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Antibiotic Stewardship and Culturing: The Role of Nurses and Infection Preventionists

This presentation discusses the importance of antibiotic stewardship and culturing in improving patient outcomes. It explores the role of nurses and infection preventionists in antibiotic management efforts and highlights the impact of stewardship on infection rates and colonization. Opportunities for diagnostic stewardship of urine culturing and proper use of microbiology tests are also addressed.

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Antibiotic Stewardship and Culturing: The Role of Nurses and Infection Preventionists

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  1. Stewardship IP Linda R Greene ,MPS,RN,CIC,FAPIC linda_greene@urmc.rochester.edu

  2. Objectives • Describe antibiotic stewardship • Discuss culturing stewardship • Explain the role of the nurse and the infection preventionist • Connect the dots between robust stewardship and patient outcomes

  3. Talking Points

  4. Some Interesting Information Effect of Stewardship on Infection and Colonization • Meta-analysis (32 studies) • 19% reduction MDRO & C difficile in hospitals  MDRO Gram-negative MRSA ESBL Gram-negative C difficile • 31% reduction with Infection Prevention Programs • Hand hygiene Lancet Infect Dis; 2017: 990-1001

  5. Antimicrobial Stewardship (AS) “AS refers to collaborative, coordinated programs and interventions….designed to improve antibiotic prescribing…..to optimize clinical outcomes while minimizing unintended consequences of antimicrobial agent use……” Infect Control Hosp Epidemiology, April 2018.

  6. IN OTHER WORDS…….. THE RIGHT ANTIBIOTIC AT THE RIGHT DOSE FOR THE RIGHT DURATION BY THE RIGHT ROUTE

  7. Reason #1 3 classes: Urgent Serious Concerning

  8. Reason #2

  9. Reason #3

  10. C difficile • Increased prevalence • Morbidity and mortality • Cost • Quality measures

  11. Reason #4

  12. Cost of Antiobitic Mis-use

  13. Overall Goals • Ensuring an antibiotic is needed through appropriate culture and sensitivity testing • Prescribing narrow spectrum antibiotics whenever possible • Administering antibiotics orally rather than intravenously whenever possible • Using the shortest course and lowest dose of antibiotics feasible • Avoiding certain antibiotics in hospital settings

  14. Greatest impact for Nurses and IP

  15. Challenges for Nurses • Nurses currently don’t have the formal training needed to contribute to antibiotic management efforts—including most of those trained as infection preventionists. • Need to acknowledge that the power structure in many hospitals makes it difficult for nurses to speak up and challenge a physician’s orders. • Increasing nurses’ knowledge of antibiotic use and involving them in the decision making process, perhaps is likely to have a positive impact on ASP effectiveness. • Even though nurses don’t prescribe, they can support or influence the decisions of other providers. • CDC suggests that nurses can ensure cultures are performed before starting antibiotics, monitor adherence to recommended guidelines, and question instances of suboptimal antibiotic therapy

  16. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdfhttps://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf

  17. What is Diagnostic Stewardship? Modifying the process of ordering, performing, and reporting diagnostic tests to improve the treatment of infections” Infection preventionists share the responsibility along with pharmacy , microbiology, information technology, and health care providers to ensure the correct specimens are collected at the appropriate time to diagnose a true infection Goal: optimize clinical outcomes while minimizing unintended consequences of antimicrobial use such as the emergence of antimicrobial resistance

  18. Opportunities for Diagnostic Stewardship of Urine Culturing

  19. Testing on first day of hospitalization Koch AJM 2017

  20. Harmful Practices • > Order sets – with urine culture – Pre op • > Reverse urine reflex (Cx ALL + UA) • > Nurse ‘screening’ cultures • > Fever bundles

  21. Infections vs. Colonization • Most infections are syndrome and + test • > UTI: dysuria + urine culture • > C. difficile: diarrhea & + C. diff test (PCR) • Most HAI publicly reported rates and use of antibiotics rely on positive test alone

  22. Diagnostic Test Right Test Right Time Right Patient

  23. Proper Use of Microbiology Tests Targeting Testing Eliminate duplicate test orders • Computer alerts • Laboratory hard stops • Encourage the Best Test for a diagnosis • Requires education and consultation • Leads to more rapid diagnosis with more targeted therapy • Discourage routine testing in the asymptomatic patient

  24. What is the Role of the Microbiology Lab? Proper specimen collection guidelines • Make available to all ordering healthcare workers • Establish standard guidelines and education Clearly expressed rejection criteria for suboptimal specimens • Poor sputum specimens using gram stain criteria • Urine specimens not stored correctly (preservative, refrigerated) • “Quantity not sufficient” • “Test of Cure”

  25. Proper Use of tests- Urine Cultures There is over ordering of urine cultures without true symptoms of UTI • Urinalysis (UA) can be used as a screening test to predict the usefulness of a urine culture with a high negative predictive value • Preventing the performance of an unnecessary urine culture on a patient without symptoms could prevent unnecessary treatment with antibiotics and assist with antimicrobial stewardship efforts

  26. The Reflex Urine Culture Urinalysis first performed, and based on findings… Culture is reflexed (ordered and performed) only if one or more of the screening tests are positive

  27. Results of Reflex Urine Protocol Reflex protocol has led to: • a decrease in the number of urines ordered for culture • a decrease in reporting catheter-associated urinary tract infections from patients that do not truly have an infection • a promotion of antimicrobial stewardship -less use of antibiotics will be prescribed to treat asymptomatic bacteriuria • a cost savings in the microbiology laboratory

  28. Urine Culture Guidelines

  29. The Challenge of C. difficile Diagnosis Rapid and accurate diagnosis is essential for: • Implementation of appropriate therapy • Infection control and prevention of further transmission Over-diagnosing C. difficile can result in: • Unnecessary isolation or contact precautions that can increase cost and patient distress • Unnecessary antibiotic treatment and antibiotic-related adverse events Under-diagnosing C. difficile can result in: • Delays in treatment and a poor clinical outcome • Disease transmission and associated infection-related costs and outcomes

  30. Wait and Evaluate Considerations beforeordering a C. difficile Test • Does the patient have clinically significant diarrhea? • Are there other reasons for diarrhea? • Does the stool sample take the shape of the collection container? • Has the patient received laxatives or enteral feeding? • Repeat testing or testing for “cure” is discouraged

  31. Testing Strategies forC.difficile Detection Enzyme Immunoassay vs. Nucleic Acid Amplification Testing • There is no perfect test to diagnose CDI because none of the available testing methodologies can reliably differentiate colonization from infection • Enzyme-based assays are less sensitive than nucleic acid-based tests and likely underdiagnose CDI, resulting in missed cases and worse outcomes • Because Nucleic-acid methods are more sensitive, they can detect organism in both colonized and infected patients, especially if solid stools are tested

  32. Proper Use of Tests: C.difficile Testing Specimen Criteria Soft or Liquid stool from patient is required • Do not test formed stools unless from a paralytic ileus • Refrigerate to prevent toxin deterioration • Discourage repeat testing during same diarrheal episode • Develop hard stop to prevent repeat testing within 7 days • Testing for cure is not recommended • Molecular tests positive for 2-3 weeks • High colonization rate in children

  33. C difficile Test Best Practice Alert • Alert if laxative administration < 24 hours • Responses to BPA warning • Remove (Follow up action taken) • Test cancelled • Test can be subsequently ordered • Keep (Testing appropriate option to comment) • Test ordered • Test can be subsequently cancelled

  34. Proper Use of tests Blood Cultures (BC) Most guidelines recommend that specimens: • Should be collected in the absence of antimicrobials at or around the time of fever spikes • Should be sampled simultaneously from the catheter and through a venipuncture, to diagnose a Central line-associated bloodstream infection • Meticulous skin antisepsis at the time of blood collection is paramount to reduce the risk of BC contamination • Adequate volume sampling is the most important parameter for the detection of bloodstream microorganisms

  35. Proper Use of tests Blood Cultures (BC) • Cultures obtained from either arterial lines or peripheral IVs should be discouraged due to the higher contamination rates. • When only a single culture is performed, it is difficult to determine contamination and real infection. • Incubation time in microbiology labs • Documentation of number of attempts/dedicated phlebotomy team • Positive blood cultures obtained from indwelling catheters might lead to unnecessary treatment due to colonization of hub or catheter.

  36. Collection of Blood Cultures

  37. Role of Nurses in Optimizing Antimicrobial Stewardship

  38. Role of Bedside Nurse • Obtain appropriate cultures, using proper technique, before antibiotics are started. Understand how the microbiology laboratory processes those samples. • Use microbiology results to help guide the optimal selection of antibiotics and guide decisions to stop therapy in cases where culture results represent colonization, rather than infection. • Help inform decisions to start antibiotics promptly at the time early signs of likely bacterial infections, including sepsis, are identified. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf

  39. Bedside Nurse • Help ensure that practices to ensure good antibiotic use are embedded in other quality improvement efforts. For example, for sepsis, help ensure that antibiotics are started promptly and then reviewed once additional data, especially cultures, are available. • Prompt, and participate in, discussions about antimicrobial usage including antibiotic de-escalation by evaluating each patient’s clinical status and readiness for change from intravenous to oral therapy, when possible. • Take a more detailed allergy history, especially around penicillin allergy. Help educate patients and families about what constitutes an accurate antibiotic allergy history. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf

  40. IP and ASP

  41. IP and ASP Synergy

  42. CLABSI Prevention, ASP and IP • Central Line Order Review • Long Term Antibiotic Indication • 35 patients, 13 months

  43. Adjusted HR for antacids, laxatives, age, prior CDI, HIV, immunosuppressants, chemotherapy, hospital LOS, chronic disease score Clin Infect Dis 2011

  44. UTI and IP

  45. Action – Education –

  46. C difficile Testing, ASP and IP • The PCR test cannot distinguish between colonization and active infection

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