1. Antimicrobial Stewardship in Long Term Care Facilities
CMDA Annual Conference
April 27, 2018
Travis Neill, PA-C

2. Financial Disclosures

3. No antibiotics!

4. Antimicrobial Stewardship Defined
“Optimize the treatment of infections while reducing the adverse events associated with antibiotic use.”
The 5 R’s:
Right drug
Right dose
Right duration
Right route
Right reason
ONE MORE - Right Documentation

5. Infections In Nursing Homes
~4 million Americans receive care each year in NH
70% of NH residents receive one or more courses of antibiotics each year
20% of providers prescribe 80% of antibiotics
Between 40% and 75% of antibiotic prescriptions in NH are inappropriate or wholly unnecessary
Estimated over 2 million illnesses and 23,000 deaths each year caused by complications from antibiotic resistance
Estimated 250,000 illnesses and 14,000 deaths each year from C-diff

6. Factors Influencing Inappropriate Antibiotic Prescribing Decisions
You want to do the right thing but what if you miss something?
Factors Influencing Inappropriate Antibiotic Prescribing Decisions
Unclear guidelines
Prescriber characteristics not patient characteristics
Fear of illness progression (sepsis, hospitalizations)
Family Pressures
Nursing home staff and culture
Litigation fears

7. Antimicrobial Stewardship Program
CDC Core Elements at
Time Outs
Antibiograms
Active Monitoring/Careful Observation
Find a Champion!

8. Active Monitoring/Careful Observation
Frequent vital signs
Hydration – oral or consider IVF
Assess for other reasons for symptoms: constipation, referred pain, changes in medicine, poor nights sleep
Have an action plan in place – Ex: if patient temp goes above or CBC comes back with leukocytosis then initiate antibiotics

9. SECC Stewardship Results
Reduced C-diff and nosocomial infection rates
Reduced antibiotic use by 35%
Reduced annual costs from antibiotics from $116k to $28k

10. Stewardship Lessons Education alone does not work
Prescriber feedback is helpful and collaborative
LTC is a nursing led field – culture of quality and improvement
Must have a champion! – Medical Director, DON, Pharmacist
Data collection can be a challenge
Monthly webinars are helpful
Teamwork is key
Change takes time
Stewardship Lessons

11. Antimicrobial Stewardship Resources
Minimum Criteria for Initiation of Antibiotics in Long-Term Care Residents
Agency for Healthcare Research and Quality (AHRQ) is seeking LTC facilities to join a
national project for antibiotic stewardship. It will provide expert coaching, online training, tools, and resources to help your facility implement an effective antibiotic stewardship program. This 1-year program will begin December 2018 and recruitment begins in July No Cost
Can the project team with questions at:
CDC antibiotic stewardship resources

12. CDC Core elements for antibiotic stewardship in Nursing Homes
Leadership commitment
Demonstrate support and commitment
to safe and appropriate antibiotic use in your
facility
Accountability
Identify physician, nursing and pharmacy leads
responsible for promoting and overseeing
antibiotic stewardship activities in your facility
Drug expertise
Establish access to consultant pharmacists or
other individuals with experience or training in
antibiotic stewardship for
your facility
Action
Implement
at least one
policy or practice to
improve antibiotic use
Tracking
Monitor
at least one process
measure of
antibiotic use and
at least one outcome
from
antibiotic use in your facility
Reporting
Provide regular feedback on antibiotic use and
resistance to prescribing clinicians, nursing staff
and other relevant staff
Education
Provide resources to clinicians, nursing staff,
residents and families about antibiotic resistance
and opportunities for improving antibiotic use
CDC Core elements for antibiotic stewardship in Nursing Homes

14. antibiotic has been st
arted (Antibiotic “Time Out”) -
Ensure all antibiotic dosing has been adjusted for renal or hepatic
dysfunction 5.
Trackin g: A.
Will track the number of U
As ordered, If they meet
Established
Criteria
, if there was a
positive culture and the correct antibiotic was selected. Will then separate this
Data based on physician group B.
Next step: is to ensure the duration of antibiotics for UTIs is correct and separate
That data based on physician group C.
Nex
t Step: monitor the rate of facility acquired CDI each month 6. R
eporting
: Will report our tracking to the QAPI meeting monthly and at least twice a
year in the form of an in
service to the front
line staff. Will also report to the staff if
We note an increase in either infections or antibiotic use in a specific nursing station
Feedback
: Will provide feedback to providers via the tracking of ordering UAs that
do not meet
criteria and via
Antibiotic
Stewardship
recommendation form
that will provide feedback in real time
on the dosing, duration and indication of the antibiotic choice 7.
Education :
Revi
ew the antibiotic stewardship program with the QAPI team, The providers both
In person and via an In
service all nursing staff about the antibiotic stewardship program and review
When they should ask for a UA
per established criteria
have laminated sheets on every med cart reviewing when to order a UA based on c
riteria
Standard of care for the length of antibiotic treatment for a simple UT
Tis, skin/soft
tissue infection, and pneumonia
Have a provider meeting to review the antibio
tic stewardship program,
criteria
for
UTI, GI, Soft tissue infections, and Pneumonia
, and to review the sheets on every
med card that nursing
well be usin g D.
Give feedback to Providers: via tracking of
UAs ordered
and antibiotic rx’s
and
giving the
Antibiotic Stewardship Recommendation form
with feedback on
individual
patients E.
Educate patients and families upon
admission with the
handout developed by
The Massachusetts Infection Prevention Partnership: Suspect a Urinary Tract
Infection? How Taking Antibiotics When You Don’t need Them Can Cause more
Harm Than Good
Created by Leslie Eber MD CMD