long-term care infection prevention
By Cindy Fronning , RN , GERO-BC , IP-BC , AS-BC , RAC-CT , CDONA , FACDONA , ELFA
Antibiotic Stewardship in the Long-Term Care Arena
As early as
1968 it was estimated that 50 percent of antimicrobial use was either inappropriate or unnecessary ( referenced as late as 2015 ).”
We have been hearing about antibiotic stewardship for many years . Alexander Fleming , a Nobel Prize winner who discovered penicillin in 1928 ( released to public in 1941 ) warned of the misuse of penicillin in his Nobel lecture of 1945 . He stated , “ It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them , and the same thing has occasionally happened in the body . The time may come when penicillin can be bought by anyone in the shops . Then there is the danger that the ignorant man may easily under-dose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant .” 1
The first systemic assessment of antibiotic use was completed in 1966 in a general hospital in Winnipeg , Manitoba , Canada . 2 As early as 1968 it was estimated that 50 percent of antimicrobial use was either inappropriate or unnecessary ( referenced as late as 2015 ). 3 In the 1970s , the first formal evaluation of antibiotic use in children regarding antibiotic choice , dose and necessity of treatment , was undertaken at The Children ’ s Hospital of Winnipeg . 4 This study found an error rate in therapy orders to be 30 percent and 63 percent in surgical orders – with the most common error being unnecessary treatment ( 13 percent in medical and 45 percent of surgical orders ).
During the 1980s , infection control programs began to be established in hospitals , which systematically recorded and investigated hospital-acquired infections . Evidence-based treatment guidelines and regulation of antibiotic use surfaced . Australian researchers published the first medical guideline outcomes research .
In the 1990s , antibiotic stewardship was first used , and monitoring antibiotic use and tracking outcomes was suggested . 5 In 1997 , the Society for Healthcare Epidemiology of America ( SHEA ) and the Infectious Diseases Society of America ( IDSA ) published guidelines to prevent antimicrobial resistance . 6
As time went on , there came a stronger push to use antibiotics appropriately . In 2012 , SHEA , IDSA and Pediatric Infectious Diseases ( PIDS ) published a joint policy statement on antibiotic stewardship . 7 In 2014 , the Centers for Disease Control and Prevention ( CDC ) recommended that all U . S . hospitals have an antibiotic stewardship program . 8
The SNF Rules of Participation outline a regulation that all nursing homes must implement an antibiotic stewardship program by Nov . 28 , 2017 . 9
The obvious distinction between hospitals and nursing homes is that we are regulated to develop and implement an antibiotic stewardship program . Even with the regulation , creating an environment that will encourage and sustain an antibiotic stewardship program takes much effort and continuous support . Nursing homes , also through regulation , must have an infection preventionist on staff .
CORE ELEMENT OF ANTIBIOTIC STEWARDSHIP PROGRAM
Leadership
Accountability
Drug Expertise
Action
Tracking
Reporting
Education
COMPONENTS OF ELEMENT
Leaders need to establish antimicrobial stewardship as a priority of the organization & demonstrate support and commitment to safe and appropriate antibiotic use in the facility
Identify individuals accountable for the antibiotic stewardship activities who have the support of facility leadership .
Ensure that the consultant pharmacist has training in Antibiotic Stewardship or Specialized infectious diseases
Taking action through policy & practice change to improve antibiotic use such as 72-hour antibiotic time-outs , facility – specific treatment recommendations , complete antibiotic orders , SBARS , and use of established infection prevention criteria .
Establish process measures for tracking antibiotic stewardship activities . These would include process audits ( antibiotic orders , use of criteria , appropriate drug for sensitivity etc .
Provide a system for the provision of feedback reports on : antibiotic usage , antibiotic resistance patterns , prescribing practices per practitioner as well as outcomes measures such as antibiotic days , Infection rates , and adverse drug effects . Reporting infections to outside agencies .
Provide antibiotic stewardship education to clinicians , nursing staff , younger adult residents , and families . Provide education and feedback to providers and staff . Engage residents and their families in stewardship educational efforts