long-term care infection prevention
long-term care infection prevention
By Buffy Lloyd-Krejci , DrPH , MS , CIC , LTC-CIP
Potential Solutions for Antibiotic Resistance in Long-Term Care Facilities
In September 2016 , the Centers for Medicare & Medicaid Services ( CMS ) issued guidance requiring all licensed long-term care facilities ( specifically , skilled nursing facilities ) to have a fully implemented antibiotic stewardship program . 1 Several years later , CMS updated and refined these guidelines by requiring every long-term care facility that participates in the Medicare and Medicaid programs to have an onsite part-time infection preventionist . 2
CMS viewed these revisions as critical steps in mitigating infectious diseases — and they are . However , these guidelines do not adequately address the increasing prevalence of antibiotic resistance that has resulted from the overuse and overprescribing of antibiotics . Antibiotic resistance is a full-blown global health crisis ; multidrug-resistant organisms ( MRDOs ) are killing people in the millions , and the crisis is only expected to get worse .
In particular , the profligate overprescribing of antibiotics is a serious threat to the health and wellbeing of long-term care facility residents . Research consistently shows that antibiotic prescribing practices contribute to local resistance patterns , 3 which can then give rise to MRDOs . To give you a sense of the scale of this problem , consider this : in 2021 , Clinical Infection Diseases published findings indicating that at least 28 percent of antibiotics prescribed are unnecessary . 4 Furthermore , studies have found that up to 50 percent of all outpatient antibiotic use is inappropriate . 5
There ’ s more bad news : bacteria develop resistance to antibiotics very quickly . 6 Less than 10 years after Tetracycline was introduced , for example , antibiotic resistance to it was identified . Only two years after Methicillin became available , bacteria developed resistance to it . The same year that Levofloxacin was introduced , resistance to it was also seen . This pattern plays out over and over with devastating consequences , and to make matters worse , the Centers for Disease Control and Prevention ( CDC ) released a special report in 2022 that shows COVID-19 made it even harder to combat antimicrobial resistance . 7
Given that nearly 5 million people died from antimicrobial resistance in 2019 alone , 8 it ’ s imperative that long-term care facilities take steps to move the needle forward in decreasing antibiotic resistance . There are several ways facilities can achieve this goal .
First and foremost , physicians at long-term care facilities must be far more judicious in prescribing antibiotics to residents . The importance of this cannot be overstated : it is easy to think of antibiotics as “ superdrugs ,” but the truth is , they are only indicated in certain instances . Far too often , however , antibiotics are the first response utilized when a resident becomes sick . It is crucial to remember that antibiotics only work for bacterial infections . They don ’ t work to combat viral infections and prescribing them for a virus may contribute to antibiotic resistance down the road .
Next , long-term care facilities must recognize that antibiotic resistance impacts them . Because this problem is so big , it ’ s often easy for facilities to dismiss it as something that is happening elsewhere .
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However , as the rising number of nursing home cases of the drug-resistant C . auris 9 has shown , antibiotic resistance has the potential to affect long-term care facilities anywhere in the country .
Third , long-term care facilities must consistently implement and utilize antibiotic timeouts . Seventy-two hours after a resident is placed on an antibiotic , the facility should evaluate the results of the culture that was taken when that resident first showed signs of an infection . Is the culture positive for a bacterial infection ? Does it indicate the need for an antibiotic ? If so , has the resident been placed on the proper antibiotic ? Used correctly , the antibiotic timeout can provide crucial information about the appropriate course of action ( i . e ., keeping the resident on the antibiotic , changing to a new antibiotic , or discontinuing antibiotic use altogether ).
Long-term care facilities should also utilize a team of people to monitor appropriate antibiotic use . Their infection preventionist , for example , can use line listing and surveillance tracking in the resident ’ s electronic health record to ensure that antibiotics are an appropriate response to a resident ’ s illness . Along with the facility ’ s pharmacy consultant , they can also use antibiograms 10 to identify and monitor local antibiotic-resistance patterns and antibiotic susceptibility . Additionally , facilities can also implement monthly antimicrobial meetings . These meetings , which help ensure the facility ’ s physician or nurse practitioner is prescribing appropriately , should include the facility ’ s infection preventionist , medical director , and pharmacy consultant .
Finally , I recommend that long-term care facilities utilize the guidance about antibiotic stewardship programs provided by the Agency for Healthcare Research and Quality ( AHRQ ). Indeed , whether a facility has an established antibiotic stewardship program already or is just launching it , the AHRQ ’ s Toolkit to Improve Antibiotic Use in Long-Term Care 11 is a phenomenal resource that can help nursing homes create that all-important culture of safety around antibiotic prescribing and improve their antibiotic stewardship programs .
The bottom line is that antibiotic resistance is a serious and growing healthcare crisis . While progress to address this threat was being made leading up to 2020 , the COVID-19 pandemic derailed many of those efforts . However , by following the strategies described above , long-term care facilities can help mitigate the impacts of antibiotic resistance and keep their current and future residents safe and healthy .
Buffy Lloyd-Krejci , DrPH , CIC , LTC-CIP , is a leading authority on infection prevention in the long-term care industry . Her firm , IPCWell , delivers in-person gap analysis , training , and support to nursing homes across the country .
1 . CMS finalizes improvements in care , safety , and consumer protections for long-term care facility residents 2 . Updated Guidance for Nursing Home Resident Health and Safety 3 . Outpatient antibiotic prescribing and nonsusceptible Streptococcus pneumoniae in the United States , 1996 – 2003 4 . Unnecessary Antibiotic Prescribing in US Ambulatory Care Settings , 2010 – 2015 5 . Measuring Outpatient Antibiotic Prescribing 6 . The Antibiotic Resistance Crisis , Figure 1 7 . COVID-19 & Antimicrobial Resistance 8 . National Infection & Death Estimates for Antimicrobial Resistance 9 . Candida auris : A Drug-resistant Germ That Spreads in Healthcare Facilities 10 . What is an antibiogram ? 11 . Toolkit To Improve Antibiotic Use in Long-Term Care
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