You will not get influenza this winter and you will not send urine to the

laboratory only because it smells: Germ doctor’s wishes that can come

true. Greg German MD PhD FRCPC DTM&H

Medical Microbiologist & Infectious Diseases Consultant

October 15, 2015www.healthpei.ca/micro

Making the Connection Conference Summerside

Considerations and Treatment Guidelines for Older adults (UTI’s,

URI’s, Influenza)

No DisclosuresObjectives:

•1. Discuss the new medical directive on urinary tract infection management in long term care including the use of RN initiated antibiotics, physician guidelines, rapid testing, and nursing leadership.•2. Analyze the @Urinematters successfully collaboration and tapping into new funds or tools for education•3. Establish a top 10 list of flu prevention strategies for your home and work. •4. Strategize on how your health care role and role-modeling plays a key part to prevent infections and outbreaks.

The SUPERBUGS

Seniors (Age 65+)

• 17.3% of Island population (2013)• Projected to about 1 in 3 by 2040

Cdiff Cases Per Year on P.E.I.

*

Total: 82 118 142 137

Cdiff Cases by Age

*2014 Data: Lab Generated pending confirmation/validation by Provincial Epidemiologist

*

Very very bad E.coli • XDRO

Extensively (Gram Neg) Drug Resistant Organism PEI Public health reported since 2013

• For urines intermediate or resistant to 3 of 4 following groups of oral antibiotics Cotrimoxazole “Septra or Bactrim” Nitrofurantoin “Macrobid or Macrodantin” Amox/clav or cefixime Ciprofloxacin

XDROs in Urine by Age Bracket

11

139

31

54

23530/10k

16089/10k

7221/10k

11784/10k

LTC BedsXDRO per

10K Patient days XDROs 2014

Andrews Lodge 221 0.0

Atlantic Baptist Home 100 0.0

Beach Grove Home 131 4.4 21

Clinton View Lodge 35 0.0

Colville Manor 52 4.2 8

Dr. John Gillis Memorial Lodge 78 1.8 5

Garden Home 133 0.0

Maplewood Manor 48 6.8 12

Margaret Stewart Ellis Home 40 4.1 6

Park West Lodge 39 0.0 0

Prince Edward Home 120 1.8 8

Riverview Manor 48 22.3 39

South Shore Villa 56 0.0 0

Stewart Memorial 23 6.0 5

Summerset Manor 82 0.0 0

Wedgewood Manor 76 4.0 11

Whisperwood Villa 126 2.4 11

PILOT

PILOT

PILOT

Sorting of plates into different categories

GOOD

JU

NK

EA

SY

More time = more contaminants

Riverview Manor Urines N= 104 tests

Garden Home Urines N = 203 tests

Mixed Growth 22% 15%No significant Growth 25% 39%

No growth 12% 23%Pathogen 37% 47%

Non-pathogen 5.8% 7.3% Plating characteristics

Average time to plating 20.3 hours 11.6 hoursSamples between 24-30

hours 38% 7.9%

Quality due to transport?

Problem Specifically• Too many inappropriate specimens sent

When patient not clearly symptomatic True Midstream urine collection challenges Unable to obtain in/out catheter order easily

• Ciprofloxacin started before culture results• Urine Specimen transport, pyuria

detection, and turn around unsatisfactory

Problem Generally

•Increase Cdiff•Increase drug resistance•Increase admissions due to missing the target

•Increase IV antibiotic therapy

The Teams and GroupsLong Term Care UTI Management Team•Shelley Woods (LTC CNO)•Shelley MacCallum •Kelly Blanchard •Pam Handrahan•Kim MacPhee•Jennifer Boswell (Antibiotic Stewardship Pharm)•Dr. German (Micro-Inf. Diseases), •Drs. Grimes, & MacLeod (House Physicans)

Committees Involved•PICPAC

Brenda Worth, Chair

•PD&T Including Antibiotic

subcommittee

•Engagement Event #UrineMatters a CADTH

cosponsored event with 120 stakeholders

The Teams and GroupsLong Term Care UTI Management Team•Shelley Woods (LTC CNO)•Shelley MacCallum •Kelly Blanchard •Pam Handrahan•Kim MacPhee•Jennifer Boswell (Antibiotic Stewardship Pharm)•Dr. German (Micro-Inf. Diseases), •Drs. Grimes, & MacLeod (House Physicans)

Committees Involved•PICPAC

Brenda Worth, Chair

•PD&T Including Antibiotic

subcommittee

•Engagement Event #UrineMatters a CADTH

cosponsored event with 120 stakeholders

Nurse Initiated antibiotics by medical directive

• Thames Valley Family Health Team (London Ontario), 2011 Limited to usually young females as

greater than 2 medication or one blood thinner is a contraindication

• Hamilton Family Health Team, 2014 Nurse able to give treatment course and

modify once susceptibilities are known

Nitrofurantoin and Benefits

• Less collateral damage: Doesn’t target gut less resistance Doesn’t target gut less C. difficle

• Costs Inexpensive cost effective Opportunity to safe fluroquinolone or

TMP/SMX for future use decrease need for IV antibiotics

Use of Nitrofurantoin in Men

• Supported in the UK when pyleonephritis or recurrent infection not suspected

• Appreciate may fail therapy due to lack of prostate penetration 20% of all UTI, 50% of recurrent or associated with catheter

have prostate involvement 90% of men with febrile UTI

Nitrofurantoin and Side effects• Long term use pulmonary fibrosis

• Long term use peripheral neuropathy

• Long term use hepatic toxicity• Renal damage increased toxicity• G6PD Hemolytic Anemia• Lack of prostate penetration

potentialclinical failure

• Lack of Vaginal penetration in elderly Relapse/Reinfections?

BEERS Criteria 2012

• Avoid for long-term suppression• Avoid in patients with CrCl

<60ml/min

BEERS Criteria 2015

• Avoid for long-term suppression

• Avoid in patients with CrCl <30 ml/min

• Quality of Evidence Low, Strength of Rec Strong

Nitrofurantoin in Kidney function including males

• 600 bed long Island N.Y. Hospital• Retrospective study

30 years of using across age / gender / GFR

Only one case of Autoimmune hemolytic anemia.

Used >30 CrCl as cutoffCunha et al Journal of Chemotherapy 2014

Proposed Implementation and Monitoring

• To start at Three sites • Awaiting final layers of approval• Developing training tools / Video• Attempting to marshal resources for

quality tracking

GUIDELINES FOR IMPLEMENTATION

• A 30 minute instructional video followed by a 10 minute online quiz will be provided to nursing staff with a single use personal web token.

• The nurse shall be provided the opportunity to retake the quiz a total of three times in a one month period.

• When passed, the online quiz with email confirmation of passing to the immediate supervisor and a copy of this confirmation shall be printed and placed in the RN’s file.

• The video and quiz shall be retaken at least yearly.

Monitoring the Process1. Percent of eligible residents enrolled at a facility.2. Percent of RNs certified in medical directive at a facility.3. Percent of urine specimens collected outside of medical

directive.4. Frequency of Appendix A (Worksheet) successfully

completed by RN5. Frequency of MD / NP using appropriate antibiotic(s).6. Frequency of continuation orders for nurse initiated

antibiotic.7. Frequency of requiring a 2nd or 3rd antibiotic per UTI event.8. Frequency of repeat UTI per resident per time period.

Monitoring Outcomes1. Frequency of urine specimen collection from facility

per defined time period and by type of urine collection.2. Percent positivity of urine culture vs. mixed growth vs.

negative per defined time period3. Frequency of ER transfer / hospital admission4. Frequency of bacteremia5. Frequency of UTI associated mortality6. Change in urine culture antibiotic resistance per time

period7. Stakeholder satisfaction

Fools gold vs. Really gold In the Micro Lab

Improved microbiology• When LTC checked

Treated as a careful urine Glass Slide prepared in case Gram stain

for pyuria needed Early reporting by fax/printer of

preliminary info East side of Island: Moving towards

having urine specimens plated at Kings County Memorial and shipped the next morning

Recap• Cdiff and XDROs are likely linked and target our

Seniors disproportionately• Poor urine specimens lead to poor care

In and out catheter specimens preferred Bed pans are dangerous

• Short term Nitrofurantoin is safe again a good therapy for a RN to start via directive

• Our snowiest winter brought forth our warmest interdisciplinary partnership.

What percentage of antibiotic prescriptions are outside of

acute care hospitals?

A. 85%B. 66%C. 50%D. 33%E. 15%

• #urinematters• Feb 10, 2015• 120 Strong

and brave Islanders

• #coughmatters

Which Monster will really get us

• Sepsis 9,300 Canadians die a year (CIHI) (~37 Islanders)

• 350 True Influenza Deaths per year (PHAC) (~2-5 Islanders) 9! in 2015• Cdiff 29,000 deaths in USA (2011) ~2900 in Canada, ~2 a year on the Island

Influenza

How you will not get the flu1. Don’t touch your face or eyes2. Get the flu shot for you and the family3. See a doctor/NP quickly with a high fever and you are at risk of

severe flu 4. “Avoid sticky situations”5. Be a role model for hygiene and etiquette6. Protect your hands7. 8. 9. 10.

http://www.travelmath.com/feature/airline-hygiene-exposed/

Treatment Guidelines

In the clinic• Asthma / COPD• CHF / unstable Angina• Malignancy / Pregnancy / Obesity• Diabetes / CRF• >age 65, Chronic care facility• < 48 hours Start• >48 hours Offer / Consider (if Adult)

• During Flu Season ADD Oseltamivir (not currently on PEI Pharmacare Formulary) 75mg PO BID x 5 days for patients presenting within 48 hours of symptom onset AND

• Any of age ≥ 65, • Obesity (BMI≥40), • Diabetes Mellitus, • Asthma or COPD, • CHF or unstable Angina, • Malignancy, • Chronic Renal Insufficiency, • Pregnancy including up to 4 weeks post-partum, • Immune suppression (HIV, iatrogenic due to medication, hyposplenism).

In the ERTreat even if after 48 hours

• Progressive Disease Chest pain Poor oxygenation (Tachypnea, hypoxia,

laboured breathing Confusion / delirium Severe dehydration Exacerbation of chronic disease (↑Cr ↑BS)

In the ICU Progressive or complicated

Disease Treat all (5-10d)

• Hypoxia, abnormal Xray, Ventilation• Severe CNS disease• Severe Sepsis• Myocarditis or Rhabdomyolysis• Secondary Bacterial infection

(Persistent high fever beyond 3 days)• *Consider Zanamivir inhaled / IV

Uncommon Oseltamivir Side effects

• Nausea (4 to 10%)• Vomiting (2% to 15%) • Diarrhea (1 to 3%)• Epistaxis (1%)• Wheezing• Oseltamivir resistance

• When and How does influenza get it’s name?

Italy: 1300’s A.D. Astrological Influences

Influenza: Italian form of Latin influentia, "epidemic", originally used because epidemics were thought to be due to astrological or other occult "influences".

–ICTVdB (2002)

Role Modeling

• Either positive or negative…• Perception of being a role model

positively contributes to culture of approachability…

Somebody is Watching You!

Healthcare workers in room with a senior staff person or peer who did not wash hands were significantly less likely to wash their own hands

80% less likely; p<0.001

Lankford EID 2003

Influence of Mentor Hand Hygiene Practices on Student Practices

Snow AJIC 2006

• If the mentor attempted HH, the student was 70% more likely to attempt HH

• Mentor’s HH practice was strongest predictor of student’s HH rate

Nursing Data IJNS 2013 A. Huis et al.

• Cluster randomized controlled trial in 67 nursing wards of three hospitals in the Netherlands

• State of the Art Strategy vs. • State of the Art Strategy + “Social

influence and Leadership”

State of the Art Strategy

• Education: Leaflet, website with quiz and reward for partcipation, practical demonstrations

• Reminders: Posters changed every 3 months, newletters, emails to opinion leaders/ manager

• Feedback: Bar charts

State of the Art Strategy + enhanced Team work and Role

modeling• Setting Norms and Targets

Three 60-90min ward sessions with goal setting lead by manager and external coach

Analysis of barriers to determine how best to adapt Nurses address each other in case of undesirable

hand hygiene

• Commitment from manager• Modeling by informal leaders

Demonstrate, model, instruct and stimulate

ResultsGroup Baseline Post Intervention Followup

State of the art(37 wards)

23% 42% 46%

Team / role model(30 wards)

20% 53% 53%

64% relative improvement with team/role modelP<0.001

Preserve Hand IntegrityDO / TRY DON’T USE / AVOID

Use your own moisturizer before leaving house, consider long acting like Aveeno

washing with soap and water and then use alcohol based hand rub just after .

Wear Gloves/Mitts to protect from winter large bottle of moisturizer

Use facility provided moisturizer at start of shift and PRN.

refill non-facility dispensers or personal supply containers.

Seek occupational health / medical assistance if pain, itchiness, or oozing

occurs.

a barrier cream unless coordinated by occupational health.

Trust that Alcohol based hand rub is less drying for your hands than soap and

water

jar or putty moisturizers (see below)

Influenza testing on PEI• MWF PCR testing except holidays• Stat or at least next AM testing available• Viral respiratory panel (off Island) limited• Nasopharyngeal swab for 13 and older

Youtube TFwSefezIHU for instructions Physicians should aim to do in office

Use N95 when you have them and fit tested JAMA 2009 302; 1865-71 Hamilton RCT no difference

Patients on Oxygen will receive combined NP and throat swab in the same sample by RT

• Nasopharyngeal aspirate for ≤12

Take home messages

• Seniors are at greatest risk of infections• Improving UTI management likely to

make a big difference• #UrineMatters and #CoughMatters• I believe you will not get the Flu• Role modeling and team work critical

for above

Acknowledgements and Gratitude

Long Term Care UTI Management Team•Shelley Woods (LTC CNO)•Shelley MacCallum •Kelly Blanchard •Pam Handrahan•Kim MacPhee•Jennifer Boswell (Antibiotic Stewardship Pharm)•Dr. German (Micro-Inf. Diseases), •Drs. Grimes, & MacLeod (House Physicans)

Committees Involved:•PICPAC

Brenda Worth, Chair Dr. Heather Morrison

•PD&T Including Antibiotic

subcommittee

•Matters Events Lisa Pyke, CADTH

•Microbiology Labs Becky Moore & team Andrea Dowling & team

I want a safe, resilient, and sustainable health system for our family

One by one

Sepsis• TIME is GOLDEN; every hour delay for

septic shock survival decreases by 7.5%1

Only ½ of hospitals make it to 6 hours or less

• For Severe Sepsis we miss the antibiotic boat ~40% of the time2

• Severe Sepsis mortality of ~40% in the ICU3

• Incidence of Severe Sepsis 40/100K/Year• Non-Severe Sepsis ~60/100K/Year

1Kumar et al. CCM 2006 34: 15892Mikkelsen et al. Chest 2010 138: 551-5583CIHI

Sepsis What you can do• Stage Better and faster• Culture Better and faster

Page micro tech to gram and culture after 3-4 pm. Early rough susceptibilities for day 1 blood cultures

• Source Control faster < 12 hours• Profuse, oxygenate, and monitor lactate• Start antibiotics Bigger, Smarter and faster

Loading doses for Vanco 25 mg/kg (Only 50% do) Empiric sepsis guidelines www.healthpei.ca/micro

PCH-Bacteriology Laboratory on Call with early results

• Between 4pm and 3am• Any positive blood culture from ICU or

Neonates• Any two positive blood bottles from a patient• Set up of direct “from the bottle”

susceptibilities and screening for MRSA These are not reported but are known to the

laboratory / Medical Microbiologist• Urine STAT Gram stain and Evening Setup

Septic patients with indwelling Foley catheter culture

ICU when requested

Start of antibiotics at QEH and PCH

• Using the computerized Sepsis Power Plan at QEH 4 patients investigated 2 of 4 not given within an hour, and one given at 5 hours after order

• PCH Audit of 6 cases coded as Sepsis in discharge diagnosis No significant delay to antibiotics

Calling a code

• A defined process• Multi-disciplinary• Clear communication• Specific Entry Criteria• Time sensitive• Quality focused

Code Sepsis

Code Sepsis• A misc stat medication ordered by

the physician. NO OVERHEAD PAGE• On its own or in conjuction with the

Sepsis Management PowerPlan• Multidisciplinary response

Who does what when• Top of the list of Tasks Nursing to Give,

clarify that all antibiotics are to be given STAT

• Pharmacy Confirms availability of ordered antibiotics

• Emphasis on fluids > cultures > drug in <1hr• Trackable as Code Sepsis stops at the start of First

Antibiotic• Can also involve antibiotic stewardship and

laboratory in the future.

Code Sepsis

A new STAT medication called

• Code Sepsis: initiation of IV bolus, culture(s) and antibiotics must be performed in sequence and STAT in first hour of diagnosis".

• Automatically activated with Sepsis Management PowerPlan

Not specifically addressed in these sepsis guidelines

Follow up

• Discontinuation of sepsis power plans for Old skin and soft tissue Community Acquired Pneumonia

• Reassessment after 6 months for Code sepssi 2 years for Sepsis antibiotics

Which Monster will really get us

• Sepsis 9,300 Canadians die a year (CIHI) (~37 Islanders)

• 350 True Influenza Deaths per year (PHAC) (~2-5 Islanders)

• 0 Ebola deaths in Canada Nigeria 687US$/person, 167 M, Lagos 12-21M 20 Cases and 8 deaths and outbreak halted October 10th……….Was this just luck???

Who is the real monster anyway?

Acknowledgements:• Trent Ferrish, Jennifer Boswell, and Wendy Cooke• Provincial Drug and Therapeutics Committee

Iain Smith and Dr. Patrick Bergin Co-chairs• Physician reviewers for Sepsis:

Dr. Lenley Adams Dr. Patrick Bergin Dr. Michael Irvine Dr. Paul Seviour Dr. Philip Champion (febrile neutropenia) Dr. Barry Fleming (intra-abdominal)

• Dr. Dan Smyth infectious disease Moncton City Hosp.• Julie Cole QEH Librarian• Vanessa Arseneau Micro-Antibiotic Susceptibility Tech

2• Becky Moore PCH-Microbiology lab supervisor