CASE STUDIES FOR HALT-2

1. LECTURE 4 CASE STUDIES FOR HALT-2

2. LECTURE OBJECTIVES • To use case scenarios to aid completion of HALT resident questionnaire and understanding of HALT definitions.

3. RESIDENT: O. Ophelia • O. Ophelia, 76-year old female resident. • Full time resident in the long-term care facility for 10 years. • Present at 8am on the survey day. • Can walk alone without assistance.

4. RESIDENT: O. Ophelia • She has not been admitted to hospital in the last 1 year. • She has no urinary catheter/no vascular catheter/ no pressure sores / no wounds. • She is fully orientated and continent. • She is on no medication on the day of the survey.

5. RESIDENT: O. Ophelia • She has had watery stools for the past three days. In the last day she had four episodes of watery stools. • She has no vomiting or blood/mucous and her temperature is within the normal range. • She has no past history of diarrhea.

6. RESIDENT: O. Ophelia • She had been prescribed levofloxacin by her GP for a chest infection two weeks previous. • On the survey day (8th May 2012) the culture results and C. difficile toxin test on a stool sample are not available.

7. RESIDENT: O. Ophelia - Questions • Must a resident questionnaire be completed for O. Ophelia? • If so - Is she on antimicrobials? - Is she presenting with signs and symptoms of infection? - If she is presenting with signs and symptoms what infection do you suspect is present? - How do you decide if a true infection is present or not?

8. RESIDENT: O. Ophelia – Answers Q: Must a resident questionnaire be completed for O. Ophelia and why? A: Yes, she is showing signs/symptoms of an infection

9. RESIDENT: O. Ophelia - Answers Q: How are O. Ophelia’s general data and risk factors recorded in the resident questionnaire?

10. RESIDENT: O. Ophelia - Answers Q: Which of the following boxes should be ticked on the resident questionnaire for O. Ophelia? X

11. RESIDENT: O. Ophelia - Answers A: Gastrointestinal infection Q: What infection do you suspect O. Ophelia has?

12. RESIDENT: O. Ophelia - Answers Q: How would you complete the signs and symptoms of infection section of the resident questionnaire for O. Ophelia? A:

13. TEACHING POINT Q: What is an eligible resident? A: Residents are eligible if they are: • living full-time (24/24h) in the LTCF AND • present at 8 AM on the day of the PPS AND • at least present in the LTCF since 24h (the medical history of new residents is often not fully known or important data could be missing at the time of the admission)

14. TEACHING POINT Q: O. Ophelia has gastroenteritis. How would a C. difficile infection be confirmed in this resident? A: If a stool sample is found to be positive for C. difficiletoxin A or B, or positive C. difficile culture or positive C. difficilePCR and/or If pseudomembranous colitis found at endoscopy, surgery or biopsy

15. RESIDENT: R. Rosalind • R. Rosalind, 91-year old female, has been living in the residential care setting full time for less than a year. • She is present at 8am on the survey day. • She is very debilitated, doubly incontinent, bedridden and disorientated. • She has a sacral pressure sore. • She has no urinary catheter/no vascular catheter/ no wounds. • Her last hospital admission was eight months ago.

16. RESIDENT: R. Rosalind • On the day of the survey (8th May 2012) she has lower leg oedema of her right leg which is hot to touch, red and tender. • The previous day, 7th May 2012, R. Rosalind’s GP had prescribed fucidic acid cream for twice daily application for seven days.

17. RESIDENT: R. Rosalind - Q & A A: Yes, she is showing signs/symptoms of infection. Q: Must a resident questionnaire be completed for R. Rosalind and why?

18. RESIDENT: R. Rosalind - Q & A Q: Why was the “BOTH” option not ticked if R. Rosalind has been prescribed fucidic acid cream? A: TOPICAL antimicrobial agents are recorded in the infection part of the resident questionnaire only (see later).

19. RESIDENT: R. Rosalind - Q & A A: Skin/ Soft Tissue infection. Q: What infection do you suspect R. Rosalind has?

20. RESIDENT: R. Rosalind - Q & A Q: How would you complete the signs and symptoms of infection section of the resident questionnaire for R. Rosalind? A:

21. TEACHING POINT Q: How is topical administration of antimicrobial ointment recorded in the resident questionnaire? A: Local use of antimicrobials for cellulitis/ soft tissue/ wound infections and conjunctivitis can be reported by checking a tick box in the signs and symptoms section of the resident questionnaire. This information is NOT entered in the antimicrobial treatment data section of questionnaire.

22. RESIDENT: G. Gertrude • G. Gertrude, 89-year old female has been living full time in the LTCF for over a year. • She is in her bed at 8am on the survey day. • She is generally well with no hospital admissions since she has been in the LTCF. • She requires a wheelchair. • She has no urinary catheter/no vascular catheter/ no pressure sores / no wounds. • She is fully orientated and continent.

23. RESIDENT: G. Gertrude • Three days ago she complained of pain on urination. She was otherwise well and had no temperature. • Her in-house GP started her on oral ciprofloxacin 250mg twice daily (BD) for five days. • Dipstick test on urine showed positive result for nitrites and Ieucocytes. • A mid-stream urine sample (MSU) was sent to laboratory for culture and sensitivities three days previously. • On day of the survey (8th May 2012), G. Gertrude is feeling much better. The MSU results showed >105cfu/ml E. coli, which were cefotaxime resistant and meropenem susceptible.

24. RESIDENT: G. Gertrude – Q & A A: Yes, she an eligible resident and she is showing signs/symptoms of infection and is receiving antimicrobial treatment. Q: Must a resident questionnaire be completed for G. Gertrude and why?

25. RESIDENT: G. Gertrude – Q & A

26. RESIDENT: G. Gertrude – Q & A Q: How would you complete the antimicrobial treatment data section of the resident questionnaire for G. Gertrude?

27. Microorganism code for E. coli (see microorganism code list) RESIDENT: G. Gertrude – Q & A Antimicrobial resistance markers and codes (see protocol)

28. RESIDENT: G. Gertrude – Q & A A: Urinary tract infection Q: What infection do you suspect G. Gertrude has?

29. RESIDENT: G. Gertrude – Q & A Q: How would you complete the signs and symptoms of infection section of the resident questionnaire for G. Gertrude? A: As she does not have a urinary catheter in situ the algorithm for urinary tract infection without a catheter should be completed as follows:

30. RESIDENT: G. Gertrude – Q & A

31. TEACHING POINTS Q: If a resident is suspected of having a urinary tract infection, what steps should you take to determine whether it is present or not? A: - Establish if the resident has a urinary catheter or not; the signs and symptoms criteria differ for each. - Check resident’s notes for information on mid-stream urine (MSU) or catheter sample collection and culture/ susceptibilities results of same.

32. TEACHING POINTS Q: If the microorganisms highlighted in red in the microorganism code list, e.g. E. coli, Acinetobacter baumannii etc., are isolated from a sample taken for culture, how are their susceptibilities recorded in the resident questionnaire? A: 0, 1, 2 or ? as below

33. RESIDENT: R. Romeo • R. Romeo, 75-year old male has been a full time resident in the LTCF for two years. • He is present at 8am on the survey day. • He has general poor health, disorientated, bedridden, and incontinent (urinary). • He has no urinary catheter/no vascular catheter/ no pressure sores / no wounds. • He was admitted to hospital electively 30 days ago for a prostatectomy.

34. RESIDENT: R. Romeo • On day of the survey (8th May 2012) his medical notes indicate that he had passed blood in his urine in the last 24 hours and his temperature is 37.9oC. • The prescribing nurse has prescribed oral trimethoprim 200mg twice daily (BD) for three days. • Laboratory results on the mid-stream urine sample were not available. • A urine dipstick test had not been carried out.

35. RESIDENT: R. Romeo • Complete a resident questionnaire for R. Romeo.

36. RESIDENT: R. Romeo

37. RESIDENT: R. Romeo

38. RESIDENT: R. Romeo For codes see later slides

39. RESIDENT: R. Romeo

40. TEACHING POINTS Q: This case was deemed to be a probable urinary tract infection (for a resident without a urinary catheter). What other information would have led to a confirmed infection outcome? A: Culture result. If the result of the mid-stream urine specimen is as follows, then a urinary tract infection can be confirmed: At least 105cfu/ml of no more than 2 species of micro- organisms in a voided urine sample • OR • At least 102cfu/ml of any number of organisms in a specimen collected by in-and-out catheter

41. TEACHING POINTS Q: If a sample is taken for culture and susceptibilities to guide antimicrobial treatment how are the culture results recorded in the resident questionnaire? A: The three most important isolated microorganisms should be indicated using the microorganism code list or one of the following options should be selected: _NOEXA EXAMINATION NOT (YET) DONE _NA RESULTS NOT AVAILABLE _NONID MICROORGANISM NOT IDENTIFIED _STERI STERILE EXAMINATION e.g.

42. TEACHING POINTS _NOEXA EXAMINATION NOT DONE: no diagnostic sample taken, no microbiological examination done _NA RESULTS NOT AVAILABLE: the results of the microbiological examination are not yet available or cannot be found _NONIDMICROORGANISM NOT IDENTIFIED: evidence exists that a microbiological examination has been done, but the micro-organism cannot be correctly classified _STERI STERILE EXAMINATION: a microbiological examination has been done, but the result was negative (e.g. negative culture)

43. RESIDENT: J. Juliet • J. Juliet, 80-year old female who has been living full time in the LTCF for two years after being unable to live on her own due to the onset of dementia. • She had a stroke 20 years ago but made a full recovery with no lasting affects. • She is present at 8am on the survey day. • She is on medication for the dementia and is also on medication to prevent strokes. • She also has high blood pressure (which she is on medication for) and a mobility problem (due to a hip replacement two years ago) for which she has a walking aid. • She has a history of recurrent urinary tract infection.

44. RESIDENT: J. Juliet • She has no urinary catheter/no vascular catheter/ no pressure sores / no wounds. • She is disorientated due to her dementia, but fully continent. • She has had no hospital admissions in previous 6 months. • Her medication regime, as prescribed by her geriatrician in his clinic, is as follows: bendroflumethiazide2.5 mg once daily (morning), donepezil hydrochloride 10 mg once daily, oral trimethoprim 100 mg once daily. • On the day of the survey (8th May 2012) staff have not noticed any changes in her condition for at least the last two weeks. • She has no dysuria, no fever, no leukocytosis and no new or increased frequency, urgency, hematuria, or suprapubic pain.

45. RESIDENT: J. Juliet • Complete a resident questionnaire for J. Juliet.

46. RESIDENT: J. Juliet

47. RESIDENT: J. Juliet

48. TEACHING POINT Q: This patient is receiving antimicrobial treatment for a UTI but this is not due to current or resolved signs and symptoms. Why then is she receiving antimicrobials? A: Antimicrobial prophylaxis for the prevention of recurrent urinary tract infection.

49. RESIDENT: R. Rosencrantz • R. Rosencrantz, 62-year old male with early onset dementia living full time in the LTCF for the last five years. • He is in his bed at 8am on the survey day. • He is physically well but disoriented to the reality of the world around him. • He has no idea of staff names, current affairs, the country he lives in or the day/month/year he is living in. • However, he can find his way unattended to the dining room for meals, and knows which drawer in the nurses office cigarettes are stored in.

50. RESIDENT: R. Rosencrantz • He has had no hospital admissions since arriving in the LTCF. • Over the last two days he has been urinating more often. • He has no urinary catheter/no vascular catheter/ no pressure sores / no woundsand is fully continent. • His temperature was taken on the morning of the survey (8th May 2012) and was recorded as 37.6oC. • No urine sample has been sent for laboratory analysis nor has a dipstick test been carried out.