Antibiotic Stewardship in Nursing Homes
– What is it, what are your roles and
opportunities?
JARRETT R. AMSDEN, PHARMD, BCPS
ASSOCIATE PROFESSOR
BUTLER UNIVERSITY COPHS
&
INFECTIOUS CLINICAL SPECIALIST COMMUNITY
HEALTH NETWORK
CO-CHAIR OF THE COMMUNITY HEALTH NETWORK
ANTIMICROBIAL STEWARDSHIP PROGRAM
Objectives
Review and discuss antibiotic stewardship (ASP)
and its application to nursing homes
2. Identify opportunities for ASP across a broad
setting or an individual LTCF site
3. Discuss how to devise a process, identify each
person’s role in the process and implement the
process
4. Discuss methods of evaluating and revising the
process during the pilot stages
1.
Disclosure: I have no financial or commercial conflicts of interest
Antimicrobial Stewardship
“the optimal selection, dosage, and duration of
antimicrobial treatment that results in the best
clinical outcome for the treatment or prevention of
infection, with minimal toxicity to the patient and
minimal impact on subsequent resistance.”
 Missing is the appropriate diagnosis of the infection
for which the antibiotic is prescribed
Clin Infect Dis. 2007;44(2):159-177
Baseline Assessment Question
 The antibiotic choice
 Is there a best choice for a patient?

Yes
How would you characterize this choice?


After allergies, the most narrow spectrum and most likely to
promote adherence
Is there a best dose for a patient and/or infection?


Yes, it is in the drugs pharmacodynamics???
Is there an optimal duration for this infection



Yes and No
Yes there is, but in some circumstances it is less clear and/or
hard to define
Why is Antimicrobial Stewardship Important?
 70% of LTCF residents receive an antimicrobial
course annually
 40-75% of these antimicrobial courses is
inappropriate
 Overexposure to antibiotics leads to:





Resistance
Collateral infections – C. difficile
Adverse events
Drug interactions
Multidrug-resistant organism colonization and transmission
Clin Infect Dis. 2007;44(2):159-177; JAMA 2003;289: 1107–11; Infect Control Hosp Epidemiol 2000; 21:537–45
Why is Antimicrobial Stewardship Important?
Prevention
National
Action Plan
CMS
CDC
• National ASP implementation could prevent 619,000
infections over 5 years
• Calls for developing ASP in LTCFs
• Expanding, developing and monitoring programs
• Will include infection control, ASP and antibiotic
monitoring in their forthcoming LTCF requirements
• Developed “Core Elements” for ASP in LTCFs
JAMDA 2016;183.e1-183.e16
Approaches to ASP
Antimicrobial Stewardship
The “Front-end”
The “Back-end”
 Process that occurs
 Process that occurs
pre-prescription –
(RESTRICTION)

Employ tactics that limit
what can be prescribed
and by whom
post-prescription –
(Prospective audit
and feedback)

Provides
recommendations on
antibiotic selection, dose
and duration
Clin Infect Dis. 2007;44(2):159-177
Antimicrobial Stewardship
The “Front-end” Methods
The “Back-end” Methods
 Education and
 Education and





Transparency
Formulary restriction
or approvals
Order-sets or pathways
Guidelines
Dose optimization
Decision support tools






Transparency
Guidelines
De-escalation
Duplication
Duration
Dose optimization
IV to PO
Clin Infect Dis. 2007;44(2):159-177
Antimicrobial Stewardship
The “Front-end” Methods
The “Back-end” Methods
 PROs
 Target antibiotic utilization issues
 Encourage formulary adherence
 Decrease costs
 Necessary during outbreaks
 CONs
 Questionable effect on resistance
 Compromises prescriber
autonomy
 Variability in who staffs the
process/resources
 Application across facilities is
challenging
 Loopholes in the programs
 PROs



Direct caregiver interactions
Trained individuals making
recs?
Interventions can be tailored
 CONs




Requires persistent
monitoring and time
Training and competency
Personnel and resources
Continuous feedback
Clin Infect Dis. 2007;44(2):159-177
Antimicrobial Stewardship
 How to get it going
 Assess your current resources
 Identify and determine areas of need
 Get “top-down” buy-in
 Develop a plan or business plan pending resources
 Put it into action
 Measure and re-assess or re-adjust
 Barriers
 Resources and priorities
 Provider and personnel acceptance
 Direct causality of your efforts
 Keeping the fire lit
Clin Infect Dis. 2007;44(2):159-177
Building a Multidisciplinary Team
Admin
Support
ID
Physician
or
Physician
Champion
Information
Technology
Antimicrobial
Stewardship
Micro
Infection
Prevention
ID-trained
Pharmacist
Nursing
Clin Infect Dis. 2007;44(2):159-177
Measuring Success
 Metrics
 Defined Daily Dose (DDD) – Antibiotic consumption


Day of Therapy (DOT) – Clinical antibiotic use




The DDD is calculated as the total number of grams of
antimicrobial agent used divided by the number of grams in an
average daily dose
DOTs are expressed as the administration of a single agent on a
given day regardless of the number of doses administered or
dosage strength
Resistance rates via the antibiogram or infection control
Incidence of resistant or problematic organisms
Number/percentage of successful interventions or
prescriptions considered appropriate
Clin Infect Dis. 2007;44(2):159-177
Antibiotic Stewardship
APPLICATIONS TO
LONG-TERM CARE FACILITIES
Optimal Care in LTCF – an upward climb
 LTCFs house 50-200 residents
per facility

Average staffing per 100 resident
beds




 Indiana Staffing Minimums



7 RNs
13 LPNs
35 CNAs

< 20% have fulltime physician
providers

 Statutes for staffing vary by state
 Guidelines for staffing ratios



CNAs to residents > 1:12
RNs + LPNs to residents > 1:30
RNs to residents > 1:120
Nursing

1DON RN full-time included in
1 RN 8 consecutive
hours/7days/wk and 1 LPN
Charge Nurse each shift
For 1-60 resident: DON may be
Charge Nurse included in:
RN/LPN RATIO
0.5 LPN hour per resident day to
resident ratio (averaged over 1
week, excluding DON)
Physician – in person



Must see a resident at least once
every 30 days for the first 90
days
Then at least every (60) days
thereafter
Alternating visits by PA, NP, etc.
are acceptable
Infections in elderly – the challenges
 Higher incidence of infection
 Lower barriers to infection (skin, immune deficits, etc.)
 More indwelling devices
 Comorbid conditions
 Elderly patients tend to:
 Have poor localization of or atypical “text book” symptoms
 Inability to demonstrate physical declines
 Inability to communicate physical or mental changes
 Changes are often slow or too subtle to be detected
 Detecting an overall functional decline is the key
Suspecting infections in LTCF patients
 Defining a declining functional status
 New onset or increase in:
Confusion
 Incontinence
 Falling
 Decreasing mobility
 Decreasing food intake
 Failure to cooperate with staff

High KP, et al. Clin Infect Dis 2009;48:149-171
Suspecting infections in LTCF patients
 Fever
 Elderly have lower basal body temperatures
 Defining fever as 100°F (37.8°C) had a sensitivity of 70% and
specificity of 90% for detecting infection
 Accepted criteria for defining fever in LTCFs
 Single temperature of 100°F (37.8°C)
 Repeated temperatures of > 99°F (37.2°C) orally or > 99.5°F
(37.5°C) rectally
 2°F (1.1°C) increase in temperature above baseline
High KP, et al. Clin Infect Dis 2009;48:149-171
The Patient Assessment
 1st Layer
 CNAs measuring the resident vital signs and clinical symptoms

Must convey the possibility of a fever and symptoms to LPN/RN
 2nd Layer
 LPN/RN should corroborate these findings and conduct a complete
resident examination and document the critical findings

This examination and documentation is vital to communication to the
physician or physician extender
 3rd Layer
 LPN/RN to call physician or physician extender with COMPLETE list of
findings


Ideally the provider should facilitate the evaluation over the phone and order
directed tests/labs as able and necessary to make appropriate clinical
decisions
Conduct their own patient assessment/evaluation at the next time point
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 CBC with differential within 24 hours
 WBC > 14,000 cells/mm3 (LR 3.7), > 90% neutrophils (LR
7.5), bands > 6% (LR 4.7) are potential indicators of infection

If normal, this may limit further testing needs
 BMP
 While not needed for infectious sources it may be useful for
establishing or ruling out metabolic causes
 May aid with optimal drug dosing
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 UTIs


Incidence 0.1-2.4 cases/1000 resident days
Patients with indwelling catheters will almost always have WBCs and
bacteriuria, but this is rarely indicative of a UTI
 Urinalysis +/- Culture

MUST have symptoms to support testing


10-50% of institutionalized patients will have asymptomatic
bacteriuria


Must define symptoms for those catheterized vs non-catheterized
Absence of WBC in the urine or negative leukocyte esterase and nitrite
in a dipstick test can be used to rule-out bacteriuria
If a patient has a chronic indwelling catheter this should be changed
before culturing
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 Bacteremia


Bacteremia occurs in 5-40/100,000 resident days
Secondary bacteremia occurs in 6% of patients
~50% from urinary tract
 ~10% from respiratory tract and skin or soft tissue
 ~5% from abdominal source
 ~3% from IV catheters
 ~20% unidentified sources

 Blood cultures



Generally low yield in elderly patients
Symptoms of bacteremia are less obvious the elderly and are
frequently associated with other organ system issues
Necessary in patients where bacteremia or urosepsis is suspected
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 Pneumonia
 Common source of infection with high mortality in LTCF patients
 Monitoring and imaging
 RR > 25 breaths/min and SAO2 < 90% are strong predictors of potential
respiratory failure





SAO2 < 94% had 80% sensitivity, specificity 91% and PPV 95% for diagnosing
pneumonia
CXR can be helpful to determine origin of hypoxemia
Sputum specimens can be o potential value, but are low yielding – mixed
flora in >35% of cases
Urine antigen testing for S. pneumoniae or L. pneumophila are limited
by sensitivity, but potentially useful for early detection
Rapid influenza testing may identify the index case and reduce outbreaks

Multiplex panels can detect other viruses including RSV – treatment is limited
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 Skin and Skin structure infections (SSTIs)
 3rd most common infectious etiology – 1-9% (0.9-2.1
cases/1000 resident days
 Most common infections
Cellulitis
 Pressure ulcers
 Scabies

 Obtaining culture specimens
 Do not perform superficial swab cultures
 Areas of discrete abscess or deep tissue specimens in select
circumstances can be used to direct therapy
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 Gastrointestinal
 1/3 of LTCF residents will have an episode of diarrhea annually
 1/3 of deaths attributed to diarrheal causes are in LTCF residents > 74
years
 3 or more unformed, loose stools for > 48 hours
 C. difficile
 Most common identifiable cause of diarrhea in LTCF
 3 or more loose, watery (often explosive) stools in 24 hours


Rates of asymptomatic carriage range from 10-30%



When using PCR testing, this is often combined with clinical criterion
Carriers can transmit disease
Highly susceptible to antibiotic flora disruptions
New diagnostic tests and/or algorithms with older tests have improved
sensitivity and specificity

Use of PCR tests may increase rate of false positive tests due to detecting
carriers
High KP, et al. Clin Infect Dis 2009;48:149-171
Laboratory Testing for Infection
 Gastrointestinal

Illnesses of the small bowel can be watched for 7 days with volume
assessment provided that
Not in an outbreak setting
 Clinically stable
 Symptoms do not persist past 7 days
 Persistent symptoms, but clinically stable should have the stool
checked for O&P


Colitis is associated with fever, abdominal cramps, diarrhea w/ or
w/o blood, and/or WBCs in the stool
Patients exposed to antibiotics in the past 30 days
 C. difficile
 Patients not exposed to antibiotics or with a negative C. difficile test
 Enteric pathogens – Salmonella, Shigella, Ecoli O157:h7

High KP, et al. Clin Infect Dis 2009;48:149-171
The McGreer Criteria
STONE ND, ET AL. SURVEILLANCE
DEFINITIONS OF INFECTIONS IN LONG-TERM
CARE FACILITIES: REVISITING THE
MCGREER CRITERIA.
INFECT CONTROL HOSP EPIDEMIOL
2012;33(10):965-977
The McGreer Criteria
 Criteria developed to help define infections in LTCFs that
are likely to be true infections
 These definitions may not be adequate for real-time case
finding, diagnosis, clinical decision making - antibiotic
selection
 Definitions are aligned with the IDSA criteria for
evaluating fever in LTCF residents
 Criteria for using these definitions



All symptoms must be new or acutely worse
Consider and evaluate non-infectious etiologies before calling this an
infection
Identification of infection MUST be based upon multiple pieces of
data
Stone ND, et al. Infect Control Hosp Epidemiol 2012;33(10):965-977
The McGreer Criteria
 Elements of the McGreer Criteria may provide a
more complete definition for assessment criteria

Definitions for acute changes in mental and/or functional
status


Uses a more objective ADL scale for functional declines
Common cold/pharyngitis signs and symptoms
 Elements may be to stringent at the clinical decision
point


UTIs must have microbiological confirmation
GI illness definitions of diarrhea are uniform for C. difficile vs
non-C. difficile infections
Stone ND, et al. Infect Control Hosp Epidemiol 2012;33(10):965-977
Loeb vs. McGreer
Evaluation of Fever (Loeb)
Surveillance of Infections
(McGreer)
Similar infections and basic definitions
 Screening criteria
 Less detailed criteria to
allow decision to order
tests or prescribe
therapies
 Intended to help guide
antibiotic prescribing
(prospective)
 Documenting criteria
 More detailed criteria to
enhance infection
identification
 Intended to define if an
infection is present and
could be used to determine
antibiotic appropriateness
(quasi-prospective , mostly
retrospective)
High KP, et al. Clin Infect Dis 2009;48:149-171
Stone ND, et al. Infect Control Hosp Epidemiol 2012;33(10):965-977
AMDA and CDC
Antimicrobial Stewardship
Core Elements
AMDA PRESS RELEASE WITH HYPERLINKS TO CDC:
HTTP://WWW.AMDA.COM/NEWS/RELEASES/2015/CD
C%20RELEASES%20CORE%20ELEMENTS%20FOR%20N
HS.PDF
PRIMARY CDC SITE:
HTTP://WWW.CDC.GOV/LONGTERMCARE/PREVENTIO
N/ANTIBIOTIC-STEWARDSHIP.HTML
MORRILL HJ, ET AL. JAMDA 17 (2016);183.E1-183.E16
AMDA and CDC Process
Leadership Commitment
• Support and commit to appropriate antibiotic use
Accountability
• Identify physician, nursing and pharmacy “leads” in and
across facilities
Drug expertise
• Access to antibiotic stewardship experts within facilities
Action
Tracking
• Implement at least one policy or practice to improve
antibiotic use
• Monitor process measure of antibiotic use and outcome
Reporting
• Provide feedback to providers, nursing staff and stakeholders
Education
• Provide resources to staff, residents and families
Antimicrobial Stewardship in LTCFs
 There are only 14 published works on ASP
interventions in LTCFs

Noted needs for ASP
High rates of unnecessary antibiotic use
 Increased risk or prevalence of MDR organisms
 Increased risk for C. difficile


Noted barriers to ASP
Lack of proven ASP strategies
 Lack of funding, resources and infrastructure at LTCF sites
 Diagnostic dilemmas and appropriate prescribing
 Lack of ID-trained physicians or pharmacists
 Resident and family expectations

Morrill HJ, et al. JAMDA 17 (2016);183.e1-183.e16
Selected Studies to Discuss
Antimicrobial Stewardship in LTCFs
 33 month prospective study in a 190 bed VA LTCF in
proximity to an acute care hospital

3 months of monitoring practice habits followed by 30 months
of data collection following an educational intervention
 Results
Outcome
3mo preintervention
6mo postintervention
7-30mo postintervention
Ur cx sent /1000 pt days
3.7 (2.8-4.9)
1.5 (1.1-2.1)*
1.3 (1.1-1.5)
Inappropriate Ur cx /1000 pt 2.6 (1.8-3.6)
days
0.9 (0.6-1.4)*
0.6 (0.5-0.8)*
ASB treated /1000 pt days
1.7 (1.1-2.6)
0.6 (0.4-1.0)*
0.3 (0.2-0.4)
Abx days /1000 pt days
167.7
117.4*
109*
Ur= urine; cx=culture; pt=patient; ASB=asymptomatic bacteriuria; Abx=antibiotics; * indicates p<0.05
compared to pre-intervention period
Zabarsky et al. Am J Infect Control. 2008;36:476-480
Antimicrobial Stewardship in LTCFs
 Retrospective cohort study of LTCF patients who received
antibiotic therapy for suspected UTI

Data from a 6 month period across 4 LTCF sites


Dependent variable: signs/symptoms of a UTI using the Loeb et al. criteria
Independent variables: resident characteristics, site, etc.
 Indwelling catheter patients were excluded from the primary analysis
(n=16, #23 antibiotic Rx’s)
 Results
 56% were > 85 years, mean ADLH 2.0 (1.2), mean CPS 2.0 (0.6)
 204 antibiotic courses for 151 residents (26% with multiple courses)



71-97% had urine studies and 64-85% of prescribers had the result prior to
their antibiotic order
Mean duration of antibiotic therapy was 7.6 days vs 8.1 days for asymptomatic
vs symptomatic patients, respectively (p=NS)
Multivariate analysis demonstrated that only the LTCF site impacted the
likelihood of an antibiotic prescription for an asymptomatic UTI
Phillips CD, et al. BMC Geriatrics 2012;12:73
Antimicrobial Stewardship in LTCFs
 Prospective cluster randomized controlled study across
30 LTCFs evaluating the use of an ASP tool to direct
antibiotic prescribing

15 NHs were stratified to the intervention tool and 15 as controls
 Primary outcome measure is mean number of antibiotic
prescriptions/100 residents (prevalence) and
DDD/1000 residents (consumption)
 Results



Mean number of prescriptions was not significantly different
between groups in either period
DDD/1000 residents was significantly decreased using the
intervention tool 4.9% (95%CI 1-8.6%, p=0.02) compared to a 5.1%
increase (95% CI 0.2-10.2%, p-0.04)
100% compliance to the interventional tool was only 46% and 31%
for parts A and B, respectively
Fleet E, et al. J Antimicrob Chemother 2014;69:2265-2273
A case to ponder
JAMA 2014;312(16):1687-1688
UTI Case
PMH:
 80-year-old female with 2-year history of 8 UTIs and 6 treated with
antibiotics (no catheter)
 History of falls, cognitive impairment and incontinence
Primary problem:
 Increased confusion, urinary frequency, cloudy urine,
lethargy, hallucinations and falls
HPI
 Family reports that she “doesn’t look right,” but the nursing staff states
she is not confused.
 The patient reports no dysuria or abdominal pain but does chronically
complain of voiding frequently.
 She is afebrile with no abdominal, suprapubic, or flank tenderness, but
her urine has a foul odor.
 Newly inserted catheterized urine was collected
JAMA 2014;312(16):1687-1688
UTI Case
Result
Reference Range
Color
Yellow, hazy
Yellow
Specific gravity
1.005
1.005-1.030
pH
7.5
5-7.5
Blood
1+
Negative
Protein
Negative
Negative
Nitrite
1+
Negative
Leukocyte esterase
3+
Negative
Bacteria
3+
None-few/hpf
White blood cells
40-100/hpf
0-5/hpf
Red blood cells
2/hpf
0-5/hpf
Epithelial cells
0-5/lpf
None-few/lpf
Culture: > 100,000 cfu/mL Ecoli – Only resistant to
Ampicillin
JAMA 2014;312(16):1687-1688
UTI Case
 How do you interpret these test results in the context
of this patient case?
A.
B.
C.
D.
The patient has asymptomatic pyuria and bacteriuria.
The patient has a UTI due chronic incontinence and a
positive urine culture.
A positive urinalysis and urine culture are always a UTI.
Since the patient has a history of recurrent UTIs, current
urine test results are also indicative of an UTI.
JAMA 2014;312(16):1687-1688
Discussion Points
 In adults >= 65 years or older, positive dipstick ((+ )
leukocyte esterase, nitrite,or both) for a urine culture with
more than 100 000 CFU/mL




Sensitivity: 65% - 100%
Specificity:20% - 77%
Positive predictive value(PPV): 31% - 45%
Negative predictive value(NPV),90% - 100%


Positive likelihood ratio (LR+): 1.25 - 2.8
Negative likelihood ratio (LR−): 0 - 0.46.
Take home points
 PPV is too low to use to determine UTI
 NPV is high enough to make the diagnosis of a UTI unlikely
JAMA 2014;312(16):1687-1688
Discussion Points
 Urinalysis - > 10 WBCs/hpf is an accepted threshold for
pyuria required for a UTI diagnosis

> 10 WBCs/hpf in relation to a culture with > 100,000 CFU/mL
Sensitivity: 78%
 Specificity: 63%
 PPV: 64%
 NPV: 74%
 LR+: 2.11
 LR−: 0.35.

 Pyuria should only be used to confirm a clinical diagnosis
of UTI (guided by signs and symptoms).
JAMA 2014;312(16):1687-1688
Does this patient have a UTI?
 How do you interpret these test results?
A.
B.
C.
D.
The patient has asymptomatic pyuria and bacteriuria.
The patient has a UTI due chronic incontinence and a
positive urine culture.
A positive urinalysis and urine culture are always a
UTI.
Since the patient has a history of recurrent UTIs,
current urine test results are also indicative of an UTI.
JAMA 2014;312(16):1687-1688
Does the patient have a UTI
 The clinical criteria for symptomatic UTI in older
women (no catheter) include 2 or more:





Fever
Worsened urinary urgency or frequency
Acute dysuria
Suprapubic tenderness
Costovertebral angle pain or tenderness
 Patient did not have these symptoms, so she was
diagnosed with

Asymptomatic pyuria and bacteruria
JAMA 2014;312(16):1687-1688
Opportunities and Roles
in Antimicrobial Stewardship
 Opportunities



The opportunities are limitless
Any intervention directed at a perceived or actual problem will likely
result in a benefit
In time, these opportunities will soon be expectations so now is the
time to start thinking about these items
 Roles



It will vary by your role in the facility or process, but be pro-active
The AMDA and CDC core elements should offer you guidance on
how and where you CAN or NEED to fit into this process
This needs to be multi-disciplinary, so tap your colleagues or anyone
interested
Conclusions
 Antibiotic stewardship is clearly needed in LTCFs
 The opportunities are vast and can be either self-identified or






identified by data gathering
ASP processes are multi-disciplinary and interventions should
be multi-faceted
Getting involved and using the CDC core elements is a start
Education needs to be directed to both nursing and
prescribers
Evaluating the process needs to be based on the data that is
accessible and applicable
Revising the process with feedback from the nursing staff and
providers is essential
Transparency of the process to residents, family and all
caregivers is a must