Common Suspected Infections: Tools to Improve Communication

and Decision Making

www.ahrq.gov/NH_ASPGuide ● May 2014 AHRQ Pub. No. AHRQ 14-0011-6-EF

Quality Improvement for Antibiotic Prescribing

1. Problems with taking antibiotics

2. Drug resistance and lack of new antibiotics

3. Approaches to antimicrobial stewardship

4. Description of the tools and how to use them

5. Additional information about suspected infections

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

Antibiotic Resistance

Multi-drug resistance is increasingly common

• Streptococcus pneumoniae• Staphylococcus aureus• Enterococcus, E coli, Pseudomonas

aeruginosa• Acinetobacter baumannii • Tuberculosis

Resistant Strains Spread Rapidly

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Source:  Infectious Diseases Society of America  http://www.idsociety.org/10x.20.htm

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.

Developing a New Drug is Expensive

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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. 

Consequences

World Health Organization:

“Antibiotic resistance is one of the three biggest threats to

human health”

Indications of Overuse

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.

Journal of General Internal Medicine. 16(6): 376-383, 2001.

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

Goal: Better Informed Prescribing

Components of the Communication and Decision Making for Four Infections

1. Evidence-based communication between nurses and prescribers using a Medical Care Referral Form (MCRF)

2. Nurse vigilance to 12 common situations and infection control practices (pocket cards)

3. Prescriber training

4. “Be Smart About Antibiotics” resident and family handout

5. Quality improvement practices

Evidence-based Communication Between Nurses and Prescribers:

Using a Medical Care Referral Form (MCRF)

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 criteriaDeveloped the MCRF to assure attention to and communication of key signs and symptoms

The Medical Care Referral Form (MCRF)

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

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 (“?”)

End-of-LifeAntibiotics 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

Twelve Common Situations and Infection Control

Practices and the Pocket Card

Situations in Which Systemic Antibiotics are Generally Not Indicated

1. Positive urine culture in asymptomatic resident2. Urine culture ordered because of change in urine appearance3. Nonspecific symptoms or signs not referable to urinary tract (with or

without positive urine culture)4. Upper respiratory infection (common cold)5. Bronchitis or asthma in resident who does not have COPD6. “Infiltrate” on chest x-ray in absence of clinically significant symptoms7. Suspected or proven influenza in absence of secondary infection8. Respiratory infections in resident with advanced dementia, on palliative

care, or at the end of life9. Skin wound without cellulitis, sepsis, or osteomyelitis (regardless of culture

result)10. Small (<5 cm) localized abscess without significant surrounding cellulitis11. Decubitus ulcer in resident at the end of life12. Acute vomiting and/or diarrhea in the absence of a positive culture for

shigella or salmonella, or positive toxin assay for Clostridium difficile

Infection Control Guidelines

Vancomycin-resistant enterococci Clostridium difficile Methicillin-resistant

Staphylococcus aureus

Pocket Card

Pocket Card

“Be Smart About

Antibiotics” Handout

“Be Smart About Antibiotics” Handout

“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

Quality Improvement Practices

Monthly Meetings

Be held monthly to review progress All individuals responsible for the QI

program should attend the meetings

Additional Information AboutInfections and Symptom

Management

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

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.

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/signsof other infection?

Do not orderurine culture

YES

Order urine culture if you observe 1 or more:

•New onset burning urination (dysuria)•Urinary catheter•New or worsening:oUrgencyoFrequencyoFlank painoGross hematuriaoUrinary incontinenceoSuprapubic pain

NO

YES

Order urine culture if you observe 2 or more:

•New onset burning urination (dysuria)•New or worsening:oUrgencyoFrequencyoFlank painoGross hematuriaoUrinary incontinenceoSuprapubic pain

NO

Order urine culture if you observe 1 or more:•New CVA tenderness•Shaking chills (rigors)•New onset of delirium

Urinary catheter?

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

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