Antibiotics in LTC: Changing from 'Just in case' to 'Only when needed'
Philip Sloane, MD, MPH
Prior to the discovery of antibiotics, the most common cause of death was infection. There was no good treatment for pneumonia, complications of urine or ear infections were common, and many people died of simple wounds. Antibiotics rapidly became a crucial component of medical practice, and now, it's hard to imagine what life was like before we had them.
In nursing homes, antibiotics are among the most prescribed medications – in fact, the average resident is on antibiotics nearly 10% of the time.
Over the past few years, however, the situation has become more challenging. For one thing, bacterial resistance to antibiotics has increased to the point that treating “simple” infections is no longer simple. The last 15 years have seen very few new antibiotics developed, so as bacterial resistance climbs, experts are concerned that we will run out of effective antibiotics. Indeed, already some 20,000 people die annually in the U.S. due to infections from multi-drug resistant organisms, and in the past few years we've begun to identify bacteria for which no antibiotics are effective.
The cause of antibiotic resistance is antibiotic use, so to help preserve today's antibiotics for tomorrow's infections, antibiotics must be used only when they are needed. This is a change in the practice mindset, because in the past we've often prescribed antibiotics when they were not necessary – in a “just in case” type of mentality. Indeed, between 25% and 75% of antibiotic prescriptions in nursing homes are not necessary.
Another change in clinicians' prescribing mindset is using shorter courses of antibiotics. In the past, we thought that long antibiotic courses would reduce the emergence of resistant infections, but now we realize that the opposite is true – meaning that antibiotic treatment durations should be no longer than is necessary to clear the infection.
In terms of changing care practices, it's helpful to know that a few prescribing behaviors appear responsible for much of the antibiotic overuse in nursing homes. At the top of the list is over-diagnosis of “urinary infection.” Over-diagnosis typically happens because bacterial colonization of the bladder of healthy older persons is common (a condition known as asymptomatic bacteriuria) and is frequently mistaken for infection.
Another common source of antibiotic overprescribing is the use of antibiotics to treat viral respiratory infections. Similarly, many skin conditions, such as simple wounds or stasis dermatitis in the legs, can and should be treated without systemic antibiotics.
The practice of optimizing antibiotic use and minimizing inappropriate prescribing is referred to as antibiotic stewardship. It is now commonplace in hospitals, but until recently has not been part of routine nursing home practice.
This situation is about to change, because the U.S. Center for Medicare & Medicaid Services mandated that as of November 2017, all certified nursing homes must have in place an antibiotic stewardship program.
The U.S. Centers for Disease Control and Prevention identifies the following seven components of a nursing home antibiotic stewardship program:
- Leadership commitment, including designation of an infection control leader (usually a nurse) and inclusion of antibiotic stewardship in the quality assurance and performance improvement (QAPI) plan
- Accountability – creation of a team that includes the infection control leader, the medical director, and the consultant pharmacist, each of who is charged with overseeing infection policies
- Drug expertise – involvement of a pharmacist or other individual to advise the nursing home on appropriate prescribing
- Action – implementation of at least one policy or practice to improve antibiotic use
- Tracking infection diagnoses, tests performed, and antibiotics prescribed, to help determine whether the new policies and practices are affecting prescribing and clinical outcomes
- Reporting progress to the medical and nursing staff, and relating outcomes to goals or benchmarks
- Educating medical providers, nursing staff, and residents/families about the need to follow evidence-based prescribing guidelines
Certain tools are necessary to implement an effective antibiotic stewardship program. One tool is a simple yet comprehensive system for tracking key infection and antibiotic-related quality indicators.
Such a tracking system can be maintained on an Excel spreadsheet, particularly if the spreadsheet includes built-in formulas to calculate key statistics such as the number of urine cultures per 1,000 resident days, the number of antibiotic starts per 1,000 resident days overall and by body system (respiratory, urinary, skin/soft tissue, other), the mean duration of antibiotic prescriptions by body system, and the incidence of multidrug-resistant infections (such as Clostridium difficile, methicillin-resistant Staphylococcus aureus, and carbapenem-resistant gram negative bacteria).
Educational materials and programs are needed to help effect the change in knowledge and attitudes that is needed for antibiotic stewardship to be successful. Since nursing staff, medical care providers, residents, and families all share in treatment decisions, a nursing home's antibiotic stewardship program should include materials for all of these groups.
A multidisciplinary team from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill has conducted two successful multi-site trials demonstrating that antibiotic use in nursing homes can be successfully reduced with positive resident outcomes. They have developed a variety of training resources for nursing homes interested in implementing antibiotic stewardship; these are available at nursinghomeinfections.unc.edu.
Philip D. Sloane, M.D., MPH, is a Elizabeth and Oscar Goodwin Distinguished Professor in the Department of Family Medicine at University of North Carolina at Chapel Hill. Sheryl Zimmerman, Ph.D., is a Distinguished Professor, Associate Dean, and Director of Aging Research at the School of Social Work at UNC. She also serves as co-director of the Program on Aging, Disability, and Long-Term Care at the Cecil G. Sheps Center for Health Services Research at UNC.