1. Antimicrobial Stewardship in Chicago Nursing Homes
February 2019
Amy Hanson, PharmD, BCPS AQ-ID
Project Administrator, Antimicrobial Stewardship
Infectious Disease Pharmacist
Chicago Department of Public Health

2. Intro to Antimicrobial Stewardship Needs in Nursing Homes
*incorrectly = prescribing the wrong drug, dose, duration or reason 1 AHCA Quality Report 2013.
2 Lim CJ, Kong DCM, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential
care setting: current perspectives. Clin Interven Aging. 2014; 9:
3 Nicolle LE, Bentley D, Garibaldi R, et al. Antimicrobial use in long-term care facilities.
Infect Control Hosp Epidemiol 2000; 21:537–45.

3. Intro to Antimicrobial Stewardship Needs in Nursing Homes
1 Strausbaugh LJ, Joseph CL. Burden of Infections in Long-Term Care.
Infect Control Hosp Epidemiol 2000;21:
2 Daneman, N et.al. Variability in Antibiotic Use Across Nursing Homes and the
Risk of Antibiotic-Related Adverse Outcomes for Individual Residents.
JAMA Intern Med. 2015; E1-E9.

4. More than science, the art of prescribing antimicrobials
Fishman N. Antimicrobial stewardship. Am J Infect Control Jun;34(5 Suppl 1):S55-63; discussion S64-73.

5. Antimicrobial Use Correlates with Antimicrobial Resistance
As use of fluoroquinolones increases, the percentage of Pseudomonas isolates resistant to fluoroquinolones increases proportionately.
Polk RE, et al. Predicting hospital rates of fluoroquinolone-resistant Pseudomonas aeruginosa from fluoroquinolone
use in US hospitals and their surrounding communities. Clin Infect Dis. 39:497–503, Aug. 15, 2004.

6. Impact of Restricting Use of Broad-Spectrum Antimicrobials
Hospitals with carbapenem restriction (n=8) have lower rates of carbapenem resistance than hospitals without carbapenem restriction (n=14).
Pakyz AL, Oinonen M, Polk RE. Relationship of carbapenem restriction in 22 university teaching hospitals to carbapenem use and
carbapenem-resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother. 53:1983–1986, May 2009.

7. Antimicrobial Resistance in Chicago
Exposure network graph showing extensive transfer of KPC-positive patients throughout the exposure network of 14 acute care hospitals, 2 LTACHs, and 10 nursing homes.
Won SY, Munoz-Price LS, Lolans K, Hota B, Weinstein RA, Hayden MK. Emergence and rapid regional spread of
Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis.2011 Sep;53(6):

8. Antimicrobial Stewardship is Mandated by CMS
As part of the revised Requirements for Participation, the Centers for Medicare and Medicaid Services (CMS) required all long-term care (LTC) facilities to have an antibiotic stewardship program by November 28, 2017.
If surveyors haven’t visited facility yet, they likely will in 2019 to assess the 7 CDC Core Elements of Nursing Home Antimicrobial Stewardship Programs are in place.
Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Available at:
requirements-for-longterm-care-facilities; 2016.
Medicare State Operations Manual, Appendix PP: Interpretive Guidelines for Long-Term Care Facilities. Available at:

9. Good Cop, Bad Cop: We’re the Good Cops!
Free consultation (several other companies not part of a public health department charge significant cost for same service)
Completely confidential
No penalties
100% quality improvement focused
We will provide you step-by-step guidance to ensure your facility's antimicrobial stewardship program in “Surveyor Ready”!

10. Goals: remember “Chicago”
Combat antimicrobial resistance, and decrease
Health-care associated
Infections, including
Clostridium difficile, by expanding
Antimicrobial stewardship initiatives to
Gain improved clinical
Outcomes in Chicago Nursing Homes

11. Outcomes from other Nursing Home Antimicrobial Stewardship Programs
42 Nursing Homes in North Carolina demonstrated, after implementing an Antimicrobial Stewardship Program:
Reduced overall antibiotic prescribing between 10% and 28%
Reduced hospitalizations between 8% and 11%
Reduced Clostridium difficile infections between 11% and 21%
Reduced MRSA infections by 8%
Optimizing Antibiotic Use in Nursing Homes Through Antibiotic Stewardship. North Carolina Medical Journal. 77: , 2016.
Successfully Reducing Antibiotic Prescribing in Nursing Homes. Journal of the American Geriatrics Society. 62: , 2014.
Clinical Situations in Long-Term Care for which Antibiotics are Often Prescribed but are Rarely Necessary.
Annals of Long-Term Care. 20(4):23-29, 2012.

12. Join the “GAIN” Collaborative
Our goal is 100% facility participation!
Chicago Department of Public Health (CDPH)’s new Generating Antimicrobial Stewardship Initiatives in Chicago Nursing Homes, or GAIN collaborative, will seek to:
Define compliance rates to the CDC 7 Core Elements of Antimicrobial Stewardship Programs for Nursing Homes
Participate in implementing any recommended action items to bridge any gaps in compliance after free consultation
Optional pre- and post- chart review “snap shot” of antimicrobial use in facility

13. Details on Participation in GAIN

14. Benefits of participating in GAIN
Participating in the Generating Antimicrobial Stewardship Initiatives in Chicago Nursing Homes, or GAIN collaborative, will allow access to the following Antimicrobial Stewardship Tools:
Sample Leadership Commitment Statements to Stewardship
Sample Antimicrobial Stewardship Policies
McGreer Criteria for common infections
Pocketcards with Loeb criteria
SBAR communication forms when an infection is suspected
City-wide, cumulative nursing home antibiogram
Facility-specific treatment guidelines

15. Participation makes your facility eligible for a new CDPH Center of Excellence Designation!
There are three levels of achievement in the new CDPH Center of Excellence (CoE) designation, recognizing the efforts Chicago Nursing Homes are making in advancing their Antimicrobial Stewardship Programs:
CDPH Bronze CoE: participate in on-site visit and demonstrate 7 CDC Core Elements are achieved
CDPH Silver CoE: Complete CDPH recommended action plan
CDPH Gold CoE: Demonstrate improved antimicrobial use and/or improved clinical outcome

16. 7 CDC Core Elements for Antimicrobial Stewardship in Nursing Homes

17. Self-Assessment: Reflection on the CDC Core Elements for Nursing Homes
The following slides ask self-assessment questions regarding the 7 CDC Core Elements of Antimicrobial Stewardship Programs for Nursing Homes
Thinking about these questions will help in preparation for the intake survey (you will receive a surveymonkey link via ), and preparation for any action items after an on-site initial learning visit

18. CDC Core Element #1: Leadership Support
Facility can demonstrate leadership support for antibiotic stewardship:
Written statement of leadership support to improve antibiotic use
Antibiotic stewardship duties are included in medical director and director of nursing job descriptions
Leadership monitors adherence to antibiotic stewardship policies
Antibiotic use and resistance data are reported in the quality assessment and assurance (QAA) meetings

19. CDC Core Element #2: Accountability
Facility has identified at least one leader who is accountable for antimicrobial stewardship activities:
Medical Director
Director or Assistant Director of Nursing
Consultant Pharmacist / Facility Pharmacist
Other (Infection Prevention Nurse)

20. CDC Core Element #3: Drug Expertise
Amy during CDC Be Antibiotics Aware week
Facility has access to individual(s) with antibiotic stewardship expertise:
Consultant pharmacist with training/experience in antibiotic stewardship
Antibiotic stewardship team at partnering hospital
External infectious diseases/antibiotic stewardship consultant group

21. CDC Core Element #4: Action
Facility has policies to improve antibiotic prescribing/use:
All antibiotic orders have dose, frequency, duration, and indication
Use of facility-specific algorithms to assess residents for suspected infections and request diagnostic tests for specific infections
Use of facility-specific treatment recommendations for infections
Antibiotics are reviewed before being added to the medication formulary, if one exists

22. CDC Core Element #4: Action Continued
Facility has implemented practices to improve antibiotic use:
Standard assessment/communication tools (SBAR)
Antibiotic use information are communicated/received on transfers
Reports summarizing antibiotic susceptibility patterns (antibiogram)
Antibiotic reviews/time-outs are performed for antibiotic orders
At least one infection-specific intervention to improve antibiotic use has been successfully implemented

23. CDC Core Element #4: Action Continued
Facility has a consultant pharmacist to support antibiotic stewardship activities:
Reviews antibiotic appropriateness based on agent selected, dosing regimen, duration of therapy AND indication
Establishes standards for clinical/laboratory monitoring for antibiotic-associated adverse drug events
Reviews microbiology culture data to assess and guide antibiotic selection

24. CDC Core Element #5: Tracking
Facility monitors one or more measures of antibiotic use:
Adherence to clinical assessment documentation (including signs/symptoms, vital signs, physical exam findings)
Adherence to include dose, frequency, duration and indication for antibiotic orders
Adherence to facility-specific treatment recommendations for infections
Point prevalence of antibiotic use, new antibiotic starts/1000 resident-days, and antibiotic days of therapy/1000 resident-days

25. CDC Core Element #5: Tracking Continued
Facility monitors one or more outcomes of antibiotic use:
Rates of Clostridium difficile infections
Rates of antibiotic-resistant organisms (e.g., MRSA, VRE, ESBL Gram negative bacilli)
Rates of antibiotic-associated adverse drug events

26. CDC Core Element #6: Reporting
Facility shares facility-specific reports on antibiotic use and outcomes with clinical providers and nursing staff:
Measures of antibiotic use at the facility
Measures of outcomes related to antibiotic use (i.e., C difficile rates)
Report of facility antibiotic susceptibility patterns within the past months (i.e., antibiogram)
Personalized feedback on antibiotic prescribing practices (shared only with individual clinical providers)

27. CDC Core Element #7: Education
Facility provides educational resources/materials on antibiotic resistance and opportunity to improve antibiotic use:
Staff
Clinical providers (e.g., MDs, PAs, NPs, pharmacists)
Nursing staff (e.g., RNs, LPNs, CNAs)
Patients
Nursing home residents and residents’ families

28. Staff Antimicrobial Stewardship Training for Nursing Homes

29. Staff Antimicrobial Stewardship Training for Nursing Homes

30. Sample Patient Education Flyer

31. What Questions Do You Have?
Amy Hanson, PharmD, BCPS AQ-ID
Project Administrator, Antimicrobial Stewardship
Infectious Disease Pharmacist, Chicago Department of Public Health
Office: