What Is Antibiotic Stewardship and Why Do Nursing Homes Need It

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  Listen to this first recording from the TMF Quality Innovation Network’s Long-Term Care Antibiotic Stewardship podcast series to hear from Russell Kohl, MD, FAAFP, the chief medical officer at TMF Health Quality Institute, who discusses antibiotic stewardship and why nursing homes need it. Duration: 10:44

What Is Antibiotic Stewardship and Why Do Nursing Homes Need It

Welcome to the first episode of the TMF Quality Innovation network's antibiotic awareness podcast series, what is antibiotic stewardship, and why do nursing homes need it. I'm Dr. Russell Kohl, the chief medical officer at TMF Health Quality Institute, a leading non-profit health care consulting organization based in Austin, Texas.
Throughout this series, I'll discuss how your facility can work with TMF Quality Innovation Network consultants to adopt antibiotic stewardship strategies. I'll also provide relevant information you need to know about antibiotic stewardship.
During today's podcast, we will define antibiotic resistance and the dangers it poses to Americans. We will also discuss what we as a nation are doing about it.
Later, we'll define antibiotic stewardship and explain why it is so important for nursing homes to begin incorporating antibiotic stewardship methods into their policies, procedures, and everyday practices. Let's get started.
Why do we need antibiotic stewardship? The answer is because of antibiotic resistance. According to the Centers for Disease Control and Prevention, or the CDC, antibiotic resistance is the ability of bacteria to resist the effects of antibiotics. Resistant bacteria will grow within the body, impeding the attempt to improve the individual's health. Resistance happens faster than we think after the introduction of a new antibiotic.
Since penicillin was developed in 1928 for military use, bacteria have shown the ability to become resistant to every antibiotic that has been developed. And the more antibiotics are used, the quicker the bacteria develop resistance. There are several examples of this quick resistance throughout history.
Penicillin was released for public use in 1943, and the first resistance identified was a penicillin-resistant pneumococcus in 1965. The antibiotic ceftazidime was introduced in 1985, and just two years later, deftazidime-resistant enterobacteriaceae was discovered.
In 1994, levofloxacin was introduced. Later that same year, the first levofloxacin-resistant pneumococcus was identified. And most recently, ceftaroline was released in 2010, and in 2011, ceftaroline-resistant staphylococcus was identified.
Antibiotics are among the most commonly prescribed medications used in human medicine. The CDC has concluded that up to half of the time, antibiotics are not optimally prescribed. They're often prescribed when not needed, with incorrect dosing, or incorrect duration.
Prescribers and health care professionals must consider patient safety in the overuse of antibiotics. Not only can prescribed antibiotics interfere with the effects of other medications, but they also become less effective the more they're used.
The CDC has estimated that at least two million illnesses and 23,000 deaths are caused by antibiotic-resistant infections each year in the United States. Antibiotic-resistant infections cost an estimated $20 billion in excess direct health care costs annually, and this does not include the $35 billion in estimated loss of productivity from illness-related absences.
In 2014, President Barack Obama signed an executive order to strengthen our focus on improving the appropriate use of antibiotics. The order proposed adopting the National Strategy to accomplish these goals.
The goals include slowing the emergence and preventing the spread of resistant bacteria, as well as strengthening national efforts to identify and report cases of antibiotic resistance. The order calls for advancing the development and use of rapid diagnostic tests to identify and characterize antibiotic-resistant bacteria. Additionally, it calls for the acceleration of basic and applied research and development for new antibiotics, as well as other therapeutics and vaccines.
Lastly, the US will improve international collaboration, capacities for antibiotic resistant prevention, surveillance, control, and antibiotic research and development. Collectively, the actions outlined in the National Strategy will enhance antibiotic stewardship, strengthen national surveillance capabilities, and expand the arsenal of diagnostics, antibiotics, and other countermeasures available to combat resistant bacteria.
If we are to reach these goals though, we must implement antibiotic stewardship, which brings us to the second part of today's podcast, what is antibiotic stewardship. Experts with the Association for Professionals in Infection Control and Epidemiology define antimicrobial stewardship as, a coordinated program that promotes the appropriate use of antimicrobials, including antibiotics, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug resistant organisms.
Experts in the program label antibiotic stewardship as the effort to measure antibiotic prescribing, to improve antibiotic prescribing by clinicians, and use by patients so that antibiotics are only prescribed and used when needed, to minimize misdiagnosis or delay diagnoses leading to under-use of antibiotics and to ensure that the right drug, dose, and duration are selected when an antibiotic is needed.
Further, according to the CDC, antibiotic stewardship can be implemented in all health care settings in which antibiotics are prescribed. Stewardship remains a cornerstone of efforts aimed at improving antibiotic-related patient safety and slowing the spread of antibiotic resistance. The goal of antibiotic stewardship is to maximize the benefit of antibiotic treatment, while minimizing harm both to the individual person and to their community.
Neither of these definitions tell you not to prescribe antibiotics. Instead, antibiotic stewardship is the call to use antibiotics for the conditions where they are specifically indicated and to use the right choice of antibiotic, the right dose, route, and the right duration.
Prescribers should carefully consider if the patient's condition warrants an antibiotic. For example, providers may know that viral conditions will not improve with antibiotics, and therefore, shouldn't prescribe in this situation. Antibiotic stewardship also aims to help providers recognize that in some situations, like suspected sepsis, call for a quick administration of the appropriate antibiotic.
Antibiotic stewardship is fundamentally about patient safety and delivering high quality health care. Antibiotics are lifesaving, but like all medicines, they have risks and benefits. To keep our patients safe, we want to make sure that we're using antibiotics appropriately.
Part of this initiative includes the availability of resources and a framework for successfully implementing antibiotic stewardship in nursing homes. In the fall of 2016, the CDC released the core elements of antibiotic stewardship to aid in the implementation of a successful program.
The core elements of antibiotic stewardship in the nursing home are leadership support, accountability, drug expertise, actions to improve the use, tracking, monitoring of antibiotic prescribing, use and resistance, reporting information to staff on improving antibiotic resistance, and finally, education. Let's review them in greater depth.
A nursing home demonstrates leadership support through the actions, such as crafting a written statement of support. The nursing home would include antibiotic stewardship duties in the job descriptions of both the medical director and director of nursing.
A nursing home can show accountability through identifying a lead person or champion for antibiotic stewardship activities. This champion could include the medical director and/or the pharmacy consultant.
Another core element is drug expertise. A nursing home would have drug expertise when it has access to individuals with antibiotic stewardship knowledge, including a pharmacist or infectious disease consultant. The nursing home could also partner with the stewardship team of a hospital.
Actions to improve use include policies to improve antibiotic prescribing and use that may include algorithms for assessing residents and for appropriate diagnostic testing for specific infections. The tracking core element includes monitoring antibiotic prescribing, use, and resistance.
To accomplish this, the nursing home must have a process in place to monitor rates of Clostridium difficile infection, antibiotic resistant organisms, adverse drug events, adherence to clinical assessment documentation, and facility-specific prescribing. For example, nursing homes contract dose, duration, and indication.
The next element is reporting out information to staff on improving antibiotic use and resistance, which entails sharing facility-specific reports on antibiotic use and outcomes with clinical providers and nursing staff. These reports can include measures of antibiotic use in the facility, outcomes related to antibiotic use, antibiotic susceptibility patterns, and personalized feedback to clinical providers on their antibiotic prescribing practices.
Lastly, education is key when it comes to antibiotic stewardship. This means providing educational resources and materials about antibiotic resistance and opportunities for improving antibiotic use to clinical providers, nursing staff, residents, and their families.
Implementing these elements requires a thoughtful and consistent effort to achieve desired outcomes. This includes creating a strategic plan for stewardship, preparing your team for change, choosing diagnoses to improve, and testing your chosen stewardship interventions. These core elements and more information about antibiotic stewardship in long-term care may be found by visiting the CDC's website at www.cdc.gov/antibiotic/use.
Bacteria will always form a resistance to antibiotics. Action is needed now to keep new resistance from developing and to prevent current antibiotic resistance from spreading. Appropriate antibiotic use through antibiotic stewardship is key.
The TMF Quality Innovation Networks consultant staff are available to help you begin or strengthen your antibiotic stewardship plan. They can work with you to identify and address your goals, and also to assist you in making progress towards those objectives.
For more information or to request assistance, please email the TMF Quality Innovation Network at NHNetwork@TMF.org. Thanks for joining me for this long-term care antibiotic stewardship podcast. Watch for our next episode, coming soon.
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