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Over-prescribing of antibiotics has become a signifi-
cant problem in nursing homes. A urinary tract in-
fection (UTI) is the most common indication for the
prescribing of antibiotics in long-term care (LTC) set-
tings, and it is the condition most commonly associ-
ated with inappropriate antibiotic use. True cases
of UTI undoubtedly occur with some frequency in
nursing homes, but
there is compelling evi-
dence that UTI’s are
both over-diagnosed
and over-treated in this
setting.
The rise in antibiotic
resistance in LTC facili-
ties threatens to create
what the WHO (World
Health Organization)
has called the post-
antibiotic era, a poten-
tial future in which ex-
isting antimicrobial
therapies fail to treat
common, previously
treatable infections.
Recently, the Centers for Medicare
and Medicaid Services (CMS) have
cited an increasing number of
nursing homes for inappropriate
antibiotic use per the Unnecessary
Drug Surveyor Guidelines (F-Tag
329). Antimicrobial stewardship
is becoming an increasingly im-
portant focus in long-term care
settings. The Notice of Proposed
Rulemaking, Medicare and Medi-
caid Programs: Reform of Require-
ments for Long-Term Care Facili-
ties proposes that facilities must
establish an infection prevention
and control program, which must
include, (among other elements), an antibiotic stew-
ardship program with antibiotic use protocols and a
system to monitor antibiotic use.
By definition, symptomatic UTI requires the pres-
ence of symptoms along with significant bacteriuria.
The symtoms of UTI in community-dwelling older
adults are well defined and include urethritis
(dysuria and hematu-
ria), cystitis (urethritis
with urgency, frequen-
cy, and suprapubic
pain), and pyelonephri-
tis (flank pain, fevers,
and nausea/emesis that
may or may not be pre-
ceded by urethritis/
cystitis).
Currently,
there is no agreement
on an evidenced-based
definition for the symp-
toms of UTI in LTC resi-
dents, but it is impera-
tive to distinguish
symptomatic UTI from
asymptomatic bacteriu-
ria in this population.
Treatment of asymptomatic bacteriuria increases the
rate of adverse drug effects from the use of antimi-
crobial medicines; increases the rate of recurrent
infections with MDR (multiple drug resistant) bacte-
ria; and does not change survival, chronic genitouri-
nary symptoms, or the rate of symptomatic UTI. As a
result, the Infectious Diseases Society of America
(IDSA) does not recommend treatment of asympto-
matic bacteriuria.
The Loeb Criteria are commonly used by clinicians
for making treatment decisions for a suspected UTI
in the long term care setting. These criteria were
written based on evidence from randomized con-
trolled trials, observational studies, and qualitative
studies.
UTI’s in Long Term Care
A Publication of Neil Medical Group, The Leading Pharmacy Provider in the Southeast
July/August 2017
PHARM NOTES
Inside this issue:
UTI’s in Long
Term Care
1
Post Herpetic
Neuralgia
2
Sleep Aid
Alternatives
3
UTI’s in LTC:
conclusion
4-5
Clostridium Dif-
ficile: An Over-
view
6-7
Neil Medical
Group Contact
Information
8
continued on page 4
Volume 20, Issue 4
Post-Herpetic Neuralgia
Page 2
PHARM NOTES
Introduction
Postherpetic neuralgia is the most common chronic complica-
tion of herpes zoster,
also known as shin-
gles. Herpes zoster is
a viral infection caused
by reactivation of the
varicella-zoster virus,
which lies dormant in
sensory nerves after
initial infection, usual-
ly presenting as chick-
enpox in childhood.
The acute phase of
shingles usually begins
with prodromal symp-
toms, including ma-
laise, tingling or abnormal skin sensations, photophobia, and
fever, which may last 1-5 days. After the prodromal phase, a
painful, vesicular rash, develops, typically presenting at the
midline and may spread to the back and face, which crusts
over and heals over 2-4 weeks. Postherpetic neuralgia is pain
that occurs after a shingles outbreak and is due to destruction
of nerves extending from the spinal cord to the skin after the
varicella-zoster virus replicates in the basal ganglia. The dura-
tion of the pain varies greatly among patients, lasting any-
where from a few months to lifelong, but most cases resolve
spontaneously. It can cause extreme suffering and significant-
ly affect a patient's quality of life, as well as increase individu-
al and societal healthcare costs.
Epidemiology
The incidence of herpes zoster ranges from 3.4 -11 cases per
1000 patients, about 1 million cases per year in the U.S.
Postherpetic neuralgia pain has been reported in approximately
one-fifth of those patients three months after onset of symp-
toms and about 15% of patients report pain after two years.
Postherpetic neuralgia may affect up to 40% of patients over
age 50 and 75% of patients over age 75.
Risk Factors
Increased age, especially over age 50
More women are affected than men (60% of women vs.
40% of men)
Severity of prodromal symptoms, pain, and rash during
acute shingles phase
Ophthalmic involvement of herpes zoster
Patients with chronic illness (i.e. diabetes, COPD)
Immunocompromised patients (i.e. patients with HIV, or-
gan transplants)
Use of immunosuppressive medications (i.e. cyclosporine,
mycophenolate, azathioprine)
Signs and Symptoms Pain that may be chronic or paroxysmal
Pain that may be described as burning, stabbing, itching,
or electric shock-like
Types of pain
Dysesthesia: abnormal sensation that occurs with-
out a stimulus
Allodynia: pain that occurs without a non painful
stimulus
Hyperpathia: severe pain that occurs with a slight-
ly painful stimulus
Numbness or loss of sensory function to thermal and me-
chanical stimuli
Diagnosis
Postherpetic neuralgia is diagnosed after performing an exam
with history. It is defined as dermatomal pain persisting for at
least 90 days after the onset of the herpes zoster rash.
Treatment
Tricyclic antidepressants
Amitriptyline, nortriptyline, desipramine
Good evidence for efficacy, but many adverse ef-
fects
Capsaicin 0.075% or capsaicin 8% patch
May cause burning, stinging, and redness
May take up to 4 weeks for pain relief
Higher concentration patches have shown better
efficacy than cream
Good option for mild pain
Lidocaine 5% patches
Some evidence for efficacy
Good option for mild pain
Anticonvulsants
Gabapentin, pregabalin
Off-label use, some evidence for efficacy
May also improve sleep, which is often an issue
Opioid analgesics
Oxycodone, morphine sulfate, tramadol
Controversy over efficacy; adverse effects in-
creased in elderly patients
Should be considered as 3rd line option or in com-
bination with topical agents
Patients receiving treatment for postherpetic neuralgia should
be educated that pain relief may not be immediate and can take
weeks for benefits to be seen. Patients should also be in-
formed that several therapies may need to be tried before find-
ing an agent that works for them.
Prevention
The herpes zoster vaccination (Zostavax) has been shown
to significantly reduce the prevalence of herpes zoster and
therefore postherpetic neuralgia. Postherpetic neuralgia may
also be prevented with the use of antivirals, such as acyclovir,
valacyclovir, and famciclovir, and corticosteroids within 72
hours of initial onset of herpes zoster attack. Initiation of
amitriptyline after initial onset may reduce incidence of pain,
but more studies are needed to evaluate its role in preventing
postherpetic neuralgia. Article by Tami Harty, PharmD Candidate Wingate University School of Pharmacy
Page 3
Volume 20, Issue 4
There are several Popular Supplemental and Non-Pharmacologic Options for Sleep in the Elderly. Below is a sum-
mary of several options and the evidence supporting their use.
MELATONIN
Endogenous hormone involved in regulation of circadian rhythm
Levels may be decreased with benzodiazepine use and advanced age.
Sustained release 2-3mg preparations seem to increase sleep quality and sleep
Immediate release formulations (also 2-3mg) seem to decrease sleep latency.
Generally well tolerated, but reported adverse effects include daytime drowsiness, dizziness, and nausea.
CHAMOMILE TEA
Volatile oils in chamomile are thought to have activity in the central nervous system
Evidence that chamomile is effective for sleep is lacking/unavailable.
Chamomile tea is generally recognized as safe for consumption by the FDA.
May cause allergic reaction in patients who are allergic to ragweed.
AROMATHERAPY
Preliminary research suggests lavender oil may be helpful in patients with mild insomnia.
A more cost-effective method of providing aromatherapy is gauze soaked in lavender left at the bedside for up to 5 nights.
MUSIC THERAPY
Preliminary research suggests listening to classical and New Age music before bed improves sleep quality in elderly patients.
MAGNESIUM
Essential for ATPase activity. Intrinsic calcium channel blocker and NMDA antagonist.
Evidence that oral or topical magnesium helps with sleep is lacking/unavailable.
Oral magnesium may cause diarrhea, nausea, and GI irritation. 5-HTP
Endogenous precursor of serotonin produced from L-tryptophan.
Only animal studies and case reports exist suggesting efficacy in sleep disorders.
May cause drowsiness, dizziness, nausea, or epigastric pain.
Avoid with SSRIs and other serotonergic agents due to overlapping mechanism of action.
No standard doses studied for insomnia, but 50-200mg doses are commonly available.
VALERIAN ROOT
Extract from perennial flower root brewed historically as tea to help with insomnia.
Suggested mechanisms of action include GABA transaminase inhibition and adenosine-like activity.
Systematic reviews have found mixed efficacy in improving sleep quality.
Few reported adverse effects.
Studied doses for insomnia range from 450 to 900mg.
Sleep Aid Alternatives for the Elderly
Article by Phillip R. Transou PharmD Candidate
Page 4
UTI’s in Long Term Care………………………...Continued from page 1
PHARM NOTES
2005 Loeb Diagnostic Minimum Criteria for Order-
ing a Urine Culture
Fever > 100 degrees F and 1 (ONE) or more of the fol-
lowing:
Dysuria
Urgency
Flank Pain
Shaking Chills
Urinary Incontinence
Frequency
Gross Hematuria
Suprapubic pain
OR
If no fever, order urine culture if there is new onset
burning on urination or 2 (TWO) or more of the fol-
lowing:
Urgency
Flank pain
Shaking, chills
Urinary Incontinence
Frequency
Gross Hematuria
Suprapubic pain
OR
If fever > 100 degrees F, but 2 or more symptoms of
NON-UTI infection exist, DO NOT ORDER A URINE
CULTURE
2005 Loeb Minimal Criteria for initiating Antimi-
crobials:
Positive Urine Culture (> 100,000 CFU/ml) AND dysu-
ria
OR
Positive Urine Culture (>100,000CFU/ml) and 2 (TWO)
or more of the following:
Fever
Urgency
Flank Pan
Urinary Incontinence
Shaking Chills
Frequency
Gross hematuria
Suprapubic pain
Asymptomatic bacteriuria is defined as the presence
of bacteria in urine on microscopy or quantitative
culture in a specimen obtained from a patient who
does not have typical symptoms of a urinary tract
infection. It is widely recognized that asymptomat-
ic bacteriuria should not be treated with antibiotics
in the elderly population. Treating asymptomatic
bacteriuria does not reduce mortality and can cause
harm. Guidelines suggest that for every three people
treated with antibiotics, one will experience harm.
Evidence also suggests that treating asymptomatic
bacteriuria in nursing home patients who have chron-
ic stable incontinence does not improve incontinence
in the short-term.
Unnecessary antimicrobial therapy poses serious
threats. Antibiotic use is one of the largest risk fac-
tors for having an adverse drug event, many of which
may be preventable. In a study of 2 Rhode Island
nursing homes, inappropriate antibiotic prescribing
for asymptomatic bacteriuria was associated with a
12% incidence of Clostridium difficile colitis within 3
weeks, and an 8-fold increased risk of Clostridium
difficile colitis within 3 months of treatment.
Urine testing
should only
be performed
when there is
a reasonable
likelihood the
resident may
have a UTI, as
judged by
meeting at
least minimal
criteria for
initiating an-
tibiotics.
Some clini-
cians will give
orders to re-
test the urine
after comple-
tion of the
course of an-
tibiotics.
Current
guidelines
from the Infectious Disease Society of America
strongly recommend AGAINST testing of asympto-
matic residents and this is a core message of the
AMDA and American Geriatric Society’s (AGS) Choos-
ing Wisely Campaigns. Repeat urine testing in resi-
dents with no symptoms is never indicated and
should not be performed.
So what about treating a resident who is experiencing
a change in condition involving confusion or anxiety
and is deemed by staff “just not acting like herself/
himself”? When contacted, the prescriber (MD, FNP,
PA) is generally expected to take some tangible ac-
tion. The above symptoms could easily be due to de-
hydration, a new medication, depression with re-
Page 5
Volume 20, Issue 4
duced oral intake, or any number of other conditions.
Many clinicians now consider “watchful waiting” as an
intervention to reduce antimicrobial prescribing and
have initiated observation protocols that include moni-
toring vital signs, attention to hydration status, repeat-
ed physical assessments by nursing home staff, and
prompt communication of any changes in condition.
Informing residents and family members about obser-
vation protocols can also be reassuring. (see example
below)
Obtain vital signs (BP, Pulse, Resp Rate,
Temp, Pulse Ox) every _____hrs for
________days
Record Fluid intake each shift for
____________ days
Increase fluid intake: 120ml of juice or wa-
ter every 2hrs x 72 hours
Increase hygiene measures: cleanse anogeni-
tal area with soap and water after each in-
continence episode or toileting
Schedule toileting/diaper check or diaper
change every 2 hours
Monitor complaints of dysuria, urinary fre-
quency, or flank pain and report to charge
nurse
Assess for bladder pain and retention
Obtain the following blood
work____________________________________
Consult pharmacist to review medication
regimen
Notify MD/NP/PA if condition worsens, or if
no improvement in _________ hours
Contact MD/NP/PA with an update on resi-
dent’s condition on_______________________
Under Federal nursing home guidelines, all nursing
facilities must have an infection control program that
“investigates, controls, and prevents infections in the
facility”. It is expected that the medical director be
actively involved in oversight of this program, and
that the facility communicates information about in-
fection control to the attending physicians. Since UTI
is the most commonly diagnosed infection in LTC set-
tings, and since the prevalence of UTI’s is one of the
publically reported nursing facility quality measures,
facilities have a strong incentive to ensure they track
and manage UTI’s appropriately.
UTI management should be considered as a quality as-
surance and performance improvement (QAPI) initia-
tive by all LTC facilities. Appropriate QAPI targets are
those that are prevalent, pose significant safety and
liability risks, are associated with higher costs, and
have the potential to significantly impact resident
quality of life. The medical director might review resi-
dents being frequently treated for UTI, collaborate
with practitioners and nursing staff to establish mini-
mum criteria for ordering urine diagnostics, communi-
cate findings from the facility’s urinary antibiogram
with clinicians, or promote the use of decision support
tools such as a standardized communication form for
reporting changes in a resident condition (such as Situ-
ation, Background, Assessment, Response – SBAR
forms). The infection control program should track
the incidence of UTI’s within a facility using a stand-
ardized definition, such as that described by the Loeb
criteria. The facility should also track the rate of anti-
microbial starts when minimal criteria for antimicrobi-
al therapy are not met. This information should be
shared with the medical director and performance
feedback could be provided to individual clinicians.
The medical director should also work with the infec-
tion control program to establish continuous training
for staff regarding symptoms of UTI’s and criteria that
should be met before consideration is given to urinary
testing.
Resident and family education are also important.
AMDA’s and the American Geriatrics Society’s Choos-
ing Well Campaigns are tools that can be used to edu-
cate residents, families, as well as staff and physi-
cians. Another educational tool specifically designed
for LTC is the recently developed Agency for
Healthcare Research and Quality pamphlet, Not All In-
fections Need Antibiotics .
Practitioners must rely on consensus-based criteria for
the diagnosis of UTI. Identifying signs and symptoms
localized to the urinary tract is an important factor
to avoiding over-treatment of asymptomatic bacteriu-
ria. For patients with significant advanced cognitive
impairment who cannot reliably report symptoms, the
presence of fever, leukocytosis, or hemodynamic in-
stability alone may be adequate to justify initiation of
antimicrobial therapy. However, the use of other non-
specific symptoms such as fatigue or mental status
changes alone in diagnosing or treating UTI is not rec-
ommended.
Over-reliance on urinary tests such as urinalysis and
urine cultures leads to unnecessary treatment of
asymptomatic bacteriuria, as well as adverse drug
events, Clostridium difficile infection, and antimicro-
bial resistance. There is no role for ordering urine
tests in asymptomatic residents as tests of cure. Ob-
servation and monitoring of residents for whom the
diagnosis of UTI is unclear is a best practice that al-
lows for further data gathering, can provide reassur-
ance to residents and family members, may optimize
antimicrobial therapy, and minimizes the chance of
misdiagnosis. Facilities should consider addressing
UTI management as part of their QAPI process.
Article by Rhonda Gentry, RPh, BCGP Neil Medical Group
Clostridium Difficile: An Overview
Page 6
PHARM NOTES
Clostridium difficile (C. diff) is a spore-forming bacte-
ria that is usually spread by the fecal-oral route. The
bacterium produces two toxins that can cause mild
to severe diarrhea, colitis or pseudomembranous co-
litis. C. diff was estimated to cause almost half a mil-
lion infections in the United States in 2011, and
29,000 died within 30 days of the initial diagnosis.
C. diff has become the most common cause of
healthcare–associated infections in U.S. hospitals,
and the excess healthcare costs related to C. diff
infection are estimated to be as much as $4.8 billion
for acute care facilities alone. Some people are
asymptomatic carriers of either a toxigenic or
nontoxigenic strain of the Clostridium difficile bac-
terium. Among the elderly, carriage rates may be
higher, especially in those in long term care facili-
ties (LTCFs). In one study of an epidemic in a LTCF,
51% of asymptomatic carriers had toxigenic C. dif-
ficile indicating that LTCFs may be a reservoir for
cases of C. diff infections.
The two biggest risk factors for developing Clostrid-
ium difficile infection (CDI) are exposure to antibi-
otics and exposure to the organism, usually through
admission to a health-care facility. Receipt of anti-
microbials increases the risk of CDI because it sup-
presses the normal intestinal flora, thereby provid-
ing a suitable environment for C. diff to flourish. All
antibiotics can cause CDI, but those that carry the
most risk are clindamycin, cephalosporins, and fluo-
roquinolones. Being on multiple antibiotics and long-
er duration of antibiotic therapy also increases the
risk of CDI. Other risk factors in-
clude older age, gastrointestinal
surgery or manipulation, nasogas-
tric tube feeding, reduced gastric
acid (through the use of proton
pump inhibitors), receiving chemo-
therapy, serious underlying disease
and long length of stay in
healthcare settings.
Symptoms indicative of CDI include
watery diarrhea (at least three bow-
el movements per day for two or
more days), fever, abdominal pain,
nausea, and loss of appetite. A diag-
nosis of CDI is made by the pres-
ence of symptoms (usually diar-
rhea) and either a stool test positive
for C. diff toxins, or colonoscopic
findings revealing pseudomembranous colitis. Since
C. difficile carriage is common, especially in patients
on antimicrobial therapy, only unformed stools
should be tested, unless the patient has an ileus. A
Page 7
positive result in a patient without diarrhea is likely
not clinically significant and may complicate care.
When collecting stool sample for testing, it is im-
portant to note that Clostridium difficile toxin is very
unstable. The toxin degrades at room temperature and
may be undetectable within 2 hours after collection of
a stool specimen. A False-negative test results occurs
when specimens are not promptly tested or kept re-
frigerated until tested. Treatment for CDI should be
initiated promptly to prevent complications
such as toxic megacolon, perforations of the co-
lon, sepsis, or even death.
CDI treatment is based on the severity of
presentation. Clinical presentation of CDI can be
mild, moderate, severe, or complicated depend-
ing on factors such as serum creatinine level,
white blood cell count, and blood pressure. Met-
ronidazole, although not FDA approved for the
treatment of CDI is used for mild to moderate
disease. Severe and complicated CDI are treated
with oral vancomycin. Intravenous vancomycin
does not have a place in CDI treatment as it is
systemically absorbed without significant con-
centration at the site of infection. Fidaxomicin
was approved in 2011 for CDI treatment but its
place in therapy is not clearly defined. A problem with
antibiotics used to treat CDI is that the infection re-
turns in about 20 percent of patients. During the first
recurrence, the treatment used to manage the initial
CDI episode is the recommended treatment. Tapered
oral vancomycin or fidaxomicin is recommended for a
second recurrence of CDI. Fecal microbiota transplant
(transplanting stool from a healthy person to the co-
lon of a patient) may be considered after 3 recurrenc-
es. There is limited evidence for the use of adjunct
probiotics for treatment or to decrease recurrenc-
es in patients with recurrent C. difficile. Whenever
there is a confirmed case of CDI, all unnecessary
or inciting antibiotics should be discontinued. Lax-
atives, stool softeners, anti-motility agents, and
proton pump inhibitors without a true indication
should all be discontinued.
Since the C. diff is spore-forming, it can live a long
time on surfaces such as toilet seats, telephones,
and doorknobs. Cleaning and disinfecting surfaces
and reusable devices can help curtail the spread of
the bacteria. Standard EPA-registered hospital dis-
infectants are not effective against C. diff spores
except EPA-registered disinfectants with a spor-
icidal claim. In patients with known or suspected
CDI, contact precautions should be initiated. Patients
should be placed in private rooms if available, or with
other infected patients. Gown and gloves should be
worn when entering the rooms of patients with CDI.
Good hand hygiene should be performed after remov-
ing the gloves. Alcohol does not kill C. diff spores, so
washing hands with soap and water (for at least 15
seconds with vigorous friction) is more efficacious
than alcohol-based hand rubs. Each institution should
have strategies for prevention, policies for rapid de-
tection, and guidelines for the management of Clos-
tridium difficile infection.
Volume 20, Issue 4
Article by Kwasi Adu Nyarko, PharmD Candidate Wingate University School of Pharmacy
PHARM NOTES
Kinston Pharmacy
2545 Jetport Road
Kinston, NC 28504
Phone 800 735-9111
Louisville Pharmacy
13040 East Gate Parkway
Suite 105
Louisville, KY 40223
Phone 866-601-2982
Mooresville Pharmacy
947 N. Main Street
Mooresville, NC 28115
Phone 800 578-6506
To all the Pharm Notes Family,
More than a statistic…….My son-in law’s father, Ken Matthews, died five days after Easter. He was
too young…..65 years old. He was a father, a grandfather, a brother, a husband, an uncle and a
son. He was also my friend.
Ken was a veteran, so I’m sure when he started feeling poorly on that Saturday, and the closest VA
Hospital…..not so accessible at 90 minutes away….he opted to wait and call them the first thing
Monday morning. Josh found his Dad late Easter afternoon in such a weakened state, that he
called 911 and had him immediately transported to Cone Hospital. He was diagnosed quickly and
treatment was started. Sepsis.
That’s where the statistics come in. Recent studies have shown that once you are in septic shock,
initiating antibiotics quickly is crucial. If treatment starts within the first hour, there is an almost
80% chance of survival…...but if treatment is delayed by six hours,
the survival rate drops to 40% and continues to drop dramatically
with each passing hour. Ken’s multi-organ failure indicated it was
likely “too late” when he arrived at the hospital.
As health care providers, we rely so heavily on statistics and data.
That, in itself, is no comfort when it involves a loved one. Ken,
you’ll definitely be missed.
You were more than a statistic to us.
Till next time……..
Cathy Fuquay
Pharm Notes Editor
Pharm Notes is a bimonthly publication by Neil
Medical Group Pharmacy Services Division.
Articles from all health care disciplines pertinent
to long-term care are welcome. References for
articles in Pharm Notes are available upon request.
Your comments and suggestions are appreciated.
Contact: Cathy Fuquay ([email protected])
1-800-735-9111 Ext 23489
...a note from the Editor
Thank you for allowing Neil Medical Group to partner with
you in the care of your residents!