Infections And Antibiotic Overuse In Long
Approximately 15,000 LTC facilities in the United States provide care to an estimated 1.7 million people.4 They serve patients whose often complex medical needs leave them susceptible to illnesses that can lead to death, and to higher health care costs.5 Infection rates among LTC residents nationwide are estimated to be as high as 12 percent, with pneumonia and urinary tract infections being the most common.6
A 2003 study conducted in the U.S. and Canada showed that nearly 80 percent of LTC residents received at least one course of antibiotics over a 12-month period.7 Moreover, the study found that antibiotics are frequently prescribed in the absence of appropriate diagnostic exams.8 Such extensive use of antibiotics, exacerbated by high rates of infections, can lead to the emergence of antibiotic-resistant infections in LTC facilities.9 Antibiotic overuse can also increase the risk of adverse events such as allergic reactions, as well as Clostridium difficile infection, a potentially lethal diarrheal illness that is a growing threat in LTC facilities.10
LTC facilities can safeguard patients from the harms associated with unnecessary antibiotic useand slow the growth of antibiotic resistanceby implementing some or all of the elements of a stewardship program.
Inventory Of Tools And Guidance
Regarding the questionnaire survey of international experts, we obtained a 57.4% response rate, with 31/54 experts from 21 middle-to-high-income countries replying to our survey.
Our internet search focused on the 10 websites of leading international organizations, professional societies and non-governmental organizations described in the Methods section and led to 14 additional websites being explored .
A total of 156 tools freely available on the internet were found from the website search and the questionnaire survey, with six additional tools extracted from the literature review . They were all created between 2008 and 2019, with more than half of them being created in the last 3years. The vast majority of resources were found on national or regional agencies from the USA, with some resources coming from Canada, Australia, the UK and France.
Further details on the identified tools can be found in Table S3.
Core Elements Of Antibiotic Stewardship For Nursing Homes
Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Centers for Disease Control and Prevention recommends that all nursing homes take steps to improve antibiotic prescribing practices and outlined practical ways to initiate or expand antibiotic stewardship activities in nursing homes.
See: Core Elements of Antibiotic Stewardship for Nursing Homes
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Antimicrobial Stewardship In Long Term Care
Antimicrobial stewardship in long term care facilities involves setting commitments and actions to optimize antibiotic therapy while minimizing the emergence of antibiotic resistance and other adverse effects.
Studies have shown that 40-75% of the antibiotic courses prescribed in long term care facilities are unnecessary or inappropriate, leading to significant risks from antibiotic overuse. Any actions taken to improve antibiotic use promotes better outcomes for residents in long term care settings.
An antimicrobial stewardship program is an effective strategy for limiting the excessive use of antibiotics. Establishing an ASP requires the implementation of infection prevention and control guidelines, education and awareness of antimicrobial use regulations and collection of surveillance data to provide feedback.
NCCID links to materials produced by various organizations to promote antimicrobial stewardship in long term care facilities. These materials include steps for implementing antimicrobial stewardship programs and evidence based guidelines for clinical assessments and treatment.
AMS Programs in LTC facilities
The following links have useful information on implementing and sustaining antimicrobial stewardship programs in long term care facilities:
Stewardship Training Program Reduces Antibiotic Use In Nursing Homes
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A safety training program for antibiotic stewardship was associated with reductions in antibiotic use and urine culture collection in long-term care facilities, according to findings published in JAMA Network Open.
Improving antibiotic use in nursing homes is critically important, both for the individual resident, who may suffer side effects from unnecessary antibiotics, and for public health,Morgan J. Katz, MD, MHS, an assistant professor of medicine at Johns Hopkins Medicine, told Healio.
JAMA Netw Open
Older individuals are the most susceptible to adverse effects of antibiotic use, she added. They are often on multiple medications, which can lead to dangerous interactions such as kidney injury, arrythmias or bleeding issues.
Older adults are also particularly susceptible to severe infection with Clostridioidesdifficile, which can occur with antibiotic use, according to Katz. Antibiotic use can lead to bacterial resistance which makes treating infections difficult.
Morgan J. Katz
Antibiotic stewardship program
In a quality improvement study, Katz and colleagues investigated outcomes following the implementation of the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use, a free resource for developing and sustaining antibiotic stewardship programs in long-term care facilities.
References:
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There Is No One To Pick Up The Pieces: Sustainability Of Antibiotic Stewardship Programs In Nursing Homes
Published online by Cambridge University Press: 26 October 2020
- School of Nursing and Department of Neurology, University of Rochester, Rochester, New York
- Christina B. Felsen
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
- Craig R. Sellers
- Affiliation:School of Nursing and Department of Medicine, Geriatrics and Aging, University of Rochester, Rochester, New York
- Ghinwa K. Dumyati
- Affiliation:Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New YorkInfectious Diseases Division, University of Rochester Medical Center, Rochester, New York
- *
Characteristics Of Nursing Homes With Comprehensive Antibiotic Stewardship Programs: Results Of A National Survey
- Mansi AgarwalCorrespondenceAddress correspondence to Mansi Agarwal, PhD, MPH, Columbia University School of Nursing, 560 W 168th St, Mail Code 6, New York, NY 10032.
- Nursing home antibiotic stewardship programs are moderately or highly comprehensive.
- Antibiotic stewardship implementation increased following regulation changes.
- More infection preventionists trained in infection control, however, gaps remain.
- Trained staff are needed for comprehensive antibiotic stewardship.
- Quality Innovation Networks-Quality Improvements Organizations are valuable.
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Antibiotic Stewardship Programs In Long
While the number of hospitals with ASPs has gradually increased in the past decade, widespread implementation of these programs in LTC facilities has been limited, often because of difficulties in tailoring ASPs to meet the unique resource and staffing limitations of these institutions.11 In an effort to bolster stewardship activities in these settings, the Centers for Medicare & Medicaid Services recently proposed a rule requiring all LTC facilities to implement an ASP that includes both antibiotic prescribing protocols and a system to monitor the use of these drugs.12
To further support the optimization of antibiotic use in LTC facilities, the Centers for Disease Control and Prevention released in September 2015 The Core Elements of Antibiotic Stewardship for Nursing Homes, a guide that outlines seven useful components for implementing successful ASPs in these settings .13 These guidelines identify activities that can be carried out in a stepwise fashion to reduce inappropriate antibiotic use and prevent the growth of resistance, and they also tailor suggestions to meet the resource and funding challenges prevalent at many LTC facilities. With this guidance, every LTC facility should select one or two initial stewardship activities to implement and should expand strategies and policies over time to ensure the improvement of antibiotic use and the protection of residents.
Summary of The Core Elements of Antibiotic Stewardship for Nursing Homes
Take Action Through Policy And Practice Change To Improve Antibiotic Use
Nursing homes implement prescribing policies and change practices to improve antibiotic use. The introduction of new policies and procedures which address antibiotic use should be done in a step-wise fashion so staff become familiar with and not overwhelmed by new changes in practice. Prioritize interventions based on the needs of your facility and share outcomes from successful interventions with nursing staff and clinical providers. Below are brief descriptions of policy and practice changes. For more details, see Appendix A: Policy and practice actions to improve antibiotic use pdf icon.
Policies that support optimal antibiotic useEnsure that current medication safety policies, including medication regimen review, developed to address Centers for Medicare and Medicaid Services regulations are being applied to antibiotic prescribing and use.
Pharmacy interventions to improve antibiotic useIntegrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders.
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How To Improve Nursing Home Antibiotic Stewardship Programs
The CDCs Katryna Gouin, MPH: deally tracking antibiotic use at the facility level should be automated using either electronic health records or long-term care pharmacy dispensing data because manual tracking of antibiotics is time intensive.
Efforts to monitor and combat antibiotic overprescribing at nursing homes have been around a long time, as has the tendency of these institutions to breed a high prevalence of multidrug-resistant organisms and adverse events.
More than 3 million people receive care at these facilities each year in the United States and many of the residents come directly from other health care settings.
In research presented virtually at IDWeek 2021, investigators with the Centers for Disease Control and Prevention conducted a review of nursing home antibiotic stewardship citation deficiencies in order to improve implementation.
Here, presenting author Katryna Gouin, MPH, scientific data analyst with the CDCs Office of Antibiotic Stewardship, details in an email Q& A the top takeaways and clinical significance of the review.
Question: Why are nursing homes a prime target in which to focus antibiotic stewardship efforts?
Answer: Nursing home residents are at high risk of infection and adverse events associated with antibiotic use including colonization and infection with antibiotic-resistant organisms and Clostridioides difficile. An estimated 50%-70% of nursing home residents will be prescribed 1
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Data Sources And Search Strategy
For the systematic literature review, we searched the MEDLINE database and included articles from inception to June 2018 inclusive, using the following keywords: AND AND .
For the inventory of tools, we extracted freely available resources found in the articles included in the systematic review. In addition, we conducted a questionnaire survey among a panel of international AMS experts . This survey consisted of a short two-item questionnaire asking the international panel of experts whether they were aware of any recommendations or guidelines for AMS implementation in NHs and whether they knew any tools that could be used for such an AMS programme. Our inventory was completed by an internet search including leading international organizations, professional societies and non-governmental organizations websites and explored any links on these websites that could be related to AMS in NHs. All these websites were explored using the websites navigation menus and search boxes and the following keywords: antimicrobial stewardship and nursing home.
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Tracking And Reporting Antibiotic Use And Outcomes
Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures. For more details, see Appendix B: Measures of antibiotic prescribing, use and outcomes pdf icon and Appendix C: Data Sources, Elements, and Measures for Tracking Antibiotic Use in Nursing Homes pdf icon.
Process measures: Tracking how and why antibiotics are prescribedPerform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.
