Prudent Use of Antibiotics in Long Term Care Residents with Suspected UTI

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Prudent Use of Antibiotics in Long Term Care Residents with Suspected UTI. Shira Doron, MD Assistant Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston, MA Consultant to Massachusetts Partnership Collaborative:
Prudent Use of Antibiotics in Long Term Care Residents with Suspected UTIShira Doron, MDAssistant Professor of MedicineDivision of Geographic Medicine and Infectious DiseasesTufts Medical CenterBoston, MAConsultant to Massachusetts Partnership Collaborative: Improving Antibiotic Stewardship for UTIAntibiotics in Long Term Care:why do we care?
  • Antibiotics are among the most commonly prescribed classes of medications in long-term care facilities
  • Up to 70% of residents in long-term care facilities per year receive an antibiotic
  • It is estimated that between $38 million and $137 million are spent each year on antibiotics for long-term care residents
  • As much as half of antibiotic use in long term care may be inappropriate or unnecessary
  • The importance of prudent use of antibioticsBad Bugs No DrugsThe drug development pipeline for antibacterialsAntimicrobial TherapyUnnecessary Antibiotics, adverse patient outcomes and increased costAppropriate initial antibiotic while improving patient outcomes and healthcare A Balancing ActWhat is Antimicrobial Stewardship?Antimicrobial stewardship involves the optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost. Ultimate goal is improved patient care and healthcare outcomesDellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11:459-64Paskovaty A, et al IJAA 2005;25:1-10Simonsen GS, et al Bull WHO 2004;82:928-34The burden of infection in long-term careWhy focus on long term care?
  • Many long-term care residents are colonized with bacteria that live in an on the patient without causing harm
  • Protocols are not readily available or consistently used to distinguish between colonization and true infection
  • So, patients are regularly treated for infection when they have none
  • 30-50% of elderly long-term care residents have a positive urine culture in the absence of infection
  • Why focus on long term care?
  • When patients are transferred from acute to long-term care, potential for miscommunication can lead to inappropriate antibiotic use
  • Elderly or debilitated long-term care residents are at particularly high risk for complications due to the adverse effects of antibiotics, including Clostridium difficile infection
  • Antibiotic misuse adversely impacts patientsGetting an antibiotic increases a patient’s chance of becoming colonized or infected with a resistant organism.Association of vancomycin use with resistance(JID 1999;179:163)Annual prevalence of imipenem resistance in P. aeruginosa vs. carbapenem use rater = 0.41, p = .004 (Pearson correlation coefficient)45 LTACHs, 2002-03 (59 LTACH years)Gould et al. ICHE 2006;27:923-5Case
  • An 82-year-old long-term care resident has fever and a productive cough
  • He has no urinary or other symptoms, and a chronic venous stasis ulcer on the lower extremity is unchanged
  • A “pan-culture” is initiated in which urine is sent for UA and culture, sputum and blood are sent for culture, and the ulcer on the leg is swabbed.
  • A CXR is done and is negative
  • The urinalysis has 3 white blood cells
  • Urine culture is positive for >100,000 CFU of E coli
  • Sputum gram stain has no PMNs, no organisms
  • Sputum grows 1+ Candida albicans
  • Wound culture grows VRE
  • The patient is started on cipro for the E coli in the urine, linezolid for the VRE in the wound, and fluconazole for the Candida in the sputum
  • Two weeks later the patient has diarrhea and C. diff toxin assay is positive
  • The only infection this patient ever had was a viral URIColonized or Infected:What is the Difference?
  • People who carry bacteria or fungi without evidence of infection are colonized
  • If an infection develops, it is usually from bacteria or fungi that colonize patients
  • Bacteria or fungi that colonize patients can be transmitted from one patient to another by the hands of healthcare workers
  • There is no need to treat for colonization
  • InfectedColonizedThe Iceberg EffectWhat could have been done differently?
  • Understanding the difference between colonization and infection
  • No (or few) WBCs in a UA= no UTI
  • In the absence of dyspnea, hypoxia and CXR changes, pneumonia is unlikely
  • Candida is an exceedingly rare cause of pneumonia
  • Wounds will grow organisms when cultured- infection can only be determined clinically
  • Take Home PointsAntibiotics are a shared resource… and becoming a scare resourceAppropriate antibiotic use is a patient safety priority Know the difference between colonization and infectionTo combat resistance: Think globally, act locally
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