections in children • Long-term care populations • Developing countries • Veterinary use, food industry, and aquaculture

11. Goal: Better Informed Prescribing

12. Components of the Communication and Decision Making for Four Infections • Evidence-based communication between nurses and prescribers using a Medical Care Referral Form (MCRF) • Nurse vigilance to 12 common situations and infection control practices (pocket cards) • Prescriber training • “Be Smart About Antibiotics” resident and family handout • Quality improvement practices

13. Evidence-based Communication Between Nurses and Prescribers: Using a Medical Care Referral Form (MCRF)

14. Development and Rationale for Use:Medical Care Referral Form (MCRF) Researchers: • Reviewed prescribing criteria from consensus conference • Reviewed prescribing in six nursing homes and extent to which they met components of criteria • Developed the MCRF to assure attention to and communication of key signs and symptoms

15. The Medical Care Referral Form (MCRF)

16. Medical Care Referral Form (MCRF) • Designed to facilitate evidence-based communication between nurses and prescribers • Intended to be used for ALL situations when a resident has a new problem and infection may be suspected • In those instances, should be used for ALL referrals to medical care providers, including transfer to ED or hospital

17. MCRF: Components • Description of current problem • Vital signs • Usual cognitive function • Recent/current health status (including falls) • Falls, minor injury: require on-site first aid treatment (dressing, ice pack, pain medication) • Falls, serious injury: require stitches, immobilization, ED assessment or treatment, surgery, hospitalization • Medical history (including AD for no antibiotics) • Suspected infections – complete only relevant section • Use of question mark (“?”)

18. End-of-Life Antibiotics may not be indicated at the end of life; their use should be discussed with residents and families The Physician Orders for Life Sustaining Treatment (POLST) form is the best-accepted method to record resident and family wishes

19. Twelve Common Situations and Infection Control Practices and the Pocket Card

20. Situations in Which Systemic Antibiotics are Generally Not Indicated • Positive urine culture in asymptomatic resident • Urine culture ordered because of change in urine appearance • Nonspecific symptoms or signs not referable to urinary tract (with or without positive urine culture) • Upper respiratory infection (common cold) • Bronchitis or asthma in resident who does not have COPD • “Infiltrate” on chest x-ray in absence of clinically significant symptoms • Suspected or proven influenza in absence of secondary infection • Respiratory infections in resident with advanced dementia, on palliative care, or at the end of life • Skin wound without cellulitis, sepsis, or osteomyelitis (regardless of culture result) • Small (<5 cm) localized abscess without significant surrounding cellulitis • Decubitus ulcer in resident at the end of life • Acute vomiting and/or diarrhea in the absence of a positive culture for shigella or salmonella, or positive toxin assay for Clostridium difficile

21. Infection Control Guidelines Vancomycin-resistantenterococci Clostridium difficile Methicillin-resistant Staphylococcus aureus

22. Pocket Card

23. Pocket Card

24. “Be Smart About Antibiotics” Handout

25. “Be Smart About Antibiotics” Handout

26. “Be Smart about Antibiotics” Handout • Distributed to current and new residents • When hospice is considered • Primary purposes • educate about instances when antibiotics may not be indicated • promote shared decision making

27. Quality Improvement Practices

28. Monthly Meetings • Be held monthly to review progress • All individuals responsible for the QI program should attend the meetings

29. Additional Information AboutInfections and SymptomManagement

30. Fever and Older Adults • Do you know why a resident DOES NOT need a fever to have an infection? • Fever may be absent in 30-50% of older adults with serious infections • Factors such as chronic diseases, medications, and time of day can affect an older person’s temperature

31. Suspected UTICloudy or Smelly Urine: To Culture or Not? • Urine changes have many causes • foul-smelling urine may be caused by dehydration, hygiene, medication, diet, or infection • Will overdiagnose infection in one-third of cases • Improved toileting and fluid intake is often better treatment than antibiotics;hydration and perineal hygiene can prevent recurrence • Culture should be ordered only if new urinary symptoms are present *Archives of Internal Medicine. 160: 678-682, 2000.

32. When to Order a Urine CultureDiagnostic Pathway Fever of >37.9°C (100 °F) or 1.5°C (2.4 °F) increase above baseline, on 2 occasions over the last 12 h? 2 or more symptoms/signsofotherinfection? Urinary catheter? YES NO • Order urine culture if you observe 1 or more: • New CVA tenderness • Shaking chills (rigors) • New onset of delirium YES NO Do not orderurine culture • Order urine culture if you observe 1 or more: • New onset burning urination (dysuria) • Urinary catheter • New or worsening: • Urgency • Frequency • Flank pain • Gross hematuria • Urinary incontinence • Suprapubic pain • Order urine culture if you observe 2 or more: • New onset burning urination (dysuria) • New or worsening: • Urgency • Frequency • Flank pain • Gross hematuria • Urinary incontinence • Suprapubic pain

33. Suspected Respiratory Infection • Symptomatic care: • Monitor vital signs • Encourage fluid intake • Acetaminophen 650 mg q 6 hrs PRN for fever and pain reduction • Nasal saline 2 sprays to each nostril PRN for nasal congestion • Guaifenesin 2 teaspoons every 4 hours as needed for cough • Antihistamines, especially Benadryl, should be AVOIDED

34. Suspected Skin/Soft Tissue Infection • Appropriate care: • Mobility – encourage mobility (passive or active) • Acetaminophen 650 mg as needed or prior to cleaning/dressing changes • Cleanse wounds with each dressing change with saline or warm water; do not use antiseptic cleansers • Apply dressing as needed