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©2018 Pennsylvania Patient Safety Authority©2018 Pennsylvania Patient Safety Authority
Antibiotic Stewardship
The Time is Now!
JoAnn Adkins, BSN, RN, CIC, FAPIC
Senior Infection Preventionist
Pennsylvania Patient Safety Authority
2
Join us next year!
May 2nd
2019
Seven Springs
P2S2
10/24/2018
2
©2018 Pennsylvania Patient Safety Authority 3
Objectives
▪ Identify the core elements of an action plan to reduce antibiotic
resistant infections
▪ Recall the value of developing an antibiotic stewardship program
in healthcare setting
▪ Relate the importance of antibiotic stewardship and
implementation of evidence-based processes to optimize
resident safety
▪ Describe the importance of data analysis in supporting antibiotic
stewardship initiatives
▪ Explore ways to utilize data to assist in implementing antibiotic
stewardship
©2018 Pennsylvania Patient Safety Authority 4
https://www.youtube.com/watch?v=RpKZvnJwicA
(CDC)
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©2018 Pennsylvania Patient Safety Authority 5
©2018 Pennsylvania Patient Safety Authority 6
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©2018 Pennsylvania Patient Safety Authority 7
Antibiotic Use in Long-Term Care
(CDC)
©2018 Pennsylvania Patient Safety Authority 8
Antibiotic Usage
(Adkins)
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©2018 Pennsylvania Patient Safety Authority 9
Adverse Drug Effects from Antibiotics
▪ 1:1000 risk that taking an antibiotic will result in an
Emergency Department (ED) visit
▪ 1:5 annual ED visits due to antibiotic reactions
– 4:5 ED visits for allergic reactions
– 5%-25% of patients will develop antibiotic-associated diarrhea
▪ Common
– Rash, nausea, vomiting, diarrhea, stomach pain, fungal infections,
drug fever
▪ Serious
– Anaphylaxis, C.difficile, central nervous system and kidney toxicity,
abnormal liver function
(CDC)
©2018 Pennsylvania Patient Safety Authority 10
Antimicrobial Misuse
▪ Unnecessary
▪ No longer necessary
▪ Wrong dose
▪ Broad spectrum agents used on
very susceptible bacteria
(CDC)
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Multi-drug Resistant Organisms
▪ Risk increased by inappropriate
antibiotic usage
▪ Difficult to treat
▪ Incur greater morbidity, mortality, cost
▪ Pennsylvania April 2014 - April 2015
– 54% of gastrointestinal infections
were C.difficile
▪ BI/NAP1/027 strain
–Newer severe strain
– Increased toxin, recurrence, mortality
– Low cure rates
(SHEA,IDSA,CDC, Bradley)
©2018 Pennsylvania Patient Safety Authority 12
Antibiotic Resistance
(Source : CDC- Get Smart Know When Antibiotics Work)
(CDC)
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©2018 Pennsylvania Patient Safety Authority 13
Antibiotic Stewardship
©2018 Pennsylvania Patient Safety Authority 14
What is Antibiotic Stewardship?
▪ Process of coordinated interventions
– Change the way antibiotics are used
– Improves and measures the appropriate use of
antimicrobial agents
▪ Shared commitment
– Always use antibiotics appropriately and safely
– Use only when needed to treat disease
– Choose right drug, dose, duration
(SHEA)
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©2018 Pennsylvania Patient Safety Authority 15
Goals and Rationale for Stewardship
▪ Increases infection cures
▪ Improves pathogen
susceptibility profiles
▪ Reduces adverse effects of
antibiotics
▪ Increases appropriate, cost
effective prescribing for
therapy and prophylaxis
▪ Increases treatment
failures
▪ Increases morbidity,
mortality, hospitalization
▪ Increases adverse effects
of antibiotics
▪ Higher costs for
treatment
OPTIMAL USE SUBOPTIMAL USE
(SHEA)
©2018 Pennsylvania Patient Safety Authority 16
CMS Long-Term Care Final Rule
Effective November 28, 2017
▪ 42 CFR part § 483.80 Infection
Control
▪ Infection Prevention & Control
Program (IPCP) includes:
– Antibiotic stewardship program
– Antibiotic use protocols
– System to monitor antibiotic use
– Effective as of November 28, 2017
(CMS)
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©2018 Pennsylvania Patient Safety Authority 17
CMS Long-Term Care Final Rule
Effective November 28, 2019
▪ 42 CFR part § 483.80 Infection
Control. Phase 3
– Trauma Informed Care
– Call system for each resident at
bedside
– Compliance and Ethics Program
– Staff training
– Infection Preventionist in place
– Coordination of QAPI plan with
incorporation of Infection
Prevention(CMS)
©2018 Pennsylvania Patient Safety Authority 18
CDC Core Elements
▪ Leadership commitment and
accountability
▪ Drug expertise
▪ Specific actions to change policy
and practice
▪ Track and report antibiotic use
▪ Education
(CDC)
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Getting Started Strategies
▪ Identify champions and a team
▪ Use a checklist to identify targets for improvement
▪ Outline a plan
▪ Track prescribing practices
▪ Develop and implement an antibiogram
▪ Educate clinicians to national infection criteria and
treatment guidelines
(Adkins, Bradley, AHRQ Toolkit)
©2018 Pennsylvania Patient Safety Authority 20
Identify Champions and Team
▪ Select members
–Medical Director, Director of Nursing,
Infection Preventionist
– Pharmacist, Lab, Information
Technology support
–Clinical and prescriber champions
▪ Introduce members to antimicrobial
stewardship standards
–Core elements of stewardship
–Antibiotic resistance
(Crnich, AHRQ toolkit)
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Use a Checklist
(CDC) http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
©2018 Pennsylvania Patient Safety Authority 22
Outline Goals and a Plan
▪ Short and long term goals
– Strategies based on assessment
▪ Plan
– Statement of leadership support
– Resources to provide education,
download or develop materials
– Timeline, responsibilities,
budget, meeting schedules,
meeting agenda
– Sustainability strategies
(AHRQ Toolkit)
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Assess & Monitor Antibiotic Prescribing
Processes
▪ Clinical assessment
– Signs/symptoms, vital signs, physical exam and lab
findings
▪ Antibiotic prescribing documentation
– Dose, duration, indication
▪ Facility-specific treatment recommendations
– Broad spectrum versus narrow spectrum
– Use of facility susceptibility patterns
(CDC Core Elements)
©2018 Pennsylvania Patient Safety Authority 24
Antibiotic Use Outcome Measures
Measure Formula
Point prevalence surveys of antibiotic use
# of residents on antibiotics x 100total residents in facility that day
Rates of new antibiotic starts
# of new antibiotic prescriptions x 1000total number of resident days
Rate of antibiotic days of therapy
Total monthly days of therapy x 1000Total resident days for the month
Antibiotic utilization Ratio
Total monthly days of therapyTotal resident days
(CDC Core elements)
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What Is An Antibiogram?
Why Is It Important?
▪ Facility Susceptibility Profile
– Identifies facility antibiotic resistance patterns from resident
cultures
– Inexpensive, easily accessible reference guide
▪ Helps prescribing clinicians:
– Select the most appropriate agents for initial empirical
antimicrobial therapy
– Identify opportunities to reduce inappropriate antibiotic use
and determine success of such efforts
– Facilitates identification of changes in resistance patterns
(AHRQ Toolkit)
©2018 Pennsylvania Patient Safety Authority 26
Sample Antibiogram
(AHRQ Toolkit, Hirshon)
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Resistance Patterns
Gram Negative Susceptibility
Facility A Esch
eric
hia
coli
Kleb
siel
la p
neum
onia
Pseu
dom
onas
aer
ugin
osa
Ampicillin 51 * *
Augmentin 83 88 *
Unasyn 59 82 *
Kefzol 93 89 *
Fortaz * 100 90
Rocephin 99 100 *
Cipro 50 89 67
Gentamycin * 88 81
Primaxin 100 100 *
Macrobid 93 74 *
Bactrim 79 95 *
Gram Negative Susceptibility
Facility C Esch
eric
hia
coli
Kleb
siel
la p
neum
onia
Pseu
dom
onas
aer
ugin
osa
Ampicillin 25 * *
Augmentin 50 * 0
Unasyn 29 62 *
Kefzol 47 * 0
Fortaz * 29 51
Rocephin 51 22 *
Cipro 19 0 31
Gentamycin * 20 35
Primaxin 100 57 52
Macrobid 85 42 *
Bactrim 44 17 *
Gram Negative Susceptibility
Facility B Esch
eric
hia
coli
Kleb
siel
la p
neum
onia
Pseu
dom
onas
aer
ugin
osa
Ampicillin 60 * *
Augmentin 87 96 *
Unasyn 65 85 *
Kefzol 89 97 42
Fortaz * 100 90
Rocephin 97 99 *
Cipro 76 95 67
Gentamycin * 98 83
Primaxin 100 100 86
Macrobid 98 61 *
Bactrim 82 91 *
(Adkins)
©2018 Pennsylvania Patient Safety Authority 28
Culture and Sensitivity
▪ Culture
– Finds and identifies the
pathogen
▪ Sensitivity
– Identifies which drugs the
pathogen is most susceptible to
▪ Goals
–Detect possible drug resistance
in common pathogens
–Assure pathogen susceptibility
to drug therapy
(Stalons, CDC)
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Sensitivity Testing
▪ Disc diffusion
▪ ETest®
▪ Agar dilution
▪ Broth microdilution
(Stalons, CDC)
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Minimum Inhibitory Concentration
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(AHRQ)
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Narrow Spectrum - Broad Spectrum Antibiotics
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Overcoming Barriers
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Barriers to Antibiotic Stewardship
Lack of QAPI follow-up
No formal policies,
procedures, protocols
Unclear commitment or accountability
Offsite
physicians
Lack of tracking and monitoring
Inadequate communication
Inaccurate assessment and
diagnosis
Knowledge
deficits
(Crnich)
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Factors Influencing Practice
▪ Belief that:
– Risk of antibiotics outweighs indiscriminate use
–Appropriate antibiotic use is the expected standard of
care
– Resources are available to practice good stewardship
▪ Providers, clinicians, administrators
▪ Residents and families
(AHRQ, Bradley)
©2018 Pennsylvania Patient Safety Authority 36
Education
▪ Knowledge deficit a major
barrier
▪ Provide educational resources
and materials about antibiotic
resistance
▪ Patient Safety Authority,
Centers for Disease Control,
AHRQ
(CDC, Bradley, AHRQ toolkit)
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Communication
▪ Standardize communication
–Helps to prevent
inadequate communication
– SBAR tool
• Infection specific
• Improves communication
with offsite clinicians
(AHRQ)
©2018 Pennsylvania Patient Safety Authority 38
CDC - Diagnosis and Treatment
▪ Use established criteria for infection diagnosis
– Target empiric therapy to likely pathogens
– Target definitive therapy to known pathogens
–Obtain appropriate cultures and interpret results
with care
–Consider C.difficile in patients with diarrhea and
antibiotic exposure
(CDC)
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CDC - Use Antimicrobials Wisely
▪ Stop antimicrobial treatment
– When cultures are negative
– When infection in unlikely or resolved
▪ Treat infection not colonization
– Do not treat asymptomatic bacteriuria
▪ Know when to say “NO”
– Minimize use of broad-spectrum antibiotics
– Avoid chronic or long-term antimicrobial prophylaxis
(CDC)
Source: AHRQ Nursing Home Antimicrobial Stewardship Guide
©2018 Pennsylvania Patient Safety Authority 40
Promoting Stewardship
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Leadership Commitment
▪ Distribute written statement of expectations
– Include antibiotic stewardship duties in job descriptions
▪ Monitor and enforce antibiotic stewardship policies
▪ Quality assurance meeting agenda
– Antibiotic use and resistance data
▪ Promote stewardship culture
– Messaging
– Education
– Celebration of improvement
(CDC)
©2018 Pennsylvania Patient Safety Authority 42
Leadership Actions
▪ Require prescribers to document dose, duration, and
indication for all antibiotic prescriptions
▪ Develop facility-specific algorithm for assessing
residents
▪ Develop facility-specific algorithms for appropriate
diagnostic testing
▪ Develop facility-specific treatment recommendations for
infections
(CDC)
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Accountability
▪ Identify, empower, and support antibiotic stewardship
leaders and activities
–Medical director
–Director or assistant director of nursing services
–Consultant pharmacist
▪ Utilize existing resources
– Infection Prevention Designee
–Consultant Laboratory
– State and Local Health Department
– Pennsylvania Patient Safety Authority
(CDC)
©2018 Pennsylvania Patient Safety Authority 44
Monitor Outcomes
▪ Monitor rates of adverse events
–Antibiotic-resistant
organisms
–Diarrhea, C.difficile infection
–Allergic reactions
–Drug toxicity
▪ Monitor costs
▪ Processes and outcomes
(CDC)
Source: CDC Core Elements for Nursing Homes
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Reporting
▪ Report facility antibiotic susceptibility patterns
▪ Personalize feedback on antibiotic prescribing practices
clinical providers
▪ Use the Pennsylvania Patient Safety Reporting System
(PA-PSRS) analytic tools and the CDC National
Healthcare Safety Network (NHSN) MDRO module
▪ Standing QAPI agenda - process and outcome measures
©2018 Pennsylvania Patient Safety Authority 46
Tools to Overcome Barriers
▪ SBAR
– Standardizes communication
– HAI specific
▪ Watchful waiting protocol
– Assess mixed non-specific signs and symptoms
– Watchful waiting - symptomatic treatment
▪ Antibiotic timeout
– 48-72 hours
– Review of culture and sensitivity
▪ Evidence-based algorithms and guidelines
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SBAR
▪ Collection tool
– questions to help nursing
collect relevant information
▪ Communication tool
– information prescribers
need for clinical decision
making
(AHRQ)
©2018 Pennsylvania Patient Safety Authority 48
Active Surveillance/Watchful Waiting
▪ Promotes assessment and
evaluation of the resident
▪ Assists in preventing inaccurate
assessment and diagnosis
▪ Evaluates changes in condition
without specific symptoms
(AHRQ)
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Antibiotic Timeout
▪ Intervention to improve
antibiotic use
▪ Antibiotic review when culture
and sensitivity results are
received (48 – 72 hours)
▪ A reassessment of the need for
antibiotics and drug prescribed
▪ Answers four key questions to
determine the appropriateness
of the treatment
(AHRQ)
©2018 Pennsylvania Patient Safety Authority 50
Algorithms and Guidelines
▪ Improves antibiotic utilization
▪ Reduces the likelihood of
developing resistance
▪ Provides guidance in assessing
for signs and symptoms
consistent with infection
▪ Assists in making care more
evidence-based, shorter in
duration and safer
(AHRQ)
(IDSA)
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Education
▪ Provide educational resources and
materials about antibiotic resistance
▪ Clinicians
▪ Physicians, nurse practitioners,
pharmacists
▪ Nursing staff
▪ RNs, LPNs, CNAs
▪ Residents and families
(CDC Get Smart , Bradley, CDC Core Elements, AHRQ toolkit)
©2018 Pennsylvania Patient Safety Authority 52
Data – What Does It All Mean?
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What is a Quality Measurement?
▪ Quality measurement - the process of using data to evaluate
performance against recognized quality standards.
▪ Quality measurement can be used to improve care by:
– preventing the overuse, underuse, and misuse of
antibiotics
– identifying what is working and not working
– driving accountability
– measuring and addressing disparities
– helping staff and prescribers make informed choices
(AHRQ, CMS, IHI)
©2018 Pennsylvania Patient Safety Authority 54
Quality Measures
▪ Quality measure - A tool that is used to measure
performance against a recognized standard of care.
▪ Process measure - Determines how often the measured
service occurred
▪ Outcome measure - Evaluates health as a result of the
care they received
(AHRQ, CMS, IHI)
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Where Do the Numbers Come From?
▪ Numerator – The measure focus; Describes the target
process, condition, event, or outcome expected for the
targeted population
▪ Denominator – Represents the number of
residents/occurrences during a defined time period who
were at risk of, or eligible for, the numerator event
(CMS, AHRQ, IHI)
©2018 Pennsylvania Patient Safety Authority 56
Examples of Measures
▪ Process measures
–Number of urine cultures performed for ASB
–Number of antibiotic orders for ASB
–Number of treated UTIs not meeting PSRS criteria
▪ Outcome measures
–Number of all cause urine cultures
–Number of new antibiotic orders for all UTIs
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Facility Data Report
▪ Part of QAPI reporting
– Standing agenda item
– Report antibiotic use data at each meeting
– PA-PSRS has analytic capabilities to assist with IP
reporting
(AHRQ, Bradley)
©2018 Pennsylvania Patient Safety Authority 58
Example Items to Report to QAPI
Infections by Infection Type (ex. - UTI)
▪ Rate and number of symptomatic UTIs
▪ Rate and number of asymptomatic bacteriuria (ASB)
▪ Rate and number of urine cultures performed
▪ Rate and number of cultures performed for ASB
Antibiotic Usage by Infection Type (ex. – UTI)
▪ Rate and number of new antibiotic prescriptions for UTI
▪ Rate and number of new antibiotic prescriptions for ASB
▪ Rate and number of UTI treated with antibiotics that do not meet
PSRS criteria
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Formula Examples to Obtain Rates
Outcome Measures
▪ Compared to baseline, participants will decrease the percentage of new antibiotic orders for all UTIs
Numerator - # new antibiotic orders for UTI x 100
Denominator - total number of resident days
▪ Compared to baseline, participants will decrease the percentage of urine cultures performed
Numerator - # all urine cultures performed x 100
Denominator - total number of resident days
Process Measures
▪ Compared to baseline, participants will decrease the percentage of urine cultures performed for
asymptomatic bacteriuria (ASB)
Numerator - # urine cultures performed for ASB x 100
Denominator - # all urine cultures
▪ Compared to baseline, participants will decrease the percentage of antibiotic orders for ASB
Numerator - # ASB ordered antibiotics x 100
Denominator - total # ASB
▪ Compared to baseline, participants will decrease the percentage of UTI treated with antibiotics that do not
meet clinical criteria for a UTI
Numerator - # UTI ordered antibiotics that do not meet PA-PSRS criteria x 100
Denominator - # of UTI ordered antibiotics
©2018 Pennsylvania Patient Safety Authority 60
Data is the Key
By collecting and evaluating data, your facility becomes
closer to ensuring residents get the right drug at the right
time, every time.
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“Goals allow you to control the direction of
change in your favor.”
-Brian Tracy
©2018 Pennsylvania Patient Safety Authority 62
Goal Setting
Goals assist in:
▪ Clarifying vision
▪ Providing direction
▪ Focusing resources
▪ Clarifying decision making
▪ Providing motivation
(AHRQ)
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Goals of a Program
▪ Reduce antibiotic costs
▪ Adhere to antimicrobial
stewardship policies
▪ Capture overall antibiotic usage
▪ Improve resident outcomes
(CDC)
©2018 Pennsylvania Patient Safety Authority 64
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Example Goals
Overall 10% reduction in process and outcome measures
▪ Outcome measures
– Decrease in % of new antibiotic orders for all UTIs
– Decrease in % of urine cultures performed
▪ Process measures
– Decrease in % of urine cultures for ASB
– Decrease in % of antibiotic orders for ASB
– Decrease in % of treated UTIs that do not meet criteria
©2018 Pennsylvania Patient Safety Authority 66
Antibiotic Stewardship and Sepsis
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The Dilemma
sepsis
ABX Stewardship
©2018 Pennsylvania Patient Safety Authority 68
Can they co-exist?
Antibiotic Stewardship
▪ Coordinated
interventions
▪ Promotes the
selection of the
optimal drug regimen
▪ Use of tools
(SHEA)
Sepsis
▪ Early recognition
▪ Rapid intervention
▪ Use of tools
(CDC)
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Back to the Basics
▪ Best practices
– Identification
–Treatment
–Tools
©2018 Pennsylvania Patient Safety Authority 70
Identification of the Infection
▪ Use the criteria
– Symptoms
– Testing
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Testing & Culturing is Your Friend!
▪ McGeer criteria requires a positive culture or testing
▪ Culture if symptoms are present
▪ Proper specimen collection is vital
▪ Interpretation of culture results assists in antibiotic
stewardship
©2018 Pennsylvania Patient Safety Authority 72
Culture and Sensitivity
▪ Culture identifies the organism(s)
▪ Sensitivity guides practitioner in antibiotic selection
▪ MIC – minimum inhibitory concentration
– Lowest concentration of drug that will inhibit the
growth of an organism after incubation
▪ Start antibiotics after culture is obtained
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Antibiotic Treatment
▪ Empiric therapy
– Should be based on your
facility’s antibiogram
▪ Definitive therapy
– Based on culture and
sensitivity
–Narrowest spectrum
(CDC)
©2018 Pennsylvania Patient Safety Authority 74
Antibiotic Timing
▪ Start after culture is obtained
▪ Antibiotic Timeout
– Evaluation of ongoing treatment
– Prompts a reassessment of the need and choice of
antibiotic
– 48-72 hours
–Charge nurse and prescriber
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Antibiotic Stewardship Tools
Use the tools!
▪ SBAR
▪ Watchful waiting protocol
▪ Antibiogram
▪ Antibiotic timeout
▪ Evidenced-based
algorithms and guidelines
©2018 Pennsylvania Patient Safety Authority 76
"I have always found that plans are useless,
but planning is indispensable."
- Dwight D. Eisenhower
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Antibiotic Misuse Warning
“The thoughtless person playing
with penicillin treatment is
morally responsible for the
death of the man who
succumbs to infection with the
penicillin-resistant organism.”
https://commons.wikimedia.org/wiki/File:Synthetic_Production_of_Penicillin_TR1468.jpg#filehistory
©2018 Pennsylvania Patient Safety Authority©2018 Pennsylvania Patient Safety Authority
What questions
do you have?
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©2018 Pennsylvania Patient Safety Authority
Thank You!
@PennsylvaniaPatientSafetyAuthority @PAPatientSafetyPennsylvania Patient
Safety Authority
Pennsylvania Patient
Safety Authority
©2018 Pennsylvania Patient Safety Authority 80
Resources
Infection Criteria
▪ Infection Control and Hospital Epidemiology: Development of Minimum
Criteria for the initiation of antibiotics in residents of LTCF
– http://classes.kumc.edu/coa/Education/AMED900/InfectiousDisease-
GeneralizedAssess.pdf
▪ Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting
the McGeer Criteria
– http://www.jstor.org/stable/10.1086/667743
▪ PA-PSRS: List of Reportable Infections: Infections reportable through PA-PSRS
– http://patientsafetyauthority.org/NewsAndInformation/HealthcareAssocia
tedInfections/Documents/reportableinfections.pdf
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Resources
Treatment Guidelines
▪ Infectious Diseases Society of America Guidelines
– https://www.idsociety.org/Organ_System/
▪ CDC Get Smart Know When Antibiotics Work: Adult Treatment
Recommendations
– https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/adult-
treatment-rec.html
▪ Society for Healthcare Epidemiology of America Position paper:
Antimicrobial use in LTCF
– https://www.shea-online.org/images/guidelines/Abx-LTCF96.PDF
▪ National Institute of Health. Diagnosis and management of urinary tract
infections in older adults
– https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079031/pdf/nihms593
077.pdf
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References
▪ Adkins S, Bradley S, Finley E. Strategies to turn the tide against inappropriate
antibiotic utilization. Pa patient Saf Advis (online) 2015 Dec
▪ Agency for Healthcare Research and Quality (AHRQ). AHRQ Nursing Home
Antimicrobial Stewardship Guide[online]
https://www.ahrq.gov/nhguide/index.html
▪ Bradley S. Antibiotic stewardship in hospitals and long-term care facilities:
building an effective program. Pa Patient Saf Advis [online] 2015 Jun
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Jun;12(
2)/Pages/71.aspx
▪ Centers for Disease Control and Prevention. The core elements of antibiotic
stewardship for nursing homes [online]. 2014 [cited 2015 Sep 1].
http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
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References
Centers for Disease Control and Prevention
▪ CDC Recommends all nursing homes implement core elements to improve
antibiotic use . CDC Newsroom (online)
http://www.cdc.gov/media/images/releases/2015/p0915-nursing-home-
antibiotics.pdf
▪ Medication Safety Program: Adverse Drug Events from Antibiotics
https://www.cdc.gov/medicationsafety/program_focus_activities.html
▪ Get Smart: know when antibiotics work
http://www.cdc.gov/getsmart/community/about/antibiotic-resistance-
faqs.html
▪ Campaign to Prevent Antimicrobial Resistance in Healthcare Settings 12
Steps to Prevent Antimicrobial Resistance Among Long-term Care Residents
http://www.kliinikum.ee/infektsioonikontrolliteenistus/doc/oppematerjalid/
longterm.pdf
▪ Get smart for healthcare
http://www.cdc.gov/getsmart/healthcare/resources/slides/getsmart-
healthcare.pdf
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References
▪ Center for Medicare and Medicaid Services. Medicare and Medicaid
Programs; Reform of Requirements for Long-Term Care Facilities. Federal
Register 2015;80(136):42168–42269. http://www.gpo.gov/fdsys/pkg/FR-
2015-07-16/pdf/2015-17207.pdf
▪ Crnich CJ, Jump r, Trautner b. Optimizing antibiotic stewardship in nursing
homes: a narrative review and recommendations for improvement. Drug
Aging 2015 Aug 28. 32:699-716
▪ Department of Health and Human Services. Centers for Medicare & Medicaid
Center for Medicaid and State Operations/Survey and Certification Group
Ref: S&C-09-54 2009 August 14, State Survey Agency Directors Training
Materials
www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_54.pdf
▪ Department of Health and Human Services. Long-Term Care Minimum Data
Set (MDS).Cited 2017 October 20. https://www.healthdata.gov/dataset/long-
term-care-minimum-data-set-mds
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References
▪ Hirshon M, Schurr J. Using nursing home antibiograms to improve antibiotic
prescribing and delivery [online]. Agency for Healthcare Research and
Quality 2012 annual conference slide presentation. 2012 Sep 10 [cited 2015
Sep 1].
http://archive.ahrq.gov/news/events/conference/2012/track_a/62_garfinkel
_et-al/hirshon.html
▪ Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America (SHEA). Guidelines for developing an institutional
program to enhance antimicrobial stewardship [online]. 2007 Jan [cited
2015 Sep 1]. http://cid.oxfordjournals.org/content/44/2/159.full.pdf+html
▪ Institute for Healthcare Improvement (IHI). Antibiotic stewardship driver
diagram and change package [online]. 2012 Jul [cited 2015 Sep 1].
http://www.cdc.gov/getsmart/healthcare/pdfs/Antibiotic_Stewardship_Chan
ge_Package_10_30_12.pdf
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References
▪ National Healthcare Safety Network (NHSN) Tracking Infections in Long-
term Care Facilities(online)
http://www.cdc.gov/nhsn/forms/57.138_labidevent_ltcf_blank.pdf
▪ Society for Healthcare Epidemiology of America, Infectious Diseases
Society of America, Pediatric Infectious Diseases Society. Policy
statement on antimicrobial stewardship by the Society for Healthcare
Epidemiology of America (SHEA), the Infectious Diseases Society of
America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)
[online]. 2012 Apr [cited 2015 Sep 1]. https://www.shea-
online.org/View/smid/428/ArticleID/141.aspx
▪ Stalons, D. and Thornsberry, C. Broth- dilution method for determining
the antibiotic susceptibility of anaerobic bacteria. [online]. 1975 [cited
2018 March 4]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC429064/pdf/aac00319-
0021.pdf
