National Center for Emerging and Zoonotic Infectious Diseases

Antibiotic Stewardship in Nursing Homes�

Great Plains Quality Innovation Network�October 19th 2017�

Sarah Kabbani, MD, MSc

Medical Officer, Office of Antibiotic Stewardship

Division of Healthcare Quality Promotion

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Objectives

� Highlight the importance of antibiotic stewardship in nursing home and in new regulations�

� Define the Core Elements of antibiotic stewardship for nursing homes

� Discuss actions that can be taken to promote stewardship activities

Antibiotics are frequently prescribed in nursing homes.

A large number of Americans with increasing medical complexity reside in nursing homes.

� Around 4 million Americans are admitted to or reside in a nursing home during a year1

� 35% age ≥ 65 will receive nursing home care in their lifetime2

� By 2060 the number of Americans ≥ 65 will double3

� Residents at NH have increasingly more complex medical conditions4

1. https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx

2. https://assets.aarp.org/rgcenter/il/fs10r_homes.pdf

3. http://www.prb.org/pdf16/aging-us-population-bulletin.pdf1http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age

4. http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age

http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#agehttp://www.prb.org/pdf16/aging-us-population-bulletin.pdf1http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#agehttps://assets.aarp.org/rgcenter/il/fs10r_homes.pdfhttps://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx

Antibiotics are frequently prescribed in nursing homes.

� Estimated 50-70% of residents will be prescribed an antibiotic in a year1,2

– Based on limited data

� One day point prevalence survey of antibiotic use in U.S. nursing homes3

– December 2013-May 2014, 9 U.S. NH, 1,272 residents

Median age 85 years (range 21-91), 70% were female, 14% were short stay –

– Total AU was 11.1% (95% CI 9.4-12.9%)

• 23% of AU was for prophylaxis

• The most common indication for treatment was UTI (32%)

• AU was more common in short stay residents (21.2%) and�

residents with devices (23.5%%) p-value < 0.0001�

1. Lim et al. Clin Interven Aging. 2014 Jan 13;9:165-77.

2. Nicolle et al. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45.

3. Thompson et al. J Am Med Dir Assoc. 2016 Dec 1;17(12):1151-1153.

Antibiotic prescribing in nursing homes is frequently inappropriate.

� Estimated 40-75% of antibiotic use in nursing homes is inappropriate1,2

– Diagnosis: treatment may not be indicated

– Drug: antibiotic selection may not be correct

– Dose: dosing may be inappropriate or not adjusted

– Duration: longer than recommended guidelines

– De-escalation: not adjusted based on clinical condition or laboratory results

– Documentation: should reflect all D’s above

1. Lim et al. Clin Interven Aging. 2014 Jan 13;9:165-77.

2. Nicolle et al. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45

Testing and antibiotic prescribing for urinary tract infections in nursing homes is frequently inappropriate.

� Asymptomatic bacteriuria is common in nursing home residents1,2

� Up to half of antibiotics prescribed to treat urinary tract infection in older adults are

unnecessary or inappropriate3,4

– Appropriateness of AU for UTI ranged from 15-45% depending on appropriateness

criteria applied5

� Overtesting could lead to incorrectly diagnosing urinary tract infections, inappropriate

treatment, adverse drug events and delays in diagnosis6

1. Nicolle et al. Int J Antimicrob Agents. 2006 Aug;28 Suppl 1:S42-8.

2. Nicolle et al. Infect Control Hosp Epidemiol. 2001 Mar;22(3):167-75.

3. Crnich et a,. J Am Geriatr Soc. 2017 Aug;65(8):1661-1663.

4. Trautner. Nat Rev Urol. 2012;9(2):85-93.

5. Eure et al, Infect Control Hosp Epidemiol 2017 Aug;38(8):998-1001.

6. Hald. JAMA Intern Med. 2016 May 1;176(5):587-8.

Antibiotics save lives but increase the risk of adverse events in older adults.

� Antibiotics were the second most common drug class causing outpatient ADEs in older

adults1

� Polypharmacy is associated with an increased risk of ADEs in older adults:2

– The odds of adverse events increases with the number of regularly scheduled

medications in residents in nursing homes

� Antibiotics contribute to clinically significant drug interactions

– Antibiotic prescribing increases the risk of bleeding in patients on warfarin.3

1. Gurwitz et al. JAMA. 2003 Mar 5;289(9):1107-16.

2. Gurwitz et al. Am J Med. 2005 Mar;118(3):251-8.

3. Zhang et al. J Manag Care Pharm. 2006 Oct;12(8):640-8.

Antibiotics are a common cause of adverse drug events in nursing homes.

� 13% of adverse drug events are secondary to antibiotic use1

� Residents of high antibiotic use nursing homes had a 24% greater risk of antibiotic-related

adverse events compared to low antibiotic use nursing homes2

– Each additional day of antibiotic use leads to a 0.4% increased risk of antibiotic-related

harm

� Risk of acquiring Clostridium difficile infection and subsequent complications including

death are greatest in older adults3

– Up to 25% of patients can have recurrent disease after treatment

� In Ohio 2006, >50% of healthcare-associated C. difficile infection with onset likely in nursing

homes5

1. Gurwitz et al. Am J Med. 2005 Mar;118(3):251-8.

2. Daneman et al. JAMA Intern Med. 2015 Aug;175(8):1331-1339.

3. Zilberberg et al. Emerg Infect Dis. 2008 Jun;14(6):929-31.

4. Kelly et al, Clin Microbial Infect. 2012 Dec;18 Suppl 6:21-7.

5. Campbell et al. Infect Control Hosp Epidemiol. 2009 Jun;30(6):526-33.

Nursing home residents can spread antibiotic resistant bacteria to other residents in the nursing home and in other health care settings.

� Antibiotic exposure is one of the most important risk factors associated with the�development of antibiotic resistance1,2�

� Residents who develop colonization with antibiotic resistant bacteria can spread these

organisms to other residents3,4

� Nursing homes are a key part of our interconnected healthcare system

– Genetic and epidemiological studies of MRSA and carbapenem-resistant�

Gram-negatives highlighted transmission and interconnectedness of nursing�

homes to acute hospitals and other sites5�

Acute care hospital

1. Bronzwaer et al, Emerg Infect Dis 2002 8(3): 278-282.

2. Costelloe et al, BMJ 2010 340: c2096.

3. O’Fallon et al, Infect Control Hosp Epidemiol. 2010;31:1148–1153.

4. Furuno et al, Infect. Control Hosp. Epidemiol. 2011;32:244–249.

Nursing homes Long-term acute

care hospital (LTACH)

5. Dumyati et al, Curr Infect Dis Rep 2017 Apr;19(4):18.

The antibiotic prescribing process in nursing homes is challenging.

� Antibiotic prescribing in nursing home is frequently made off site and influenced by nursing

staff communication.

� The process of antibiotic prescribing in NH is complex and faces barriers that are different

from the acute care and ambulatory settings1

– Clinical uncertainty related to resident factors and limited resources

– Decision to initiate antibiotics

• 66% of antimicrobial prescriptions were started by telephone orders2

• Transitions in care

– Limited documentation of assessment and decision making process

• For 38% of antibiotics administered , key prescribing information were not documented3

– High staff turnover

– Family preferences influence treatment decisions 1. Crnich et al. Drugs Aging. 2015 Sep;32(9):699-716.

2. Richards et al, J Am Med Dir Assoc. 2005 Mar-Apr;6(2):109-12.

3. Thompson et al. J Am Med Dir Assoc. 2016 Dec 1;17(12):1151-1153.

Antibiotic Stewardship Core Elements provide a

framework to improve antibiotic prescribing in nursing

homes.

Antibiotic stewardship is a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

� Antimicrobial stewardship includes:

– Measuring antibiotic prescribing

– Improving antibiotic prescribing

– Minimizing misdiagnoses or delayed diagnoses

– Ensure that the right drug, dose, and duration are selected

� Antimicrobial stewardship interventions can lead to:

– Improved individual resident outcomes

– Prevention of the emergence of antibiotic resistance

– Saving healthcare dollars

Infection Prevention and Antibiotic Stewardship Drivers in Nursing�Homes

2013

HHS National Action Plan

to Prevent Healthcare

Associated Infections

2013

CDC Antibiotic Resistant

Threats Report

2014

Office of Inspector

General Report

2015

White House

Stewardship Forum

2015

CMS New Regulatory

Proposal for Long Term

Care Facilities

2015�CDC Core Elements of�

Antibiotic Stewardship in�Nursing Homes�

2016

CMS Regulatory

Requirements Finalized

2015

National Action Plan for

Combating Antibiotic

Resistant Bacteria

Centers for Medicare and Medicaid services reformed requirements of participation for long term care facilities.

� On October 4th 2016 CMS finalized long term care requirements of participation

that would require antibiotic stewardship to become part of infection

prevention and control programs (IPC) and pharmacy services

– Antibiotic Use Protocols and monitoring included in IPC programs- effective

Nov 2017

https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf

https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf

CDC Core Elements of Antibiotic Stewardship for Nursing Homes provide a framework for antibiotic stewardship implementation.

Provide a framework for assessing current�

and new antibiotic stewardship activities ,�

and for monitoring and improving antibiotic�

use:�

� Leadership Commitment

� Accountability

� Drug Expertise

� Action

� Tracking

� Reporting

� Education

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

Leadership, Accountability and Drug Expertise: Identify

and provide support to the team that will lead antibiotic

stewardship implementation.

Leadership commitment is essential to provide support for antibiotic stewardship implementation.

� NH leaders commit to improving antibiotic use

� Identify the leaders in your facility:

– Owners, facility administrators, regional and national leaders

� Examples of ways of demonstrating support

– Write statements in support of improving antibiotic use and share with staff, residents

and families

– Include stewardship related duties in position descriptions for medical director, clinical

nurse leads and consultant pharmacists

– Communicate the facilities expectations on antibiotic use and stewardship policies with

nursing staff and prescribing clinicians

– Create a culture through messaging, education and a celebrating improvement

Accountability: Identifying individuals who will lead antibiotic stewardship implementation.

� Identify physician, nursing and pharmacy leads responsible for promoting and overseeing

antibiotic stewardship activities

– Medical Director

• Set standards for antibiotic prescribing practices for all healthcare providers

• Review antibiotic use data and oversee adherence to antibiotic prescribing practices

– Nursing Director

• Set practice standards to assess, monitor and communicate changes in residents’ condition

• Assess knowledge and perceptions about the role of antibiotics in the care of residents, and convey expectation of antibiotic stewardship

– Consultant Pharmacist

• Quality assurance activities, medication regimen review and reporting antibiotic use data

Accountable individuals can use existing resources.

� Antibiotic stewardship leads can utilize existing resources

– Infection prevention and control coordinator

• Tracking antibiotics, monitoring adherence to prescribing practices

– Consultant Laboratory

• Alerting facilities if antibiotic resistant organisms are identified

• Education about differences in diagnostic testing (i.e. different test for C. difficile)

• Creating antibiograms to help with empiric antibiotic selection and monitor for resistance

– State and local health departments

• Educational support and resources on antibiotic stewardship and infection prevention by the Healthcare-Associated Infections prevention programs

Individuals with drug expertise can provide support for antibiotic stewardship implementation.

� Establishing access to consultant pharmacists or other individuals with antibiotic expertise�

– Consultant pharmacist with specialized infectious disease or antibiotic stewardship

training

– Partner with antibiotic stewardship leads in referring hospitals in network

– Develop relations with infectious disease consultants in the community who are

interested in supporting the antibiotic stewardship efforts in your facility

Action, Tracking and Reporting: Identify actions to

improve antibiotic use, track and report measures

related to antibiotic use and resident outcomes.

Action: Implementing antibiotic prescribing policies that will improve antibiotic use.

� Implement at least one policy or practice to improve antibiotic use,�ideally in a stepwise fashion�

� Antibiotic prescribing and use policies

– Documentation of dose, route, duration and indication for�

every antibiotic course�

– Develop facility specific treatment guidance for common�

infections based on practice guidelines�

http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

Ouslander et al, J Am Med Dir Assoc. 2015 Jun 1;16(6):524-6.

http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

Action: Implementing practice policies that improve communication.

� Broad practice improvements

– Standardize the assessment of patients suspected�of an infection and the communication between�onsite nursing and offsite providers�

• Ask providers’ and nurses’ input on barriers and�opportunities for improvement�

• Ensure staff is communicating all the relevant data�to make appropriate treatment decisions�

• Consider using Standard Assessment and�Communication Tools i.e. SBAR�

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/toolkit1/utisbar-form.html

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/toolkit1/utisbar-form.html

Action: Improved communication in transitions in care

� There are critical gaps in communication between residential care facilities and emergency

departments1

� The use of standardized transfer forms can improve the communication of critical

information related to resident care when transferring to the emergency department2,3

� CDC inter-facility infection control transfer form documents transmission based precautions,

infection with antibiotic resistant organisms and antibiotic treatment information4

1. Griffiths et al, Int J Nurs Stud. 2014 Nov;51(11):1517-23.

2. Dalawari et al, Geriatr Nurs. 2011 Jul-Aug;32(4):270-5.

3. Terrell et al, Acad Emerg Med. 2005 Feb;12(2):114-8.

4. https://www.cdc.gov/hai/pdfs/toolkits/InfectionControlTransferFormExample1.pdf

https://www.cdc.gov/hai/pdfs/toolkits/InfectionControlTransferFormExample1.pdf

Action: Implement specific policies that will minimize unnecessary prescribing for infections that drive inappropriate use.

� Broad practice improvements

– Develop best practices for microbiology testing

• Avoiding “test of cure” for UTI or C. difficile infection

– “Antibiotic Time-Out” reassessing treatment 2-3 days after antibiotic start based on

clinical condition and laboratory results

� Infection and syndrome specific practice improvements

– Identify drivers of inappropriate use and implement specific interventions i.e.

asymptomatic bacteriuria or prophylaxis for urinary tract infections

Nursing Home Core Elements: Appendix A-Policy and practice actions to improve antibiotic use.

� Evidence-based examples of policies, actions and�

interventions that to improve antibiotic prescribing�

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-a.pdf

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-a.pdf

Tracking antibiotic use and outcomes will inform antibiotic stewardship implementation.

� Monitor antibiotic use and outcomes to guide practice changes

– Process measures: how and why antibiotics are prescribed

– Antibiotic use measures: how often are antibiotics prescribed

– Outcome measures: adverse events and cost of antibiotics

Tracking: Antibiotic use data can be obtained from different sources.

� Electronic Health records can provide medication administration data

– May be limited in some facilities

� Dispensing data from long term care pharmacies

– Provides data on drugs dispensed and not administered

� Manual data collection

http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/

http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc

Tracking: Antibiotic use can be reported using different measures.

� Antibiotic use can be reported in several ways

– Antibiotic starts/1,000 patient days

– Days of antibiotic therapy/1,000 patient days

– One day Point prevalence studies of antibiotic use

� Data recorded could be used to look at:

– Time when antibiotics are started

– Variations by provider

– Common indication for use

– Common agents prescribed

– Duration of therapy

http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

Tracking: Antibiotic related outcome measures can also be tracked.�

� Reporting outcome measures is important to follow the effectiveness of interventions�

– Adverse events from antibiotics

– Cost of antibiotics

• Can be helpful in justifying support for staff and external consultant

– Rates of C. difficile infection

– Antibiotic susceptibility profiles

• Work with clinical laboratory to develop an antibiogram for your facility�

Nursing Home Core Elements: Appendix B-Measures of antibiotic prescribing, use and outcomes

� For more detailed examples of process, antibiotic use and�

outcome measures�

� Includes information on CDC’s National Healthcare Safety�

Network (NHSN) Laboratory-identified event reporting module�

for long-term care facilities for antibiotic resistant organisms�

and C. difficile�

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdf

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-b.pdf

Reporting antibiotic use and related outcomes is critical for the success and sustainability of antibiotic stewardship implementation.

� Provide regular feedback on antibiotic use and outcome measures to all relevant staff and

stakeholders including clinicians and nursing

– Motivate and sustain practice changes

– Provider specific feedback and peer comparison is an effective way to change�prescribing behavior�

– Improvement in clinical outcomes i.e. C. difficile rates, can increase support for

stewardship activities

Providing education on antibiotic stewardship to all

relevant stakeholders is key for the success of

stewardship implementation.

Education-Staff

� Provide education about antibiotic stewardship to clinicians and nursing staff

– May be the first element implemented to establish support among staff

– Different mechanisms (flyers, newsletters..), strongest evidence for academic detailing

(i.e. face-to-face interactive workshops)

– Address staff concerns and barriers to changing antibiotic use practices

http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/index.html

https://nursinghomeinfections.unc.edu/

http:https://nursinghomeinfections.unc.eduhttp://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/index.htmlhttp://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc

Education-Residents

� Develop resources and tools to engage residents and families to in stewardship education

efforts, this will reduce barrier of resident and family expectations in improving antibiotic

prescribing

� Start the conversation early with residents and their families

http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.htmlhttp://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

Where to start?

� Accompanying the core elements

document, 2 page checklist to assess

current practices

� Identify what practices are in place and

opportunities to add new ones

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf

http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-checklist.pdf

Additional Resources: AHRQ Nursing Home Antimicrobial Stewardship Guide

� The Agency for Healthcare Research and Quality recently updated its NH antimicrobial

stewardship guide that includes toolkits on:

– Starting and monitoring an antimicrobial stewardship program

– Communication and decision making for suspected infections

– Using an antibiogram

– Materials for resident and family engagement and education

http://www.ahrq.gov/nhguide/index.html

http://www.ahrq.gov/nhguide/index.html

Success Story

� Massachusetts – Reducing CDI through antibiotic stewardship in LTC

� Building off previous success in acute care hospitals C. difficile prevention activities were

extended into LTCF

� 16 LTCFs to reduce unnecessary antibiotic use for asymptomatic bacteriuria (ASB)

� Multifaceted educational intervention including in-person training on antibiotic use in UTI,

dissemination of evidence-based UTI management algorithms, and patient/family

engagement

� Compared of pre-intervention baseline to post-education rates over 1 year period:

– Improved UTI diagnostic practices: 28% decrease in urine cultures

– Decrease in antibiotic use: 37% reduction in treated ASB episodes

– Decrease in complications from antibiotic use: 47% reduction in healthcare acquired C. difficile

Courtesy of Nimalie Stone, DHQP, CDC

Future Plans

� Describe antibiotic use at the national, state and facility level

– Working with proprietary prescribing data, and pharmacy and electronic health record

vendors to capture antibiotic use data

– Assessment of infections and antibiotic use in NHs through a multistate recruitment of

200 NHs within the CDC’s Emerging Infections Program

� Assess antibiotic stewardship practices in nursing homes

– CDC’s Infection Control Assessment and Response (ICAR) activities in LTCFs

– CMS CDI reporting project 2016-2018, facility survey includes assessment of stewardship

practices

� Determine the best approaches to AS implementation

Questions?

For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for

Disease Control and Prevention.

http:www.cdc.gov

Resources https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

http://www.ahrq.gov/nhguide/index.html

http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/

https://www.gnyha.org/whatwedo/quality-patient-safety/infection-control-prevention/antimicrobial-stewardship

http://www.mi-marr.org/LTC_toolkit.php

https://www.cdph.ca.gov/programs/hai/Pages/ASPinNursingHomesWebinarSeries2016.aspx

http://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.html

https://nursinghomeinfections.unc.edu/

https://robinjump.coursesites.com/

http://www.choosingwisely.org/patient-resources/antibiotics-for-people-with-catheters/

http://www.choosingwisely.org/patient-resources/antibiotics-for-urinary-tract-infections-in-older-people/

http://www.choosingwisely.org/patient-resources/antibiotics-for-urinary-tract-infections-in-older-peoplehttp://www.choosingwisely.org/patient-resources/antibiotics-for-people-with-cathetershttp:https://robinjump.coursesites.comhttp:https://nursinghomeinfections.unc.eduhttp://www.rochesterpatientsafety.com/tools-for-long-term-care-facilities.htmlhttps://www.cdph.ca.gov/programs/hai/Pages/ASPinNursingHomesWebinarSeries2016.aspxhttp://www.mi-marr.org/LTC_toolkit.phphttps://www.gnyha.org/whatwedo/quality-patient-safety/infection-control-prevention/antimicrobial-stewardshiphttp://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltchttp://www.ahrq.gov/nhguide/index.htmlhttps://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

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