Antibiotic stewardship in long term care: making it work at

Bethany Health Care Center

Rohit M. Jangi, MDMedical Director, Bethany Health Care

CenterRJANGI@PCHI.PARTNERS.ORG

130 Beds Average patient age: 89 Average life expectancy: 90 years Medical Staff:

◦ 1 physician (always accessible by phone) ◦ Evercare nurse practitioners.

Bethany Health Care Center

Comprehensive approach◦ to tackle the common and complex problem

facing long term care of the elderly.

Critical thinking◦ By staff at all levels

Prevention first, then treatment

Core principles

Prevention Oral hygiene Aspiration precautions Avoid feeding tubes Avoid psychotropic drugs

Treatment We do not routinely treat aspiration

episodes with antibiotics

Aspiration pneumonia

Prevention Skilled staff

◦ High CNA retention rate ◦ Residents rarely develop decubitii

Sedative use is minimized Wound cultures are avoided Treatment Use narrow spectrum drugs Don’t use cephalosporins.

Skin Infection

Prevention Hydration hygiene, Only send urine cultures when specific signs

and symptoms of UTI are present. Minimize use of indwelling Foley catheter;

most catheters are discontinued on admission

Avoid drugs that promote urinary retention

Urinary tract infection

Prevention All staff is educated in proper clinical

assessment, which includes taking history, clinical examination, taking vital signs , and reporting to physician/NPs.

We always do urinalysis along with culture so that no UTI is treated in absence of significant pyuria.

We treat all residence with home made yogurt after course of antibiotic.

Urinary tract infection

Treatment Often patients come in with diagnosis of UTI without

evidence. We take them off if no cause. If resident shows evidence of gram negative sepsis,

parenteral broad spectrum antibiotic is chosen only on day by day basis, and switched to narrowest spectrum antibiotic as soon as culture report is available.

Generally we wait to treat for culture is patient is clinically stable, monitoring closely.

Trimethoprim / Sulfa or Nitrofurantoin are drugs of choice as these drugs do not cause C. Difficile .

We treat all residence with home made yogurt after course of antibiotic.

Urinary tract infection

10 UTIs treated in 2013◦ Of these only 1 failed meet protocol criteria

Last UTI at Bethany Health Care: August 2013

0 cases ofC. difficile infection in 5 years 0 cases of other MDROs in 5 years

RESULTS