Welcome to the second episode of the TMF Quality Innovation Network’s Antibiotic Awareness podcast series, “What is antibiotic stewardship and why do nursing homes need it.” I’m Dr. Russell Kohl, chief medical officer at TMF Health Quality Institute, a leading non-profit health care consulting organization based in Austin, Texas. This episode will focus on information for prescribers – and I’ll discuss how your facility can get started with antibiotic stewardship. But first, let’s recap the previous episode in which we discussed how antibiotic stewardship is the call to use antibiotics for conditions where they are specifically indicated. This includes the right choice of antibiotic, the right dose, the right route and the right duration. Before prescribing an antibiotic, a provider should carefully consider if the patient’s condition warrants it. For example, viral conditions will not improve with antibiotics and, therefore, they should not be prescribed.
Antibiotic stewardship also aims to help providers recognize that some situations, such as suspected sepsis, call for quick administration of an appropriate antibiotic. In the fall of 2016, the Centers for Disease Control and Prevention – or the CDC – released the Core Elements of Antibiotic Stewardship for health care providers to use as a framework for incorporating antibiotic stewardship guidelines into their workflows.The seven core elements include:
- leadership support,
- drug expertise,
- actions to improve use,
- tracking, which includes monitoring antibiotic prescribing, use and resistance,
- reporting information to staff on improving antibiotic resistance,
- and, finally, education.
Now, let’s discuss each core element in greater detail:
- The first, leadership support, is demonstrated through actions such as writing a statement of support for improving antibiotic stewardship, as well as including antibiotic stewardship-related duties in the position descriptions for both the medical director and the director of nursing.
- To show accountability, nursing home administration can identify someone to lead the facility’s antibiotic stewardship activities – such as the medical director or pharmacy consultant.
- The next core element is drug expertise, which requires facilities to have access to individuals with antibiotic stewardship expertise. This may include a pharmacist or an infectious disease consultant – or even partnering with a referral hospital’s antibiotic stewardship team.
- The actions to improve use core element ensures that facilities have policies to improve antibiotic prescribing and use – for example, algorithms for assessing residents and also for appropriate diagnostic testing for specific infections.
- Next, nursing homes can track progress by monitoring antibiotic prescribing, use and resistance. This includes having a process in place to monitor Clostridioides difficile rates, antibiotic-resistant organisms and adverse drug events. It also requires adhering to clinical assessment documentation and facility-specific prescribing – for example dose, duration and indication.
- Reporting information to staff on improving antibiotic use and resistance involves sharing facility-specific reports on antibiotic use and outcomes with clinical providers and nursing staff. These reports can include measures of antibiotic use in the facility, outcomes related to antibiotic use, antibiotic susceptibility patterns and personalized feedback to clinical providers about their antibiotic prescribing practices.
- Finally, education must be offered on a regular basis to clinical providers, nursing staff and the facility’s residents and their families. This may include resources and materials about antibiotic resistance and opportunities for improving antibiotic prescribing use.
Now, how can you, as prescribers, get started with antibiotic stewardship activities?
First, learn how to recognize high-priority conditions where antibiotics may traditionally have been overprescribed. Then, you can begin developing plans to improve or change prescribing habits.
For example, in nursing homes, antibiotics are often overprescribed for urinary tract infections – or UTIs. This overprescribing is often due to unnecessary testing without first identifying criteria-based signs and symptoms.
To avoid unnecessary testing, prescribers should use evidence-based guidance, such as the McGeer criteria6 or the Loeb criteria7. This will help determine appropriate diagnostic testing, which includes cultures for specific infections. Using evidence-based criteria provides better assessment and helps the practitioner determine the need for – and the appropriateness of – testing for suspected infections.
The use of diagnostic tests, as well as management algorithms, can help practitioners differentiate between asymptomatic bacteriuria – or ASB – and a symptomatic UTI. Diagnostic tests have been shown to reduce inappropriate antibiotic use for ASB. By reducing antibiotic exposure, the risk of side effects and the development of resistant organisms decreases, leading to improved resident outcomes. Additionally, prescribing practitioners should be educated about the potential harm a resident could experience from receiving antibiotics for UTI prophylaxis. Few studies support this practice in the general population, especially in older adults. The common practice of prescribing antibiotics for UTI prophylaxis remains a barrier for many antibiotic stewardship programs. It is crucial for the medical director to ensure compliance and adherence to the process. Best practices for microbiology testing should be established to help avoid inappropriate use of microbiology tests, as this may drive unnecessary antibiotic treatment.5
Examples of inappropriate testing might include collecting urine and/or stool samples to be submitted for a “test of cure” following a course of antibiotic therapy. It is not considered best practice when there are no further signs and symptoms of an infection. That’s because the results may reveal asymptomatic colonization that, in turn, could prompt a practitioner to order additional unnecessary antibiotic therapy.
An essential component to a successful antibiotic stewardship program is that the physician receives an accurate assessment of the resident that contains details such as signs and symptoms of an infection. This enables the physician to determine the best course of treatment for the resident. Accurate communication provides a much better clinical picture of the resident before and during a course of antibiotic therapy, which also leads to better treatment for the resident across various health care settings. Additional success can be achieved when a nursing home develops and implements a facility-specific report about antibiotic susceptibility, known as an antibiogram, and then provides this report to the prescribing clinician. An antibiogram can be created by collaborating with your consulting laboratory. This report can give the facility-specific information about antibiotic susceptibility patterns from the organisms commonly isolated in their microbiology cultures. Antibiograms can be updated periodically depending on the number of cultures a facility submits.
To ensure the success of an antibiotic stewardship program, nursing homes must have a dedicated and supportive leadership team who have the same vision and goals and who are highly focused on positive resident outcomes. The entire team should be able to identify their barriers, educate all parties involved as needed and celebrate the success that comes when key players do the right thing.
The TMF Quality Innovation Network’s consultant staff are available to help you begin or strengthen your antibiotic stewardship program. They can work with you to identify and address barriers, as well as assist you in making progress toward your goals. For more information or to request assistance, please email the TMF Quality Innovation Network at firstname.lastname@example.org.
- Nicolle LE, Bentley D, Garibaldi R et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol. 2000;21:537-45.
- Centers for Disease Control and Prevention. The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. Accessed August 2017. http://www.cdc.gov/longtermcare/index.html.
- Cohen S, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox M. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: Update by the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol. 2010 May;31(5):431-55. doi: 10.1086/651706.
- Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.
- Phillips CD, Adepoju O, Stone N. Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes. BMC Geriatr. 2012 Nov 23;12:73. doi: 10.1186/1471-2318-12-73.
- Stober, M. McGeer Criteria for Long Term Care Surveillance Definitions for Infections Updated 2012. Infection Control. Accessed August 2017. http://www.infectioncontrolct.org/uploads/2/6/2/4/26245608/nh-hac_mcgreercriteriarevcomp_2012.pdf.
- Minnesota AARC. Minimum Criteria for Initiation of Antibiotics in Long-Term Care Residents Suspected Urinary Tract Infection. Accessed August 2017. http://www.minnesotaarc.org/mat/card.pdf.