Antimicrobial Stewardship in Post-Acute and
Long-Term Care Facilities: Strategies and
Resources for Implementation
Dheeraj Mahajan, MD,
1
Muhammad Salman Ashraf, MBBS,
2
Elizabeth Frentzel MPH,
3
Nimalie Stone, MD, MS
4
1. Chicago Internal Medicine Practice and Research (CIMPAR, SC), 2. University of Nebraska Medical Center
3. American Institutes for Research 4. Centers for Disease Control and Prevention (CDC)
Speaker Disclosures
• Dheeraj Mahajan, MD: No relevant financial relationship to disclose
• Muhammad S. Ashraf, MBBS : No relevant financial relationship to disclose
• Elizabeth Frentzel, MPH: No relevant financial relationship to disclose
• Nimalie Stone, MD: No relevant financial relationship to disclose
Learning Objectives
• Recognize practical approaches towards developing a formal
antimicrobial stewardship program in post-acute and long-term-care
setting using CDC core elements
• Identify different stewardship strategies and tools relevant to the Core
Elements
• Learn about the effectiveness and limitations of various post acute
and long-term care facilities antimicrobial stewardship programs.
USING CDC CORE ELEMENT FOR
ANTIMICROBIAL STEWARDSHIP
PROGRAM DEVELOPMENT
Dheeraj Mahajan, MD, FACP, CMD, CIC, CHCQM
President and CEO
Chicago Internal Medicine Practice and Research (CIMPAR, SC)
Antibiotic stewardship refers to a set of
commitments and activities designed to
“optimize the treatment of infections
while reducing the adverse events
associated with antibiotic use.”
DEFINITION
Background
• 70% of NH residents receive one or more courses of antibiotics in a
year
• 40%-75% of antibiotics prescribed in NH may be unnecessary or
inappropriate
• Cost of antibiotic use in NHs is $ 38 to 137 million per year
• Residents with higher antibiotic use are at 24 % higher risk of antibiotic
related harm
• 20 % of providers prescribe 80 % of antibiotics
• 40-75% of antibiotics in NH are prescribed incorrectly
• 50 % of antibiotics in NH are prescribed for longer duration than
necessary
Side by Side
Core Elements of Antibiotic Stewardship for Nursing Homes
Leadership Commitment
• Written statements of Leadership support
• Define Duties of leaders and champions
• Notify and communicate
• Create and promote a culture
Accountability
• The medical director
• The director of nursing
• The pharmacist
• The Infection prevention program coordinator
• The laboratory
• State and local health departments
Drug Expertise
• Work with consultant pharmacists with additional training
• Network with area hospital with similar AMS philosophy and engage
with Infection prevention personnel
• Develop relationships with infectious disease consultants
Policy and Practice Change
• Policies that support optimal antibiotic use
• Broad interventions
• Algorithms for resident assessments
• Communication tools
• Antibiograms
• Antibiotic-time outs
• Program to prescribe antibiotic for shortest duration needed to treat infection
• Pharmacy interventions (monitoring for adverse reactions and review of
labs, cultures etc.)
• Infection and syndrome specific interventions (reduce antibiotic use for
asymptomatic bacteriuria and antibiotic prophylaxis for UTI; optimize
management of pneumonia and the use of chronic wound cultures )
Tracking and Reporting
• Tracking how and why antibiotics are prescribed ( process measure)
• Tracking how often and how many antibiotics are prescribed
(antibiotic use measure)
• Tracking the adverse outcomes and costs from antibiotics (outcome
measure)
Education
• WHO
Physicians, NPPs, Nursing, residents and families
• HOW
Flyers, Newsletters, Emails/listserves and In-person sessions
….FEEDBACK goes a long way
CONCLUSION
• Antimicrobial stewardship core elements are similar for hospitals and
nursing homes
• Start with 1 or 2 activities/interventions and build on success
• Celebrate your achievements and recognize the staff
ANTIMICROBIAL STEWARDSHIP IN POST-ACUTE
AND LONG-TERM CARE SETTINGS:
Evidence-Based Interventions
Muhammad S. Ashraf, MBBS
Associate Professor,
Division of Infectious Diseases
Medical Director,
Nebraska Infection Control Assessment and Promotion Program
Co-Medical Director,
Nebraska Antimicrobial Stewardship Assessment and Promotion Program
University of Nebraska Medical Center
Evidence Based Interventions To Improve Antibiotic Use
o Pre-prescription Interventions:
• Use of diagnostic and treatment algorithms
• Use of communication/decision aid tools
• Education of nursing staff and providers about guidelines
• Use of nursing home Antibiograms
o Post-prescription interventions:
• Post–prescribing review of antibiotics (antibiotic time out)
• Prospective audit and feedback
o Interventions targeting pre and post-prescription periods:
• LTCF ID consultation service
Utilizing Algorithms to Decrease Inappropriate Urine
Cultures and Treatment of Asymptomatic Bacteriuria
Loeb M et al. BMJ. 2005 Sep 24;331(7518):669
Utilizing Algorithms (Intervention Impact)
Clinical algorithms
targeted to physicians
and nurses caused 31%
decline in antibiotic use
for UTI
Antibiotic use for other
indications, along with
total antibiotic use, did
not change
Loeb M et al. BMJ. 2005 Sep 24;331(7518):669
Utilizing Algorithms (With Recurrent Educational Sessions)
3-Month
Pre-Intervention
Initial 6 Months
Post-Intervention
7 to 30 Months
Post-Intervention
Urine
cultures/ 1000
patient days
3.7 1.5 1.3
ASB treated 67.6% 69.2% 44%
Antibiotic
days/ 1000
patient days
167.7 117.4 109.0
• Inappropriate urine cultures and total antibiotic days went down after
setting up criteria for sending urine cultures and for the diagnosis of
UTI.
• Required semi-annual follow-up educational sessions and
individualized direct feedback in certain instances.
Zabarsky TF, et al. Am J Infect Control 2008 Sep;36(7):476-80.
Use of Communication/Decision Aid Tool
73.15%
49.35%
69.64%
68.78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Pre-Intervention Post-Intervention
Antibiotic use for
Asymptomatic bacteriuria
Nursing Home with over 25%
utilization
Nursing Home with less than
25% utilization
McMaughan DK et al. BMC Geriatr. 2016 Apr 15;16:81
Education of Nursing Staff and Providers About Guidelines
o Cluster RCT in 58 NHs in Sweden
o Prescribing guideline disseminated
through interactive case-based
sessions w/ nurses & providers
o Total antibiotic prescriptions
decreased and wait and see approach
by physicians increased
*
*
Pettersson E et al. J Antimicrob Chemother. 2011 Nov;66(11):2659-66.
-0.25
-0.2
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
Abx Start Abx Pause FQ Rx
% Change from Baseline
Intervention Control
*
*
Use of Nursing Home Antibiogram
o Up to 85% of treatment started
empirically
o Where cultures available
o only 32% of empiric antibiotic appropriate
o Antibiogram was distributed to Nursing
Staff, Administrators and Physicians in a
meeting.
o 6 months later there was a modest
increase in appropriateness; however,
the difference was not statistically
significant
32%
45%
0%
10%
20%
30%
40%
50%
Pre-intervention Post-Intervention
Appropriate Empiric Antibiotic
use
p = 0.32
Furuno JP et al. Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S56-61
Post – Prescribing
Review of Antibiotics
o Cluster RCT in 30 NHs in
United Kingdom
o Introduced a form with Part
A to be filled out at the start
of antibiotic and Part B
after 48 hour of treatment
o No additional intervention
o Part A was filled 86% of
time and Part B 57% of
time
o Antibiotic starts unchanged
o Antibiotic utilization
decreased by 10%
Fleet E et al. J Antimicrob Chemother 2014; 69: 2265–73
Prospective Audit and Feedback Targeting UTI
Doernberg SB et al. Antimicrob Resist Infect Control. 2015 Dec 1;4:54
o Immediate 26% decrease in antibiotic
prescription for UTI with 6% reduction
continuing through the intervention
period
o Immediate 25% decrease in all
antibiotic prescription with 5%
reduction continuing throughout the
intervention period
o 25% recommendations were accepted
LTCF ID Consultation Service
o 30% decrease in total antibiotic
use
o 64% decline in tetracyclines use
o 61% decline in clindamycin use
o 38% decline in fluroquinolones &
sulfamethoxazole/trimethoprim
o 28% decline in beta lactam/ beta
lactamase inhibitor use
o Rate of positive C. difficile tests
at LTCF also declined while rate
were the same in the hospital
Jump RL et al. Infect Control Hosp Epidemiol. 2012 Dec;33(12):1185-92
In Summary …….
o There are pros and cons for each of the interventions that have
been studied.
o Facilities will have to decide which approach works best for
them.
o Free resources and tools are available to help facilities
implement various components of core elements.
Stewardship: Resources and Tools
Elizabeth Frentzel, MPH
Principal Research Scientist
AMERICAN INSTITUTES FOR RESEARCH
Current Strategies and Tools
• AHRQ: Nursing Home Antimicrobial Stewardship Guide
• CDC: Core Elements of Antibiotic Stewardship for Nursing Homes
• Robin Jump: Improving the Care of Long-term Care Facility Residents with
Infections
• Minnesota: Antimicrobial Stewardship Program Toolkit for Long-term Care
Facilities
• UNC: Promoting Wise Antibiotic Use in Nursing Homes
AMERICAN INSTITUTES FOR RESEARCH
Overview of the AHRQ Guide
• Toolkits to Implement, Monitor, and Sustain
– Start an Antimicrobial Stewardship Program Toolkit
– Monitor and Sustain Stewardship Toolkit
• Toolkits to Determine Whether It Is Necessary to Treat a Potential Infection With
Antibiotics
– Suspected UTI SBAR Toolkit
– Common Suspected Infections: Communicating and Decision Making for Four Infections Toolkit
– Minimum Criteria for Common Infections Toolkit
• Toolkits to Help Prescribing Clinicians Choose the Right Antibiotic for Treating an
Infection
– Working with a Laboratory to obtain an antibiogram
– Concise Antibiogram Toolkit
– Comprehensive Antibiogram Toolkit
• Toolkit to Educate and Engage Residents/Family Members
31
AMERICAN INSTITUTES FOR RESEARCH
Overview of the CDC Core Elements
• Principals of nursing home antibiotic stewardship
• Checklist prior to initiating a stewardship program
• Policy and practice descriptions to improve antibiotic use
• Measures of antibiotic prescribing, use and outcomes
32
AMERICAN INSTITUTES FOR RESEARCH
Improving the Care of Long-Term Care Facility Residents
with Infections (Jump)
• Signs and symptoms of infection in older adults
• Urinary tract infections vs. Asymptomatic bacteriuria
• Upper respiratory tract infections, bronchitis and pneumonia
• Isolation precautions
• Collecting samples for microbiological culture
• Communication with providers
33
AMERICAN INSTITUTES FOR RESEARCH
MN ASP Toolkit for Long-term Care Facilities
• The core tools include:
– Action steps and strategies for implementing an ASP and an accompanying audit tool
– Nursing staff and provider antibiotic use attitudes and beliefs surveys
– An antimicrobial use assessment tool
– A nursing process evaluation tool
• Supplemental tools include:
– Communication tools
– Infection surveillance tips
– C. difficile infection prevention and management algorithms
– Antibiotic initiation criteria
• Additional resources include:
– Educational modules
– Fact sheets
– Helpful references
34
AMERICAN INSTITUTES FOR RESEARCH
Types of Strategies and Tools
• Developing a team and starting a program
• Identifying an infection
• Treating the infection appropriately
• Patient and family education & engagement
• Training/CEUs
• Monitoring
AMERICAN INSTITUTES FOR RESEARCH
Identifying an Infection (AHRQ)
AIR, Texas A & M University, TMF Health Quality Institute, & David Mehr, M.D., (201).
Suspected UTI SBAR. Toolkit for AHRQ under Contract No. 290-2006-000-191-8.
https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T1-SBAR_UTI_Final.pdf
AMERICAN INSTITUTES FOR RESEARCH
Treating the Infection Appropriately (CDC)
• Perform antibiotic “time outs.” Review antibiotics 2 to 3 days
after antibiotics are initiated to answer:
– Does this resident have a bacterial infection that will respond to antibiotics?
– Resident on the most appropriate antibiotic(s), dose, and route of admin?
– Can the spectrum of the antibiotic be narrowed or the duration of therapy
shortened (i.e., de-escalation)?
– Resident benefit from additional infectious disease / antibiotic expertise to ensure
optimal treatment of the suspected or confirmed infection?
• Reduce prolonged antibiotic treatment courses for common
infections
– Beyond a week has not been found helpful/ short courses are effective
– Decrease antibiotic duration among nursing home residents may reduce the
complications and adverse events associated with antibiotic exposure.
CDC. (2015). The Core Elements of Antibiotic Stewardship for Nursing Homes. Appendix A.
https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship-appendix-a.pdf
AMERICAN INSTITUTES FOR RESEARCH
Treating the Infection Appropriately (AHRQ)
Denver Health, University of Maryland School of Medicine (2012). Concise Antibiogram Toolkit. Toolkit for AHRQ under
Contract No. 290-2006-00-20, Task Order No. 9. https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_T5-
Concise_Antibiogram_Toolkit_Comprehensive_Antibiogram_Template.pdf
AMERICAN INSTITUTES FOR RESEARCH
Training/CEUs
• Almost all websites provide training
– Powerpoint presentations
– Audiofiles
– Self-paced
• CEUs and self-paced
– Robin Jump
– UNC
AMERICAN INSTITUTES FOR RESEARCH
Monitoring
• Minnesota: Antimicrobial Use Assessment for Long-term Care Facilities
• AHRQ: Antibiotic Use Tracking Sheet, Sample Monthly Summary Reports, Quarterly or
Monthly Prescribing Profile
AIR,Texas A & M U, U Wisconsin, TMF Health Quality Institute, Trivedi Consults, LLC, U Pittsburgh, and David Mehr, M.D., Monitor and
Sustain Stewardship. Toolkit for AHRQ under contract number HHSA290201000018I #2.
https://www.ahrq.gov/sites/default/files/wysiwyg/nhguide/3_TK2_T2-Antibiotic_Use_Tracking_Sheet_Final.pdf
AMERICAN INSTITUTES FOR RESEARCH
Strengths
• Multiple tools and guidance for facilities
• Based on latest information
• Much of it turn-key solutions
• Multiple training materials that support antibiotic stewardship
AMERICAN INSTITUTES FOR RESEARCH
Weaknesses
• The wealth of tools can be daunting
• Nursing homes may find it difficult to figure out a place to start
• Nursing homes typically are resource-scarce and implementation can be
difficult
• If UTIs are the focus, often significant resistance
AMERICAN INSTITUTES FOR RESEARCH
Keys to Effective Antibiotic Stewardship
45
• Education
• Communication tools
• Decision tools
• Changes in
antibiotic use
• Reporting
• Re-educate
• Identify problems
• Process mapping
• Beliefs
• Identify Team
(MD, RNs,
infection
preventionist,
pharmacist, etc.)
Leadership
commitment
Assess /
Identify
ImplementMonitor
Elizabeth Frentzel, MPH
919.918.4514
efrentzel@air.org
100 Europa Drive, Suite 315
Chapel Hill, NC 27514
General Information: 202-403-5000
www.air.org
46
