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Beyond the Urine Culture: Other Areas for Antibiotic Stewardship in Long Term Care Facilities

Explore appropriate use of antibiotics in the elderly for skin and respiratory infections in long term care facilities. Discuss treatment options, dosing, duration, and non-pharmacologic therapies.

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Beyond the Urine Culture: Other Areas for Antibiotic Stewardship in Long Term Care Facilities

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  1. Beyond the Urine Culture:Other Areas for Antibiotic Stewardship in Long Term Care Facilities Lisa Avery, Pharm.D. BCPS AQ-ID Associate Professor, Wegmans School of Pharmacy/ St. John Fisher College

  2. Learning Objectives • 1. Discuss appropriate use of antimicrobials for the treatment of skin and soft tissue infections in the elderly. • 2. Review the treatment of both upper and lower respiratory tract infections in the elderly population. • 3. Determine what type of skin and respiratory manifestations do not require antimicrobial therapy.

  3. www.cdc.gov/

  4. Antibiotic Stewardship Drug Safety!!

  5. Need for Stewardship Daneman N et al. JAMA Intern Med 2015;175(8):1331-1339

  6. Dwyer L; J Am Geriatr Soc 2013;61:341-349

  7. Case #1 • An 88 year old male resident has new onset redness on his left lower extremity. His leg has more edema than normal and he complains of some pain when he tried to walk. • PMH: Type 2 diabetes, Lymphedema • Allergy: NKA • Vitals: Temp 97.7oF, HR-85 bpm, R-18 bpm, BP 120/55 mmHg • Height/Weight: 6 foot 162 kg • Nursing Assessment: Skin: is warm and dry. There is erythema in the left leg up to the mid-thigh. Chronic swelling changes in left and right leg • Medications: metformin 1g po BID, glyburide 10mg po day, ASA 81mg po daily

  8. *Increase in 1.50C [2.4oF] above baseline temperature Loeb M et al. Bentley DW et al; Clin Infect Dis 2000;31:640-653

  9. What else can it be? Gout

  10. Right Drug? • A. Penicillin VK • B. Cephalexin • C. Doxycycline • D. Amoxicillin-clavulanic acid • E. Levofloxacin

  11. Normal Flora

  12. Nonpurulent Cellulitis • B-hemolytic Streptococcus is responsible for over 70% of diffuse, nonculturable cellulitis Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore) 2010; 89:217–26

  13. Nonpurulent Cellulitis *MRSA risk factors: Penetrating trauma, MRSA colonization, Intravenous drug abuse JAMA 2016;316(3):325-337

  14. Nonpurulent cellulitis: Mild/Moderate Treatment

  15. Antibiotic Choices…

  16. Right dose of cephalexin? • A. 500mg po 2 times/day • B. 500mg po 4 times/day • C. 1g po 3 times/day • D. 1g PO 4 times/day

  17. Dosing for nonpurulent cellulitis Liu, 2011 Stevens DL et al. Clin Infect Dis 2014;59(2):e10-52/Up to Date Accesses 6/18/18

  18. 2 Dose of cephalexin in obesity Adults – The adult dosage ranges from 1 to 4g daily in divided doses Keflex Package Insert 3/06 Kaufman KR et al. J Clin Pharm Therapeutics 2016;41:409-413 Pallin DJ et al Clin Infect Dis 2013;56(12):1754

  19. Question • Do you need to be on both TMP-SMX AND cephalexin?

  20. Important Facts about Cephalexin • Patients with a true penicillin allergy have a 0.1% to 6% cross reactivity with cephalosporins. • Side Chain Similarities • Risk of C.difficile increases with cephalosporin generation Terico A, Journal of Pharm Practice 2014;27:530-544/Pallin CID 2013;56:1754-62 Owens R CID 2008;46:S19-31

  21. Right Duration? • A. 5 days • B. 10 days • C. 14 days • D. Until the cellulitis is gone

  22. IDSA Recommendations • Duration of therapy = 5 days, treatment should be extended if the infection has not improved within this time period up to 10 days

  23. LTCF Antibiotic Prescribing Feldstein D JAMDA 2017;18:265-270

  24. Non Pharmacologic therapy • Elevation of the affected area • Treatment of predisposing factors, such as edema or underlying cutaneous disorders – use support hose • In lower extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection. Treat fungal infections.

  25. Case #2 • An 88 year old male resident recently admitted from the hospital and on the initial assessment the nurse notices he has redness on bilateral extremities. • PMH: Type 2 diabetes, Lymphedema, Vascular insufficiency • Allergy: NKA • Vitals: Temp 97.7oF, HR-85 bpm, R-18 bpm, BP 120/55 mmHg • Height/Weight: 6 foot 162 kg • Medications: metformin, glyburide

  26. *Increase in 1.50C [2.4oF] above baseline temperature Loeb M et al.

  27. Right Drug? • A. Trimethoprim-sulfamethoxazole • B. Cephalexin • C. Doxycycline • D. No antibiotics at this time

  28. Causes of Bilateral Redness • “Vascular insufficiency is frequently associated with conditions that mimic skin infections (e.g., venous stasis dermatitis) and result in misdiagnosis of cellulitis” • If it is bilateral cellulitis, it is probably NOT cellulitis • Look for other causes!

  29. Case #3 HPI: 78 yo male resident develops an abscess and redness of his left lower leg over the last 2 days. He denies any fever, loss of sensation, myalgias NKA PMH: CHF, COPD Allergy: NKA Vitals: Temp 98.5oF, HR 90 BPM, R18 BPM, BP: 123/72 Ht 72”, 90kg Serum creatinine = BUN/Scr 20/1.6 g/dl Nursing Assessment: PE: 5 cm round area of cellulitis, surrounding small area of induration. MRSA screen positive last hospital admission .

  30. *Increase in 1.50C [2.4oF] above baseline temperature Loeb M et al.

  31. MRSA Colonization Robicsek A; J Clin Microb 2008;588-592

  32. Right Drug? • A. Cephalexin 500mg po 4 times daily • B. Doxycycline 100mg po BID • C. Amoxicillin-clavulanic acid 875mg po BID • D. Trimethoprim-sulfamethoxazole 1 DS PO BID • E. Clindamycin 300mg po 4 times daily

  33. Antibiotics for MSSA and MRSA

  34. Antibiogram

  35. Definitive Therapy: Wound culture: MRSA Note: Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin should not be used for MRSA – resistance develops rapidly!

  36. Drug Dose/Safety Stevens DL et al. Clin Infect Dis 2014;59(2):e10-52/Up to Date Accesses 6/18/18

  37. Trimethoprim-sulfamethoxazole and the Kidney structurally related to potassium sparing diuretics Blocks secretion Crystallization in the urine Acute Interstitial Nephritis Acute Tubular Necrosis

  38. Trimethoprim/sulfamethoxazoleAcute Renal Injury/Hyperkalemia Variables independently associated with acute renal injury: Baseline elevated serum creatinine OR 2110 (95% CI = 724 – 7980) p< 0.0001 High dose TMP-SMX (> 5mg/kg/day trimethoprim) OR 3.70 (95% CI = 1.70-8.12) p< 0.0012 Concomitant receipt of an ACEI OR 2.36 (95% CI = 1.01 – 5.24) p<0.048 Concomitant receipt of a K+ supplement OR 4.10 (95% CI = 1.45 – 10.1) p<0.010 Gentry CA Ann Pharmacother 2013;47:1618-1626

  39. Right Duration? • A. 5 days • B. 10 days • C. 14 days • D. Until the cellulitis is gone

  40. When do you need broader coverage? Symptoms of Necrotizing fasciitis • Severe pain that seems disproportional to the clinical findings • Failure to respond to initial antibiotic therapy • The hard, wooden feel of the subcutaneous tissue, extending beyond the area of apparent skin involvement; • Systemic toxicity, often with altered mental status • Edema or tenderness extending beyond cutaneous erythema • Crepitus, indicating gas in the tissues • Bullous lesions • Skin necrosis or ecchymosis.

  41. Case #4 • A 77 year old male resident has a venous stasis ulcers has some redness around his ulcers. The nurse calls the on call practitioner and they call in an order for amoxicillin-clavulanic acid 875mg po BID

  42. Right Drug? • A. Amoxicillin-clavulanic acid • B. Cefpodoxime and metronidazole • C. Levofloxacin • D. Clindamycin + ciprofloxacin • E. Perform a culture before starting therapy

  43. Chronic Venous Ulcers Contamination Colonization Localized Infection Spreading Infection Systemic Infection

  44. Wound culture Staphylococcus: Sensitive: Clindamycin, Linezolid, TMP-SMX, Enterobacter: Sensitive: Cefepime, Ceftriaxone, Ciprofloxacin, Ertapenem, TMP-SMX Acinetobacter: Sensitive: Ciprofloxacin, Ceftazidime, Tobramycin, Don’t treat colonizers • Specimen Description: wound culture • Gram stain: No white blood cells/No bacteria • Culture Result: Moderate Staphylococcus aureus • Moderate Enterobacter cloacae complex • Moderate Acinetobacter baumanni Complex

  45. A Picture is worth a thousand words

  46. Right Duration? • A. 5 days • B. 10 days • C. 14 days • D. Until the cellulitis is gone

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