Implementation strategies to consider in smaller facilities include: • Seeking off-site support for antibiotic stewardship programs, such as enrolling in collaborative efforts with other facilities, funding remote consultation or telemedicine programs to consult with infectious disease specialists, or contracting with external pharmacy services to provide antibiotic stewardship services. • Utilizing the facility’s on-site pharmacist to provide leadership and drug expertise for their antibiotic stewardship program, often in collaboration with a physician. • Tracking antibiotic use at the provider level is often easier to monitor due to a smaller number of providers. • Providing education may be easier due to a smaller number of staff than larger facilities. Individualized education can often be provided by the pharmacist or physician leader of the antibiotic stewardship program. Implementation of Core Elements in Nursing Homes Nursing homes experience high rates of antibiotic prescribing: Up to 70 percent of nursing home residents receive at least one course of systemic antibiotics per year. Studies have shown that between 40 and 75 percent of these antibiotics may have been prescribed unnecessarily or inappropriately. Since the patient population in nursing homes is typically comprised of older and more frail adults, complications from antibiotic use—such as Clostridium difficile, antibiotic resistance, and increased rates of side effects and drug interactions—are particularly harmful. 21 Roles of Nursing Home Staff in Antibiotic Stewardship Programs Facilities should utilize the skills of their medical directors and encourage them to set antibiotic prescribing standards for all prescribers who provide care in their nursing homes. The medical director can also be held accountable for overseeing adherence to antibiotic regimens and review antibiotic use data to ensure that best practices are followed in his/her facility. 21 The director of nursing can set standards for the facility in terms of assessing, monitoring, and communicating changes in conditions by nursing staff. Since nurses and assistants play a significant role in the process of starting an antibiotic, training staff on antibiotics, as well as perceptions and attitudes about the roles of antibiotics, can influence how information is communicated to prescribers who decide whether or not to order antibiotics. 21 The consultant pharmacist can support antibiotic stewardship programs by participating in quality assurance activities. This individual can also review antibiotics during regular medication regimen reviews and report antibiotic use data. Additionally, consultant pharmacists can help nursing homes reduce antibiotic use and recommend decreases in other medications that can contribute to Clostridium difficile infections. 22
The infection prevention coordinator is responsible for collecting data and utilizing his/her expertise to come up with strategies to improve antibiotic use. This individual is often involved in tracking when antibiotics are started, monitoring adherence to evidence-based criteria for antibiotic use, and reviewing any antibiotic resistance patterns to evaluate which infections are caused by resistant bugs. If given the time, training, and resources to assess infection surveillance data, this information can be useful in monitoring and supporting antibiotic stewardship activities. 21 Laboratories that are contracted to provide services to nursing homes can provide reports and services to support antibiotic stewardship activities. This can include reports on antibiotic resistance in the area, known as antibiograms, which can help dictate appropriate empiric antibiotic use. Laboratories can also develop processes with nursing homes to alert a building if antibiotic- resistant organisms are detected, as well as provide education on the types of diagnostic tests available to detect various pathogens. 21 State and local health departments can also be utilized for educational support and resources for antibiotic stewardship programs. These departments often have Healthcare-Associated Infection Prevention programs that support antibiotic stewardship. 21 Tracking and Reporting Nursing home staff can track how and why antibiotics are prescribed by performing medical record reviews. These reviews can assess documentation of clinical assessments, prescriptions, and antibiotic selection, as well as determine if the facility’s antibiotic use policies and procedures were followed. Collecting this information over time can allow facilities to regularly monitor both staff and prescriber adherence to policies and practices for antibiotic use. 21 Tracking the amount and frequency of antibiotic prescribing can allow facilities to review prescribing patterns and assess the impact of stewardship program interventions. Monitoring days of therapy or the frequency of antibiotics started in the nursing home should be performed on an ongoing basis. Facilities can select which antibiotic use measures to track regularly, based on the type of antibiotic use interventions being implemented. For example, interventions that aim to decrease the duration of antibiotic courses may not change the rate of antibiotics started in the nursing home, but would help to decrease days of therapy. Utilizing data to improve antibiotic use impacts both individual facilities as well as public health. Facilities using electronic medical records may be more prepared for tracking data on antibiotic use, although all facilities should be holding regular antibiotic stewardship meetings, regardless of their medical record system for compliance with Centers of Medicare and Medicaid Services regulations. 21 Outcomes of antibiotic use should also be tracked in nursing homes. These include tracking adverse reactions, such as rates of Clostridium
difficile infections, antibiotic resistant organisms, and adverse drug events, which can help assess the effectiveness of stewardship interventions and their impact on patient outcomes. 21 Implementing Interventions to Improve Antibiotic Use Policies Supporting Optimal Antibiotic Use Implementing policies to support the optimal prescribing of antibiotics can have significant effects on improving overall antibiotic prescribing in a facility. Implementing facility specific treatment protocols can play a large role in ensuring appropriate antibiotics are used in appropriate situations. Treatment recommendations based on national guidelines, as well as local susceptibilities, can allow physicians to choose appropriate antibiotic treatment, particularly in conditions commonly treated with antibiotics, such as skin and soft tissue infections, pneumonia, urinary tract infections, and surgical prophylaxis. 3 In addition, routinely documenting the dose, duration, and indication for the use for each antibiotic prescription is critical to ensuring that antibiotic stewardship activities can be implemented. This helps to ensure that important information is readily accessible for antibiotic stewardship practices, such as modifying and discontinuing antibiotics, as appropriate. 3 Interventions to Improve the Use of Antibiotics Interventions should be chosen based on the needs of the facility, as well as resource availability. To avoid overloading staff, it is important not to implement too many interventions at one time; rather, interventions should be prioritized based on the needs of the facility. Interventions to improve antibiotic use can be divided into three categories: broad interventions, pharmacy-driven interventions, and infection/syndrome-specific interventions. 3 Antibiotics are commonly empirically started in hospital and long-term facility patients who present with infectious symptoms—often while the medical team is still working on obtaining diagnostic information. Unfortunately, many providers do not revisit their choices of antibiotics after the clinical and laboratory data, such as culture results or symptom changes, become available. Antibiotic “timeouts” are one way to prompt an antibiotic choice reassessment and determine the continued need for antibiotics, after the clinical picture is clarified and more diagnostic information is available. 3 Clinicians should review all antibiotics 48 hours after initiation to answer the following questions: 23 • Does the patient have an infection? Will it respond to antibiotics? • Have the appropriate cultures or diagnostic tests been conducted? Broad Interventions Antibiotic “Timeouts”
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