Antibiotic Stewardship in Long-Term Post-Acute Care Centers (LTPAC)

Antibiotics are a welcomed medical panacea throughout the healthcare world by reducing deaths from what were once deadly infections, to making organ transplants and cancer chemotherapy more successful. One particularly notably effective use of antibiotics is in the treatment of sepsis when antibiotics are administered early on in that infection.

As with almost any innovative invention or treatment, there has been a tendency to overuse antibiotics and this is a cause for concern. The Centers for Disease Control and Prevention (CDC) reports that 20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate. Medication of any type can have serious side effects; but, with antibiotics, those side effects pose increasing and greater concerns due to a growing problem of antibiotic resistance. Patients who are given antibiotics unnecessarily are at risk for “serious adverse events with no clinical benefit.” The misuse of antibiotics can negatively affect patients’ health through exposure to organisms that have become antibiotic resistant. The CDC has estimated that every year “over two million people are infected with antibiotic-resistant organisms,” with this causing about 23,000 deaths.”

Not surprising is the fact that antibiotics are prescribed quite frequently to nursing home residents. The CDC estimates that as many as 70% of nursing home residents receive one or more courses of systematic antibiotics over a one-year period. It has also been determined through various studies that between 40-75% of those prescribed antibiotics are inappropriate or unnecessary.

To address this growing concern of antibiotic over exposure, the concept of antibiotic stewardship has surfaced as the means for limiting the use of antibiotics in order to “reduce antibiotic resistance, toxicity, and unnecessary costs.” Antibiotic stewardship is an effort to decrease antibiotic use, to use antibiotics more effectively, and to ensure that correct dosages are prescribed for the right length of time.

Along with the CDC’s recommendations regarding antibiotic stewardship, the Centers for Medicare & Medicaid Services (CMS) has issued a new rule requiring LTPAC centers to have an antibiotics stewardship program in place.

Through its publication— Summary of Core Elements for Antibiotic Stewardship in Nursing Homes—the CDC has outlined the seven core elements of antibiotic stewardship for nursing homes in practical ways in order to initiate or expand antibiotic stewardship activities in nursing homes. Below is a brief description of these seven core elements from the publication:

Leadership Commitment – Demonstrate support and commitment to safe and appropriate antibiotic use in your facility.
Accountability – Identify physician, nursing and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities in your facility.
Drug Expertise – Establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship for your facility.
Action – Implement at least one policy or practice to improve antibiotic use.
Tracking – Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in your facility.
Reporting – Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff.
Education – Provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use.

The responsibility for leading the antibiotic stewardship effort in each nursing home falls on the following individuals: medical director, director of nursing, infection prevention nurse, and consultant pharmacist. The CDC recommends that medical directors set the standards for the antibiotic prescribing practices in their facilities. The director of nursing should ensure that the nursing staff correctly assess, monitor, and communicate changes in a resident’s condition that might impact the need for antibiotics. The infection preventionist nurse should track and trend antibiotic use, infection rates, and any negative outcomes. The CDC suggests that the consultant pharmacist provide staff training about the different types of antibiotics and their appropriate use. He or she should review antibiotic prescriptions as a part of the process of performing a drug regimen review, look for new orders and appropriate use, monitor for adverse events, review laboratory culture reports and give feedback on ensuring that the correct drug is used, and identify antibiotic resistance.

Infection Control Works Hand-in-Hand with an Antibiotic Stewardship Program

While working to have an effective antibiotic stewardship program, the importance of controlling the spread of infection should remain in the forefront as an obvious way of reducing the need for prescribing antibiotics. CMS has mandated that an LTPAC center must have an infection control program that successfully prevents the development and transmission of communicable diseases and infections. CR §483.80 Infection Control became effective on November 28, 2017. The following is a brief description of the required elements in infection control—

System for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and contracted service providers.
Written standards, policies, and procedures that include a surveillance system to identify diseases or infections before they can be spread, the protocol for notifying appropriate authorities, and for responding to an infection/disease outbreak.

Complete details for infection control may be found in the State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities.