Transcript PowerPoint - GRECC Audio Conferences

Antibiotic Resistance in Long
Term Care Facilities: existing
and upcoming challenges
Robert A. Bonomo, MD
VISN 10 GRECC
VAMC Cleveland, Ohio
Professor of Medicine,
Case Western Reserve University School of Medicine
Objectives
• Describe the demographics of a global aging
population and the burden of infection
• Describe the Immunology of Aging and its role in
Infection
• Understand the role of LTCF and reservoirs of
resistance; impact of resistant infections;
transmission dynamics
• Discuss the existing and upcoming challenges;
can we understand this and can we mount an
effective response ?
Demographic Imperative
Introduction
• By 2030, the population > 65 yo will 2x and
> 85 yo will 3x
• Aging and functional limitations increase
with each ensuing decade.
• More than 40% of elderly will spend at
least some time in a LTCF.
Capitano and Nicolau, JAMDA, 2003;
Strausbaugh and Joseph, 2000, ICHE
The challenge of infections in the
elderly-I
• Mean age of residents with ID
syndromes is > 80 years.
• Risk is 32.7% ; 4-10 infections per 1000
patient days; 1 infection per year (1
course of antibiotics)
• Up to 40% mortality with certain
infections admitted to hospital
The challenge of infections in the
elderly-II
• Unique living situations exist among the
elderly (socialization)
• Functional outcomes change with age and
underlying diseases
– DM
– Ca
– Frailty : Dementia, instability, falls, CVA and
swallowing, BPH and E2 depletion
Common Infections in the elderly-I
• Pneumonia
–
–
–
–
CAP-pneumococcal
NH or HCAP
aspiration
Influenza, RSV, other viruses
• UTI-catheter
• Skin and soft tissue infections
– VZV and pressure ulcers
Common Infections in the
elderly-II
• Gastrointestinnal: Intra abdominal
abscess
– Cholecystitis, diverticulitis, appendicitis,
– C. difficile colitis (a)symptomatic
•
•
•
•
Endocarditis
Meningitis not pneumococcal!!
Tuberculosis
Sepsis –the most feared! CV resiliency
“New Infections” in the
Elderly
• HIV : one in eleven cases of HIV is reported
in patients older than 50 (Ohio is 1 in 10)
• HCV ; STDs
• Surgical infections (vascular revisions)
• Travel associated infections
• WNV
CDC JAMA 1998 279 575-576
WHAT HAPPENS TO THE
IMMUNE SYSTEM WITH
ADVANCED AGE?
Immunology of Aging
• Elderly individuals are the largest group of
“immuno-compromised” patients that
physicians are asked to treat
• Immunology of aging is still poorly
understood
High KP. CID 2003 37 196-200
Immunosenescence-I
• Impairments of adaptive and innate
immunity; T and B lymphocytes?
– cellular immune responses and antibody
production
– surface expression or function of toll like
receptor (TLR1/2) that may relate to
increased risk of disease due to specific
pathogens (Listeria, Mtb, VZV) and
impaired response to ag challenge
Immunosenescence-II
 increase age, increase IL-6multifunctional cytokine- mediator of the
acute phase response
(chronic inflammation)
 decreased IL-2 and soluble IL-2 receptor
 decreased interferon g
 increased IL-4 and -1
 increased TNF
LTCFs AS
RESEVOIRS of
RESISTANCE; IMPACT
OF RESISTANT
INFECTIONS
LTCFs as “reservoirs of
resistance”-I
• Since 1975, reports identified ATBR
pathogens in LTCFs:
– MRSA , MRSE, VRE, PRP
– Mupirocin resistance
– TMP/SMX resistant GNRs
– AGR enterococci and Gram negatives
Shlaes et al; 1986 Loeb et al., American Journal of Epidemiology, 157, 2003;
Weiner et al. JAMA 1999, 281, 517-523; Terpenning et al
LTCFs as “reservoirs of
resistance”-I
– Quinolone resistant P. aeruginosa
– Amox/clav R E. coli*
– TAZ R E. coli , K. pneumoniae
• ESBLs of the TEM (TEM-12, -26), SHV
(SHV-7) varieties
• plasmid borne AmpCs
• Non TEM, non SHV ESBLs
Bonomo et al JAGS, Bonomo et al, Clin Lab Med. 2004 ,
Rice et al, AAC, 1990; Bradford 1995, AAC,
Neuhauser, JAMA, 2003, Pitout, et al, Shlaes et al,
Resistant GPCs in LTCFs
• Rates of colonization and infection range from
25-50% and 3 % of residents colonized, get
infected.
• Colonization by MRSA is often a hallmark of
significant short-term disability. In a study by
Niclaes et al., the RR of dying within 6
months was greater for MRSA carriers than
that for non-carriers
Bradley SF,. Ann Intern Med 1991; Niclase, 1999 EI
CeftazidimeR in LTCFs
• The 1st outbreak of ESBLs in the US
occurred in a LTCF in Ma. in 1990 (TEM26 and TEM-12);
• SHV-7 from E. coli UTI from LTCF in NY
• Outbreak in Cleveland (TEM-6)
• In a study of ceftazidime-resistant E. coli
and K. pneumoniae in Chicago, 31 of 35
patients from 8 nursing facilities harbored
an ESBL-producing enteric pathogen.
Rice AAC 1990, Bradford AAC 1995, Rice CID 1996, Weiner JAMA 1999
Cefotaxime-Resistant Bacteria
Colonizing Older People
Admitted to an Acute Care
Hospital
• Of the 190 surveillance cultures obtained from 143
patients, 26 cefotaxime-resistant gram-negative isolates
from 22 patients were recovered.
• The prevalence rate of cefotaxime-resistant isolates on
admission was 13.3% (19/143).
• A logistic regression model using cefotaxime
colonization as the dependent variable found that
multiple co-morbidities, admission to a surgical service,
and having a diagnosis of infection on presentation and
a transfusion history were factors associated with the
presence of colonization. These four clinical items
accurately classified 74% of patients colonized.
Bonomo 2003 JAGS
CTX GNRs Colonizing Older
People Admitted to an Acute
Care Hospital
• ATB use and NH residence were not associated
with the presence of colonization by
cefotaxime-resistant organisms.
• CONCLUSION: These data raise awareness that
there are community- and LTCF-dwelling older
patients colonized with gram-negative enteric
bacilli resistant to third-generation cephalosporins
on admission to the hospital. The "reservoir of
resistant bacteria" in older people is no
longer confined to LTCFs.
Bonomo 2003 JAGS
Spread of E. coli with high levels
of cefotaxime resistance between
community, LTCF and Hospital
institutions
• Prospective surveillance study; 151 E. coli isolates
resistant to taz and tax
• 3 hospitals, 8 LTCFs, and day care center
• Co resistance to cipro, gent, tobra, cefepime, a/c and
tmp/smx
• CTX-M-15, -14, -32; linked to ISEcp1 and IS26 elements
• Other clusters of mobile resistance genes (tetA, aac6’1b,
dfrA, sul, aac3IIb; virulence genes
• The greatest cluster of isolates were from UTIs in
elderly adults
Oteo et al, JCM, 2006
Spread of K. pneumoniae strain
producing a plasmid mediated ACC-1
AmpC beta-lactamase in a teaching
hospital admitting debilitated patients
• 57 cases acquired from a 26 yo patient with
tetraplegia with a Kp UTI bearing blaAAC-1
• PMR and other departments; 28 days to acquire
the pathogen
• First report of plasmid mediated AmpC outbreak
Ohana AAC 2005
Why AtbR pathogens are found
in the elderly LTCFs?
• Transfer of Patients from tertiary and quaternary
Care institutions; lapses in IC
• Excess use of broad spectrum antibiotics that
select for resistant strains
• Risk factors associated with recovery of resistant
strains (percutaneous endoscopic gastrostomy
feeding tubes, pressure ulcers, malnutrition,
immunosuppression [age- and medicationrelated], prior antibiotic use)
• Cycle of institutionalization and hospitalization
Bonomo CID, 2000
Hospital
***LTAC***
PM&R
LTCF
DAYCARE
Community
Culture results
not available
Diagnostic
uncertainty
Medical
devices
Hand
washing
Previou
s atb
use
?
LOS
Time to
intervention
Understaffed
Infection
control
2-4 bed
rooms
High patient to
staff ratios
Physician Rx
practices
Co-morbidities
Barrier precautions?
• Do they really work? We are learning from the
recent flu epidemic that there is significant
controversy regarding their use
• Intensity of barrier precautions, isolation or
cohorting, or environmental cleaning does not
decrease the likelihood of transmission of MRSA
or VRE.
Barrier precautions?
• Additional precautions are recommended
for patients colonized with these
microorganisms only when the patients
are a documented source of transmission
to other patients (e.g., MRSA patients with
extensive skin lesions that cannot be
covered or VRE patients with diarrhea and
incontinence)
Unresolved Questions!
• What is freq of cross transmission?
• Is there evolution from previously
susceptible organisms?
• If cross transmission, best methods to limit
horizontal spread? Targeted or
generalized surveillance ? Identify
unrecognized reservoirs?
• If evolution, antibiotic restriction policies?
Personal comment
From an analysis of this data it is clear
that atbR in LTCFs approach prevalence
rates comparable to ICU!!
Therefore, the clinical and economic
impact of infections due to MRSA and
MDR GNRs is substantial and will
present one of the greatest challenges
to the institutionalized elderly .
Critical Questions
• Should we continue to rely on empirical
antibiotic treatment in LTCF residents,
given limited diagnostic capabilities vs.
increasing antibiotic resistance (MRSA, C.
difficile, VRE)?
• How do we approach, manage and control
infectious disease outbreaks in LTCFs?
Opportunities in LTCFs
Deficiencies in ID in LTCFs
1. Transmission of
infections
(Infection Control)
2. What makes physicians
use antibiotics?
3. How much resistance is
present and what is the
origin?
4. Antibiotic (mis)use
Opportunities and challenges
1. Infection control
programs directed to
LTCFs
2. Physicians trained in ID
in LTCFS (recognition)
3. Regional programs
characterizing resistance
4. Programs to optimize
antibiotic use in LTCFs
We have implemented a new program to provide on site education and service
to geriatricians in our affiliated program to answer some of these needs
Contact
• For questions about this audio conference
please contact Dr. Robert Bonomo at
[email protected]
• For any questions about the monthly GRECC
Audio Conference Series please contact Tim
Foley at [email protected] or call (734) 222-4328
• To evaluate this conference for CE credit please
obtain a ‘Satellite Registration’ form and a
‘Faculty Evaluation’ form from the Satellite
Coordinator at you facility. The forms must be
mailed to EES within 2 weeks of the broadcast