Article Archive
July/August 2016

Developing and Implementing Antibiotic Stewardship in Long Term Care
By Peter M. Birnstein, MD, and Carole A. Lambert, MPA, RN
Today's Geriatric Medicine
Vol. 9 No. 4 P. 14

Implementing antibiotic stewardship in long term care requires leadership, education, commitment, accountability, and documentation. The resulting reduction in antibiotic resistance benefits patients, staff, and the community.

Nearly 1.4 million people, including short-stay patients with skilled nursing and rehabilitation needs as well as long-stay patients, reside in the 15,700 nursing homes in the United States.1 The vast majority of these patients have at least two and often three or more comorbidities such as hypertension, vascular disease, dementia, arthritis, depression, and gastroesophageal reflux disease.

There are fundamental challenges to health maintenance of this population that require prudent oversight of nutrition, hydration, activity, skin integrity, and overall safety. Otherwise, patients can enter a cycle of decreased engagement and activity leading to poor appetite, low energy, and even less activity. It is difficult to get a healthy person to drink eight glasses of water per day, let alone an inactive person who has difficulty swallowing and suffers from dementia. Deficits in nutrition and hydration are the gateways to infection, resulting in dry, fragile skin that shears; concentrated urine; poor circulation; decreased kidney function; decreased lung function; and impaired vision and proprioception leading to falls and other accidents. In this population, the smallest injury to the body can result in a pervasive infection that is difficult to eradicate. Factor in the use of invasive devices to manage nutrition, hydration, breathing, and incontinence, and the probability of infection increases even more.2

Incidence and Type of Infections
According to multiple studies in the United States and Europe, the most common endemic infections are respiratory, urinary, skin and soft tissue, and gastrointestinal.2 Respiratory infections include upper and lower tract infections. It is estimated that approximately 60% of lower respiratory infections represent pneumonia, which is often fatal. Urinary tract infections are the most common in long term care facilities for the elderly. Prevalence rates of bacteriuria are 25% to 50%, though most patients remain asymptomatic. Skin and soft tissue infections include decubitus ulcers, infected vascular or diabetic foot ulcers, and other types of cellulitis. Gastrointestinal infections primarily manifest as diarrhea.2

Development and implementation of antibiotic stewardship in the face of such prevalent infections is a strategy that will improve the physical and mental health of patients, the health of facility staff, and of the community beyond the walls. It will also positively affect the financial health of the organization. The following are some observations from the literature review conducted by Crnich, Jump, Trautner, Sloane, and Mody, "Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement."2

• On average, 1 in 10 nursing home residents is receiving antibiotics on any given day.

• Infections are the most common cause of transfer to acute care and a major source of nursing home morbidity and mortality.

• CRE, which stands for carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because of their high levels of resistance to antibiotics. Klebsiella species and E. coli are examples of Enterobacteriaceae, a normal part of the human gut bacteria that can become carbapenem resistant.

Clostridium difficile (C. diff) has become a major threat because the overuse of antibiotics can wipe out competing bacteria in the normal flora, resulting in opportunistic infection. This type of infection has become much more difficult to treat due to the development of a resistant C. diff strain.3

• Emergence of resistant bacteria puts patients and the wider community at risk. Colonization with multidrug-resistant organisms, coupled with inappropriate antibiotic prescribing at long term care facilities, contribute to a vicious cycle in which antibiotic resistance spreads quickly.3

As Lindsay E. Nicolle at the University of Manitoba wrote, "Intense antimicrobial treatment in long term care facilities promotes the emergence and persistence of antimicrobial-resistant organisms and leads to adverse effects."4

A study conducted in Los Angeles County found that incidence rates of CRE were nearly eight times higher for patients residing in and receiving care in long-term acute care hospitals than for those patients in short-stay acute care hospitals.3

It must be noted that the prevalence and seriousness of infections in the elderly, who comprise the greater part of the nursing home population, is not a new concern. More than 30 years ago, the Journal of the American Geriatrics Society published the article, "Geriatric Infectious Diseases: An Emerging Problem," on this topic.

Additionally, in 1997, the Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control and Epidemiology (SHEA/APIC) published its first APIC guideline, and then updated in 2008 with the "SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility." The guideline recommends the following: Infection control programs in long term care facilities should be encouraged to include a component of antibiotic stewardship; and the infection control practitioner should monitor antibiotic susceptibility results from cultures to detect clinically significant antibiotic-resistant bacteria in the institution, and antibiotic susceptibility trends should be communicated to appropriate individuals and committees. Implementation of the guideline in nursing homes, however, has been hampered by forces including patient and family influence and limited clinical and facility resources.2

A body of research demonstrating progress in understanding decision-making regarding antibiotic use in nursing homes is accumulating. There also is evidence that improved testing processes can reduce unnecessary antibiotic prescribing. The important thing is to get started. Recently, Edward Stenehjem, MD, at Intermountain Healthcare in Salt Lake City was quoted in HealthLeaders Media: "The real reason to get your antibiotics stewardship program under way is that it's one big piece of the puzzle toward combating antibiotic resistance, which is turning into a huge public health problem. … There's not going to be a day where we don't use these drugs. … The challenge is to use the least amount that's clinically necessary to slow antibiotic resistance."5

The Physician's Perspective
Physicians who have been caring for nursing home and long term care patients throughout their careers know that the response to the challenge is multifaceted, conceptual, operational, and grounded in the day-to-day realities of the environment. Successful antibiotic stewardship and reduction of antibiotic resistance in both skilled nursing facility patients and the general population as a whole depend on multiple members of the health care delivery community.

In the skilled nursing facility setting, this process is initiated most often when a physician is contacted by a nurse calling on behalf of a skilled nursing facility patient exhibiting signs and/or symptoms of a possible infection. After obtaining a history from the nurse, including the current concerns and review of the patient's comorbidities (if the physician is unfamiliar with the patient), and determining whether other patients in the facility are being treated for communicable infections, the physician must first determine whether it is appropriate to treat the patient at the facility or whether transfer to the acute hospital emergency department is indicated. Facility administrators are encouraging skilled nursing facility nurses to request that patients remain at the facility.

If a patient is to remain, the physician must then determine what diagnostic tests to order, whether it be urinalysis and culture, blood tests, chest X-rays, or wound cultures. If the diagnosis of an infection is made, the physician must confirm the existence of any antibiotic allergies. Possible serious interactions with a patient's regular medications must be determined with the assistance of the pharmacist. The correct dosage and duration of treatment are critical to reduce the risk of antibiotic resistance, as well as secondary infections such as yeast and C. diff, in this often debilitated population. Probiotics to maintain normal intestinal flora must be administered along with the antibiotics.

If the infection—such as C. diff, which can be transmitted in health care settings, person to person, and by patient care equipment—is communicable, the facility must execute the infection control policy and protocol established by the administrators, nursing staff, and its consultants in compliance with state regulations. Implementation of the policy will reduce the risk of others becoming infected and requiring antibiotics, which in turn contributes to the risk of developing antibiotic resistance.

The patient's course and outcome must be documented and reported so that patterns of infection and response to treatment, including identification of any antibiotic resistance in the facility and community, can be identified. Follow-up cultures to detect persistent infection, as mandated by infection control, must be obtained.

Finally, ensuring that all patients have been immunized against pneumococcus and that all staff and patients receive annual immunization against influenza is critical. The skilled nursing facility population is at high risk for secondary bacterial pneumonia after contracting influenza. Limiting use of indwelling Foley catheters to those patients that truly must have them will reduce the number of urinary infections and need for antibiotics. Effective measures to reduce skin breakdown will reduce the number of wound infections.2

Steps Toward Establishing an Antibiotic Stewardship Program
As we consider the research, the accumulated body of knowledge, and the urgency surrounding improving antibiotic stewardship, we look to smart and committed people to mobilize the human and technological resources that shape the future success of antibiotic stewardship and, indeed, of effective and efficient quality health care. The steps toward establishing an antibiotic stewardship program include the following:

• leadership, which is reflected in an administrative commitment to make antibiotic stewardship a quality improvement focus;

• expertise, which is reflected in the team, ideally including the facility medical director, the director of nursing, an infection control practitioner, and the facility pharmacist, if available;

• accountability and action, which are reflected in the development and implementation of basic policies, guidelines, and goals, beginning with requiring that orders for antibiotics include clear documentation of the drug, dosage, duration, and indication;

• tracking and reporting outcomes and process indicators, which are key activities in any successful quality improvement effort; and

• multidisciplinary and ongoing education, which will be reflected in increased knowledge, skill, and understanding of the implications and consequences of clinical and behavioral choices in patient care.1

To quote Crnich et al, "Education is a foundational activity of any antibiotic stewardship program and can be used to target all three domains influencing prescribing decisions in nursing homes"—patient and family, facility and staff, and health care provider.1

The Centers for Disease Control and Prevention created and made available publications and FAQs on antibiotic stewardship in nursing homes. These publications are informative, accessible complements to patient and family education efforts. They include the following:

The Core Elements of Antibiotic Stewardship in Nursing Homes;

What You Need to Know About Antibiotics in a Nursing Home;

What to Ask Your Healthcare Provider About Antibiotics; and

Top 10 Infection Prevention Questions to Ask a Nursing Home's Leader.

Echoing Stenehjem above, "[G]et your antibiotic stewardship program under way." Get your leadership team together. Assess your organization's need. Make a plan to begin to deal with your organization's particular challenges. Get everyone involved—and go!

— Peter M. Birnstein, MD, is chair of medical specialties risk assessment peer review and chair of nursing home/long term care subcommittee for the Cooperative of American Physicians (CAP). Established in 1975, CAP offers medical professional liability protection and risk management services to nearly 12,000 California physicians. In 2013, CAP organized CAPAssurance, a risk-purchasing group, to bring liability insurance coverage to member hospitals, health care facilities, and large medical groups.

— Carole A. Lambert, MPA, RN, is vice president of practice optimization and director of the residents program for CAP.

1. Crnich CJ, Jump R, Trautner B, Sloane PD, Mody L. Optimizing antibiotic stewardship in nursing homes: a narrative review and recommendations for improvement. Drugs Aging. 2015;32(9):699-716.

2. Smith PW, Bennett G, Bradley S, et al. SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008. Infect Control Hosp Epidemiol. 2008;29(9):785-814.

3. Chopra T, Rivard CM. Effective antibiotic stewardship programs at long-term care facilities: a silver lining in the post-antibiotic era. Ann Longterm Care. 2015;23(3):18-23.

4. Nicolle LE. Antimicrobial stewardship in long term care facilities: what is effective? Antimicrob Resist Infect Control. 2014;3(1):6.

5. Betbeze P. Antibiotic stewardship enters play-to-pay arena. HealthLeaders Media website.  Published April 7, 2016. Accessed April 14, 2016.