Germ Warfare: Reduce antibiotic misuse

Up to 70 percent of residents in a nursing home receive one or more courses of systemic antibiotics a year, but studies have shown that up to 75 percent of those uses may be unnecessary or inappropriate. This can open the door to antibiotic-resistant infections, such as C. difficile, which can be particularly devastating to residents of long-term care (LTC) facilities, many of whom have weakened immune systems.

The Centers for Disease Control & Prevention (CDC) in September issued new recommendations asking all nursing homes to take measures to improve antibiotic prescribing practices, calling it a national priority. “Superbugs that are hard to treat pose a health risk to all Americans, particularly the elderly whose bodies don’t fight infection as well,” said CDC Director Tom Frieden, MD, MPH, in issuing the recommendations. “One way to keep older Americans safe from these superbugs is to make sure antibiotics are used appropriately all the time and everywhere, particularly in nursing homes.”

The Centers for Medicare & Medicaid Services (CMS) also recently proposed a rule that would require LTC facilities to incorporate an antibiotic stewardship program into their infection prevention and control program.

Why now?

Phenelle Segal, RN, CIC, president of Infection Control Consulting Services, a consulting firm offering infection prevention services to healthcare facilities including nursing homes, says she believes the Affordable Care Act is part of the reason this issue is coming to the forefront right now. “Across the continuum of care, beginning with acute care facilities, moving into ambulatory surgery and then targeting nursing homes, the Affordable Care Act has been instrumental in driving change in practice for the benefit of patient safety. A large component of the Affordable Care Act that attempts to improve patient safety has been in infection prevention,” she says.

In March, the Obama administration released a national action plan to combat antibiotic resistant bacteria, and the new CDC recommendations are a result of that plan. “The elderly are definitely at increased risk because they frequently get aspiration pneumonia and urinary tract infections which require antibiotic therapy. Frequent antibiotic therapy predisposes them to infections such as C.diff,” explains Segal.

Create a monitoring program

Every nursing home, regardless of its size, needs to develop an antibiotic monitoring program that monitors the use and the misuse of antibiotics among residents, according to Segal. She suggests they start small when building these programs. “This is a huge undertaking and it needs to be tailored to the individual facility, taking into consideration the size, available resources and antibiotic usage. All facilities need to implement one or two steps at the beginning and then gradually add new strategies over time,” she explains.

Identify a core team

One of the first steps nursing homes should take is identifying a core team of people who will be responsible for developing and implementing the antibiotic stewardship program. “It cannot be handed to one individual, as successful programs happen when teamwork is present,” says Segal.

At a minimum, the team should include:

• A physician champion
• A pharmacy champion
• An administrative representative
• A nursing representative, preferably with some experience in infection prevention
• A microbiology expert from the laboratory

Examine the data

The second step is to look at the healthcare-associated infection data for the facility to identify infections or colonized residents and the organisms that are associated with the facility, particularly those that result in the use of antibiotics, and examine their multi-drug resistant organism patterns. “Do they have a problem with C. difficile infection, for example? Do they know their multi-drug resistant organism rates, such as Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), extended-spectrum beta-lactamases (ESBLs), and Carbapenem-resistant Enterobacteriaceae (CRE),” she asks. “They need to identify their areas of weakness with respect to healthcare-associated infections that could possibly be associated with the misuse or overuse of antimicrobials.”

Coordinate usage

The next step is for facilities to coordinate using certain antibiotics for certain infections, Segal said. They can develop “bundles” that make sure the medications are used in a consistent manner. “The team needs to look at the dose, the duration and why they are using an antibiotic, so that they are not used in a way that encourages drug resistance to develop,” says Segal.

“Urinary tract infections (UTIs) are a good example of a condition in which these steps can be effective, because they are a frequent cause of antibiotic misuse,” she said. “The key to treating or not treating a UTI lies in how the culture is done and how the test results are interpreted. Collection of urine for culture by the nursing staff and the microbiology lab plays a critical role,” she says. “A lot of residents develop asymptomatic bacteriuria—there are no symptoms consistent with bacteria in the urine.”

Essentially, residents who are not exhibiting symptoms of a UTI should not even be cultured, however, if they are, treatment with antibiotics needs to be thought out carefully as asymptomatic bacteriuria results in a lot of unnecessary antibiotic use.

A second problem related to the urinary tract occurs when a physician orders antibiotics prophylactically in residents who have urinary catheters in place. Although 85 percent of residents eventually become colonized, that does not mean they require treatment. “That is one of the biggest violations in antibiotic use,” she notes.

Implementing physician education

Probably the most important step that a facility can take when implementing an antibiotic monitoring or stewardship program is to educate all physicians and any midlevel providers. “This can be a big challenge because some prescribers are resistant to change,” Segal says.

Getting all prescribers on board requires education. Providing them with all information related to the program is extremely important. A key factor in making that happen is having physician champion who is fully dedicated to the control of use of antimicrobials. “It's really the physician champion who can get his or her peers onboard with the new policies,” she concludes.

Read the recommendations: “Core Elements of Antibiotic Stewardship for Nursing Homes.”

Beth Thomas Hertz is a freelance writer based in Akron, Ohio.

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