FOCUS ON INFECTION PREVENTION Antimicrobial Therapy for Pneumonia in Pennsylvania Long-Term Care: A Spotlight on Culture James Davis, MSN, RN, CCRN, CIC, HEM INTRODUCTION Senior Infection Prevention Analyst Pennsylvania Patient Safety Authority In the United States, pneumonia is responsible for an estimated 60,000 deaths annually of people age ≥65 years and is the fifth leading cause of death within this population.1 Loeb states that “residents of long-term care facilities—a distinct ABSTRACT subpopulation of elderly people—are at particularly high risk for developing pneumo- In the United States, pneumonia is nia.”1 Because of the prevalence of pneumonia and other conditions such as urinary responsible for an estimated 60,000 tract infection, antibiotic use is common in the long-term care (LTC) community. deaths annually of people age ≥65 Furthermore, the Centers for Disease Control and Prevention (CDC) states that years and is the fifth leading cause of “antibiotic-related complications, such as diarrhea from C. difficile, can be more severe, death within this population. Because difficult to treat, and lead to more hospitalizations and deaths among people over 65 of the prevalence of pneumonia, years.”2 CDC asserts that antibiotics are among the most commonly prescribed medi- antibiotics are widely prescribed and cations in LTC facilities and that nationally, “up to 70% of long-term care facilities’ administered in the long-term care (LTC) residents receive an antibiotic every year.”2 community. Empiric antibiotic therapy Several guidelines for the treatment of pneumonia with antibiotics exist,3-6 and depend- is sometimes used to target the patho- ing on the resident’s medical history or the constellation of residents in a particular gens that commonly cause pneumonia care area, a clinician may need to choose between treatment algorithms. For example, in a specific population, but without a resident who has had no hospital admissions, is active, and is visited frequently confirmatory cultures, antibiotic selec- by friends and family may be at risk for community-acquired pneumonia, whereas a tion may not be optimal. To gauge the resident with frequent admissions to the hospital and a history of multidrug-resistant extent of culture-guided antimicrobial organism infection may be an ideal candidate for a healthcare- or hospital-associated therapy for pneumonia in Pennsylvania pneumonia antibiotic treatment algorithm. Treatment decisions can be more compli- LTC facilities, Pennsylvania Patient cated for those residents who frequently require outpatient services external to the LTC Safety Authority analysts queried the facility and have a high volume of friends and family visits, as they may be exposed to Pennsylvania Patient Safety Reporting both community and healthcare-associated bacteria and viruses. System database. The percentage of Given the variety of pathogens causing pneumonia, culture data obtained to guide LTC residents who received antibiotics pneumonia treatment would appear to be an ideal approach to optimize care. However, for pneumonia in the absence of cul- obtaining diagnostic cultures in LTC remains challenging for several reasons, including ture data ranged from 85.2% to 91.0% the following: across Pennsylvania regions. There is a pressing need to attempt to collect cul- —— Debilitated residents may be unable to produce specimens in a quantity suitable ture data, rather than relying on empiric for culture. treatment algorithms, in order to tailor —— Staff may not be trained in, or comfortable with, proper culturing techniques. treatment to a specific pathogen as —— Alternative culture techniques, such as nasopharyngeal lavage or bronchial aspi- often as clinically possible. (Pa Patient rate lavage, are often unavailable or inappropriate. Saf Advis 2015 Sep;12[3]:116-8.) —— Residents may be colonized with potentially pathogenic bacteria in addition to infection-causing bacteria. Because obtaining culture data for diagnosis of pneumonia in LTC facilities is challeng- ing, diagnosis may be criteria- and symptom-based. Empiric antibiotic therapy is often used to treat pathogens that commonly cause pneumonia in a specific population.4,7,8 To evaluate the extent to which culture-guided antimicrobial therapy for pneumonia in Pennsylvania LTC facilities occurs, Pennsylvania Patient Safety Authority analysts que- ried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. METHODS Analysts queried PA-PSRS for pneumonia events reported from April 1, 2014, through March 31, 2015. This time period was chosen because it is the first full year of data available since PA-PSRS was updated to version 2 in April 2014. The updated ver- sion includes data fields specific to whether a culture was performed, combined with Page 116 Pennsylvania Patient Safety Advisory Vol. 12, No. 3—September 2015 ©2015 Pennsylvania Patient Safety Authority antibiotic administration data fields in Figure 1. Percentage of Reported Long-Term Care Pneumonia Events, Fitting Pennsylvania relation to a pneumonia event. For this Patient Safety Reporting System Criteria, for Which the Patient Had Been Treated with Antibiotics Absent Bacteriologic Culture Data, by Region, April 2014 through March 2015 query, “culture” was defined as micro- biologic culture collected as part of the Northwest Northcentral Northeast pneumonia reporting pathway. The data was then sorted by geographic region and converted to percentages in order to 86.2% 85.3% 85.2% normalize for population distribution. (417 of 484) (343 of 402) (462 of 542) Facilities reporting no pneumonia events were removed from the analysis. RESULTS 85.7% 91.0% 90.2% The percentage of reported events in (706 of 824) (724 of 796) (1,577 of which residents received antibiotics for 1,749) MS15449 pneumonia in the absence of culture ranged from 85.2% to 91.0% across Southwest Southcentral Southeast Pennsylvania regions (see Figure 1). The results indicate treatment for the majority of residents who meet pneumonia criteria is empiric rather than culture-directed. Figure 2 depicts the number of pneumonia Figure 2. Treatment of Pneumonia Events with Antibiotics, per Facility, as Reported events reported, per facility, in which anti- through Pennsylvania Patient Safety Reporting System, April 2014 through March 2015 biotics were administered in the absence of microbiologic culture data compared with NO. OF PNEUMONIA EVENTS pneumonia events in which antibiotics TREATED WITH ANTIBIOTICS were administered and a culture had been 70 performed. As shown in the figure, the vast majority of pneumonia events were treated No culture 60 with antibiotics in the absence of micro- biologic culture data, and nearly all of the Culture facilities submitting reports were more 50 likely to treat pneumonia with antibiotics without a culture than with a culture. 40 DISCUSSION 30 The Importance of Culture Antimicrobial treatment for pneumonia 20 in Pennsylvania LTC facilities seems to be guided by diagnostic criteria sets, empiric 10 therapy algorithms, and clinician experi- ence rather than by culture data. Culture 0 data and laboratory-guided antimicrobial 1 51 101 151 201 251 301 351 401 451 501 MS15480 therapy are necessary for optimal antibi- DEIDENTIFIED FACILITY NUMBER otic use. Tracking and reporting antibiotic prescribing patterns helps optimize therapy for individuals and may decrease the emer- gence of antibiotic-resistant organisms. Vol. 12, No. 3—September 2015 Pennsylvania Patient Safety Advisory Page 117 ©2015 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Leadership support, accountability, drug It has been noted that these challenges infectious agent whenever possible, there expertise, and education are imperative combined with a lack of microbiologic is a pressing need to attempt to collect in terms of optimizing antimicrobial use. culture data contributes to inappropri- culture data in order to tailor treatment Furthermore, “[microbiologic] cultures ate antibiotic prescribing.4,10 In an effort to a specific pathogen as often as clini- may have a major impact on the care of to curb inappropriate antimicrobial use, cally possible and to not rely on extended an individual patient and are important Jump et al. noted the value of infectious- empiric therapy. The establishment of for epidemiologic reasons, including the disease consultation services for the LTC antibiotic stewardship programs and infec- antibiotic susceptibility patterns used to setting. Postintervention, the researchers tious-disease consultation has been shown develop treatment guidelines.”5 In 2000, found a significant reduction in total to decrease the risks from antibiotic use the Society for Healthcare Epidemiology antimicrobial use, including fluoroquino- (especially C. difficile) in individual facili- of America noted that “the use of empiric lones, and a decline in the rate of change ties and the LTC community as a whole. antibiotics does not eliminate the need of positive Clostridium difficile tests.11 A crucial step for the future of antibiotic to establish the causative etiologic agent Fluoroquinolone use is common in the stewardship is the collection of resident- whenever possible.”4 treatment of pneumonia and is a risk fac- level culture data, thereby creating tor for developing C. difficile infection. pathogen-specific data in order to guide Infectious-Disease Consultation antibiotic stewardship activities and In addition to challenges to effective CONCLUSION enhance the effectiveness of infectious- culture collection, other challenges Healthcare in general has been slow disease specialist consultation. Further related to infectious-disease management to respond to the emerging threat of guidance on implementation of specific in LTC facilities include lack of access antibiotic resistance that has been devel- strategies for addressing practice gaps and to an accurate and complete medical oping for at least 25 years.12 Given the opportunities for improvement in antibi- record, lack of time and reimbursement, importance of establishing the causative otic stewardship will be presented in future and poor clinical and nursing support.9 Pennsylvania Patient Safety Advisory articles. NOTES 1. Loeb M. Pneumonia in older persons. 5. Mandell LA, Wunderink RG, Anzueto A, 9. Caprio TV, Karuza J, Katz PR. Profile Clin Infect Dis 2003 Nov 15;37(10):1335-9. et al. Infectious Diseases Society of Amer- of physicians in the nursing home: time 2. Centers for Disease Control and Preven- ica/American Thoracic Society consensus perception and barriers to optimal medi- tion. Antibiotic use in nursing homes. guidelines on the management of commu- cal practice. J AM Med Dir Assoc 2009 Get Smart About Antibiotics Week: nity-acquired pneumonia in adults. Clin Feb;10(2):93-7. November 18-24, 2013 [online]. 2013 Infect Dis 2007 Mar 1;44 Suppl 2:S27-72. 10. Van Schooneveld T, Miller H, Sayles H, [cited 2015 Jun 1]. http://www.cdc.gov/ 6. American Thoracic Society, Infectious et al. Survey of antimicrobial stewardship getsmart/healthcare/learn-from-others/ Diseases Society of America. Guidelines practices in Nebraska long-term care facili- factsheets/nursing-homes.html for the management of adults with ties. Infect Control Hosp Epidemiol 2011 3. Kollef MH, Morrow LE, Baughmann hospital-acquired, ventilator-associated, Jul;32(7):732-4. RP, et al. Health care-associated pneu- and healthcare-associated pneumonia. 11. Jump RL, Olds DM, Seifi N, et al. monia (HCAP): a critical appraisal to Am J Respir Crit Care Med 2005 Feb Effective antimicrobial stewardship in a improve identification, management, and 15;171(4):388-416. long-term care facility through an infec- outcomes--proceedings of the HCAP Sum- 7. Furman CD, Rayner AV, Tobin EP. Pneu- tious disease consultation service: keeping mit. Clin Infect Dis 2008 Apr 15;46 Suppl monia in older residents of long-term a LID on antibiotic use. Infect Control 4:S296-334. care facilities. Am Fam Physician 2004 Oct Hosp Epidemiol 2012 Dec;33(12):1185-92. 4. Nicolle LE, Bently DW, Garibaldi R, et al. 15;70(8):1495-1500. 12. Cohen ML. Epidemiology of drug Antimicrobial use in long-term-care facili- 8. Stone ND, Ashraf MS, Calder J, et al. resistance: implications for a post- ties. Infect Control Hosp Epidemiol 2000 Surveillance definitions of infections in antimicrobial era. Science 1992 Aug Aug;21(8):537-45. long-term care facilities: revisiting the 21;257(5073):1050-5. McGeer criteria. Infect Control Hosp Epide- mol 2012 Oct;33(10):965-77. Page 118 Pennsylvania Patient Safety Advisory Vol. 12, No. 3—September 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 3—September 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. 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