Antibiotics in Long Term Care
David Gary Smith, MD, FACP
Abington Memorial Hospital
Audience Response System
• Keypads- must return them
• Real time polling of audience
• Anonymity
Do you really want to hear a talk
about antibiotics and LTC?
1. Yes- and also
drive nails into my
fingers
2. No- I would rather
listen to elevator
music
51%
Iw
oN
Ye
s-
an
d
al
ou
ld
so
ra
th
e
dr
iv
e
na
rl
is
t..
i..
49%
What is your profession?
Nurse
MD/DO
Social Work
Administrator
Other clinical
31%
27%
29%
13%
l
ic
a
rc
lin
th
e
st
ra
to
r
O
A
dm
in
i
W
or
k
So
ci
al
D/
DO
M
ur
se
0%
N
1.
2.
3.
4.
5.
Goals
• Outline of the antibiotic “problem”
• Guidelines for antibiotic use
– address over utilization
• Antibiotics and the “Goals of Care”
dilemma
• Existential model for patient centeredness
at the bedside
Patterns of Antimicrobial Use in NH
Residents with Advanced Dementia
• Approximately 1 year of f/u
• 66% (n=142) received at least one course
of antimicrobial therapy
• 540 prescribed courses
• 42% (n=42) of decedents received
antibiotics within two weeks of their death
and 41courses were administered
parenterally
D’Agata E, Mithcell S, Arch Int Med 2008;168:357-361
•
•
•
•
•
Antibiotic Therapy in the Demented
Elderly Population:
Redefining the Ethical Dilemma
Low likelihood of benefit
Emerging resistance
Avoidance of “goals of therapy” discussion
Easier to treat than to raise the “D” word
Costs
Schaber M, Cormelli Y, Arch Int Med 2008;168:349-350
2 Studies on Benefit of Educational
Program on Antibiotic Use in LTCF
• Reported frequency of suboptimal
antibiotic use- 25-75%
• Educational interventions reduced errors
by approximately 20%
• Post intervention adherence to protocol
rates- 40-77%
Scwartz D , et.al. JAGS, 2007;.55:1236-1242
Monette J, et.al. JAGS, 2007; 55:1231-1235
Case
• 88 y.o. with indwelling foley and dementia.
The clinical attendant calls because the
urine is dark and the culture revealed
>100,000 colonies E. Coli. She wants to
know what antibiotic do you want to use.
No allergies. No fever.
What is your opinion?
1.
2.
3.
4.
TMP/Sulfa
Amoxacillin
Levafloxacin
Transfer for IV
antibiotics
5. No treatment
28%
26%
19%
17%
N
o
t
tr
ea
tm
en
tib
i..
an
IV
fo
r
sf
er
Tr
an
.
ci
n
flo
xa
Le
va
ac
m
ox
A
TM
P/
Su
l
fa
ill
in
11%
Minnesota Guidelines
• No indwelling catheter
–
–
–
–
–
–
–
–
Acute dysuria or
Fever >38.9 (102 F) and at least one of the following:
Urgency
Frequency
Suprapubic pain
Hematuria
CVA tenderness
New onset urinary incontinence
Minnesota Guidelines
•
•
•
•
•
•
Indwelling Foley
Need at least one of the following:
Fever >38.9 (102)
New CVA tenderness
Rigors
New onset of delirium
Another call from same NH
• 78 yo patient with COPD and has new
cough with yellow sputum. Temp is
normal. Pulse is 80. Respiratory rate is 15.
No delirium, rigors.
What is your opinion?
30%
28%
16%
16%
A
PO
Le
vo
flo
xa
ci
n
zi
th
O
ro
th
m
er
yc
PO
Tr
in
an
an
sf
tib
er
io
to
tic
h
os
N
o
pi
an
ta
tib
lf
o.
io
..
tic
s
ne
ed
ed
9%
PO
1. PO Levofloxacin
2. PO Azithromycin
3. Other PO
antibiotic
4. Transfer to
hospital for IV
antibiotics
5. No antibiotics
needed
Minnesota Guidelines
• Fever > 38.9 (102 F) and one of the following:
– Respiratory Rate>25
– Productive cough
• Or
• Fever > 37.9 (100 F) and cough and at least one
of the following:
–
–
–
–
Pulse >100
Delirium
Rigors
Respiratory Rate >25
Minnesota Guidelines
•
•
•
•
Or
COPD history and purulent cough*
Or
New infiltrate on chest xray and at least
one of the following:
– Respiratory rate > 25
– Productive cough
– Fever > 37.9 (100 F)
Same nurse calls you about
another case
• 83 yo with dementia has a fever of 37.9
(100 F) and some aspects of a delirium.
You are on call for this patient who is
followed by your partner. She has no other
focal symptoms or signs. Do you want to
start antibiotics?
What is your opinion?
1. Watchful waiting
2. Send her to the
hospital
3. PO Levafloxacin
4. Call her primary
care physician in
AM
32%
28%
26%
.
pr
im
ar
y
ca
r ..
ci
n
xa
va
flo
Le
ho
al
lh
er
PO
C
Se
nd
he
W
rt
o
at
c
th
e
hf
ul
w
ai
tin
sp
ita
l
g
15%
Minnesota Guidelines
• Fever with unknown focus of infection
• Fever > 37.9 (100 F) and at least one of
the following:
• New Delirium
• Rigors
Do you think that antibiotics are
over-utilized?
100%
o
N
s
0%
Ye
1. Yes
2. No
Do you have protocols in place to
guide management?
100%
o
N
s
0%
Ye
1. Yes
2. No
Contributors to unnecessary
antibiotic use
• Antibiotics are overused in LTCFs? (%
agree)
– MD
– Nurse Practitioner
– Director of Nursing
– Infection Control
82
91
66
80
• Established protocols
– Facilities
– Providers
Gahr P et.al. J Amer Ger Soc 2007;55:471-474
31
16
What do you think the most
important factor is in this overuse?
1. Family pressure
2. Nurse pressure
3. Cognitive
impairment
4. Lack of clear
guidelines
5. Other
28%
23%
20%
22%
r
th
e
O
lin
es
t
cl
ea
of
ck
La
rg
ui
de
ir m
en
re
im
pa
su
pr
es
C
og
ni
tiv
e
ur
se
N
Fa
m
ily
pr
es
s
ur
e
7%
Contributors to unnecessary
antibiotic use
• Factors which contribute to unnecessary
use of antibiotics
– Pressure from nurse– Pressure from family– Resident cognitive impair.-
54-56%
21-28%
57-58%
• Need for:
– Education for nurses– Education for MDs/NPs– Nursing guidelines-
62-73%
35-57%
60-70%
Gahr P et.al. J Amer Ger Soc 2007;55:471-474
Lessons so far…
• We suck (my teenagers classification) at
making decisions about antibiotics
• Part of the reason we suck is the lack of
clear guidelines, protocols, reminders,
systems of accountability….
• We all tend to avoid or butcher the “goals
of treatment” discussion
– Overestimate benefit of Abs etc.
– Avoid the “D” word
Good News
• We can do something about “it”, if we care
to do something about it.
• Antibiotic Protocol champion that has
stature and power!!!!
"If you want the truth to stand clear
before you, never be for or against.
The struggle between "for" and against"
is the mind's worst disease.
- Sent-Ts'an (aka Seng Tsan) c. 700 C.E.1
Existential Issues
• Talk about a patient who challenged us
recently on service.
• The details of the case have been
changed to protect the identity of all
participants except for me.
• Goals of case
– Talk about barriers to genuine patient
centered care
– Discuss a way of overcoming those barriers
Case
• 39 y.o. Persistent Vegetative State patient is
admitted for her 5th presentation for a suspected
pneumonia. She has been at home with her
family in this state for 8 months. The family
noted a change in her breathing and slight
increase in her secretions.
• Subintern (fourth year medical student) on
service is sent in to see patient but she is clearly
terrified by the assignment. Why?
View from subintern and attending
• How do I approach a patient in a PVS?
The family? My feelings of hopelessness?
My inability to form a relationship with the
patient? How do I determine the goals of
care? Can I even see the patient?
• Coping style- pretend that there is no
patient as person but just a biological
preparation (a petri dish) with bacteria that
need antibiotics.
View from subintern and attending
• Additional feelings deal with the resource
utilization; distracting the clinicians from
someone who really needs our attention; the
absurdity of the whole situation.
• These feelings underlie a lot of the ethics
consults concerning patient futility received by
ethics committees.
• Tension- between a family that demands care
and the clinicians who see no purpose in
providing that care
How do you feel about caring for
such a patient?
28%
27%
N
o
fe
el
th
e
ou
t
ab
r
th
e
al
l
in
g
as
w
ry
Ve
ry
ng
A
22%
at
t..
.
Sa
d
23%
O
1. Very Sad
2. Angry about the
waste of
resources
3. No feeling at all
4. Other
What would you recommend to the
family?
1. IV antibiotics
2. Withhold
antibiotics
3. Palliative care
consult
4. Other
100%
re
ca
e
tiv
lli
a
Pa
th
e
O
ul
t
co
tib
io
an
ol
d
ith
h
W
ns
s
ot
ic
tib
i
an
IV
r
0% 0%
tic
s
0%
Feeling and Impact on Care
• Elkman- “Your face is the mirror of
everything inside”
• The family could sense a clinical disdain
by the hospital staff in the past toward
them for wanting to continue care
Do you think you can “fake” that
you care?
1. Absolutely
2. Definitely not
3. Never thought
about it
4. Other
The medical student and I
walked through the ER
curtain and beheld a scene
of great devotion by the
husband and the daughter
for the patient that was
transformative for us.
This case
• Any prior thought, conceptions, feelings
were totally washed away.
• We just stood there and beheld a scene of
biblical proportion.
• Our direction was given us from within the
scene at the bedside.
An Approach
• Suspension of Values
• Interiorization
• Letting go and the insight will emerge
Senge P, et.al. Presence: An Exploration of Profound
Change in People, Organizations and Society. 2004
Generalizability
• Can everyone do this?
• Does it take much time?
• How will it ultimately affect me?
Downside
• None
Patient Centered
• There is no better model out there for a
truly patient centered experience!
Summary
• We can certainly do a better job prescribing
antibiotics or any other type of treatments for our
patients
• We have to embrace this whole area as primarily
important especially given all the other very
important initiatives that we should embrace
• We have to avoid yielding to the forces within
medicine that obliterates all of our humanities