Objective Define Antibiotic Stewardship Identify the core elements - PDF document

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Antibiotic Stewardship; Role of the Infection Preventionist Linda R. Greene, RN, MPS,CIC,FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu Objective  Define Antibiotic Stewardship  Identify the core elements of stewardship  Describe the role of the infection preventionist (IP) In facilitating stewardship efforts Stewardship- What is it? • An ethically-driven responsibility for protecting and one's limited resources • A steward must provide the necessary leadership to establish the rules by which all stakeholders behave in ways that reflect the interests of both public and private sectors • Stewards must ensure corrective action when behavior by stakeholders becomes a potentially harmful to the population served • Stewardship's main goal is to help the population being served achieve positive outcomes while carefully managing the limited resources available Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 1

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Antibiotic Stewardship Consensus statement from the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society: “ Coordinated interventions designed to improve and measure the appropriate use of (antibiotic) agents by promoting the selection of the optimal (antibiotic) drug regimen, including dosing, duration of therapy, and route of administration.” Fishman, N. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012; 33:322–7. Goals of Antibiotic Stewardship  Prevent or slow emergence of antibiotic resistance  Optimize selection, dose, duration of treatment  Reduce adverse drug events  Reduce secondary infection (e.g. CDI,MDROs)  Reduce morbidity and mortality  Reduce length of stay  Reduce health care expenditure Why Antibiotic Stewardship ?  Multiple Drug Resistant Organisms (MDROs) cause a significant proportion of serious healthcare-associated infections and pose a serious risk to patient safety  Regulatory, accrediting agencies and legislative bodies continue to make MDROs a priority  Integrated, multidisciplinary ASPs are crucial to promoting the prudent use of antimicrobials Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 2

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Historical Perspective The idea that penicillin and the subsequent “miracle drugs” were the end of any threat from infection led to increased use, overuse, and abuse – flooding the environment with antibiotics and POTENTIATING RESISTANCE. Since the 1960’s there have been increasingly frequent reports of antibiotic resistant bacteria in hospitalized patients (and consequently in long-term care). CMS Requirements for an IP program functioning under the infection control and prevention program Demonstrates coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services; Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 3

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Enhancing the Role of the IP Awareness Collaboration Assessment Behavior Communication Stewardship's main goal is to help the population being served achieve positive outcomes while carefully managing the limited resources available. Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 4

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Knowledge Gaps  Unfamiliar with the concept of antibiotic stewardship  Insecure with knowledge of antibiotics  Lack of metrics regarding association between direct impact on stewardship activities Antibiotic Use Prevent Uneccesary Prevent Infection cultures Appropriate Appropriate Culture communication techniques signs/symptoms Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 5

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist IP Role Appropriate Cultures Role of IP in educating on appropriate cultures Examples:  Urine cultures  Appropriate C. difficile specimens What is bacteriuria ? Bacteriuria means a positive urine culture Bacteriuria ASB UTI 18 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 6

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Asymptomatic Bacteriuria There is no role for screening or treating for asymptomatic bacteriuria Does your patient have an abnormal in the majority of patients* urinalysis? • Treatment does NOT prevent symptomatic infection, improve urinary function, or enhance Assess for urinary symptoms and survival. SIRS criteria prior to consideration of • Treatment is associated with increased adverse antimicrobial treatment. effects, and increased development of antibiotic resistance. SIRS = systemic inflammatory response syndrome In the absence of signs or symptoms, it is NOT necessary to order or collect a urine specimen! *Exceptions: Screening for and treatment of asymptomatic bacteriuria is warranted in pregnant females and patients undergoing urologic procedures in which mucosal bleeding is anticipated (e.g. transurethral resection of the prostate) CAUTI or NOT CAUTI YES: CAUTI NO: Not CAUTI   Fever Change in urine color  Rigors  Foul smelling urine  Malaise/lethargy  Cloudy urine  New onset confusion  Urinary sediment  Flank pain or CVA tenderness  Acute hematuria  Pelvic discomfort  New onset hypotension  Dysuria, urgency, frequency 20 http://www.idsociety.org/IDSA_Practice_Guidelines/ Magnitude of Overtreatment of ASB  Treatment of positive urine cultures in asymptomatic patients  30% in our studies (inpatient and long-term care)  50-68% in other inpatient studies  75% and 82% reported in long-term care Trautner and Grigoryan, ID Clinics North America 2014 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 7

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Pyuria in the Elderly  Over 90% of older adults with positive urine cultures ( bacteriuria) have pyuria  If Leukocyte esterase( L.E.) and Nitrite are both negative, it is strongly predictive that a urinary tract infection is NOT present 22 Evaluation of the Elderly for Urinary Tract Infection  Diagnostic criteria for UTI in elderly patients: Without an indwelling catheter With an indwelling catheter • Acute dysuria alone OR • At least one of the symptoms below • Fever + at least one of the symptoms (new or increased) below (new or increased) OR  For accurate diagnosis, a • Fever • If no fever, at least two of the symptoms new catheter must be • Pelvic discomfort below (new or increased): placed from which a fresh • Flank pain • Gross hematuria urinary specimen is • CVA tenderness • Incontinence obtained and sent for • Rigors (shaking chills) • Urgency testing! • Delirium • Suprapubic pain • Acute hematuria • Costovertebral angle (CVA) tenderness  The following are NOT specific signs or symptoms for UTI : Foul smelling or cloudy urine, falls or gait instability, functional decline. These findings should NOT prompt treatment in the absence of other clinical features of infection.  Acute mental status change alone is NOT a criteria for UTI unless the patient has an indwelling urinary catheter. 23 Impact of Urine Cultures  Positive urine culture leads to inappropriate antibiotics  12 of 21 (57%) asymptomatic patients treated when urine culture returned positive  (Leis, ICHE 2015)  High organism count in urine culture triggers antibiotic prescription (OR22)  (Drekonja et al, ICHE 2014) Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 8

Infection Prevention Boot Camp I for the Novice January 16 ‐ 17, 2020 Infection Preventionist Screening Urine Cultures What not to do:  Screen on admission without signs and symptoms  Screening for non- urologic surgery  Automatic triggers for cultures (temperature or WBC’s in the urine) 25 Communication Do not test urine unless it is clinically indicated When to obtain a urine culture :  Focal symptoms suggestive of urinary tract infection ( i.e. lower abdominal tenderness, flank pain, lower abdominal discomfort)  Signs and symptoms of sepsis in patients with no clear source. 26 Fakih – Improving the culture of culturing Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 9