Nurs­ing home re­duces an­tibi­otic use

Modern Healthcare - - BEST PRACTICES - By Sabriya Rice

When a MRSA out­break af­fect­ing at least 22 pa­tients and em­ploy­ees at the Park Manor Nurs­ing Home was con­firmed in the sum­mer of 2006, fa­cil­ity med­i­cal di­rec­tor Dr. Joe Bo­ero didn’t know where to be­gin.

The in­fec­tion con­trol team at the Park Falls, Wis., fa­cil­ity sus­pected the high rate of drug-re­sis­tant bac­te­ria in the fa­cil­ity was linked to physi­cians pre­scrib­ing an­tibi­otics “to any­thing that moved,” Bo­ero re­called. Nurs­ing di­rec­tor Paula Koch had just re­turned from a con­fer­ence on an­tibi­otic overuse and drug-re­sis­tant bac­te­ria. But the team had no proof this was linked to Park Manor’s methi­cillinre­sis­tant Sta­phy­lo­coc­cus au­reus out­break. “You have to get me some data,” Bo­ero told the team.

So they de­vel­oped a spread­sheet on an­tibi­otic use. “Any­thing they could think of, they started count­ing,” Bo­ero said. The spread­sheet listed the type of an­tibi­otic given to each pa­tient for spe­cific symp­toms and length of use. Each physi­cian, an­tibi­otic and type of bac­te­ria was given a color for easy track­ing.

“They es­sen­tially made an in­vis­i­ble prob­lem more vis­i­ble,” said Dr. Chris Cr­nich, an as­so­ciate pro­fes­sor in the in­fec­tious dis­eases divi­sion at the Univer­sity of Wis­con­sin, who ad­vised and eval­u­ated the pro­gram. Col­lab­o­ra­tion, chart­ing and lead­er­ship sup­port were crit­i­cal to the project’s suc­cess, he added.

The team found that staff at the 108bed fa­cil­ity had pre­scribed a to­tal of 503 an­tibi­otics in 2006, which av­er­aged 11.7 pre­scrip­tions per 1,000 pa­tient days. That led the nurs­ing home to launch an an­tibi­otic re­sis­tance-re­duc­tion pro­gram.

All physi­cians were ed­u­cated about an­tibi­otic overuse through a let­ter cam­paign at the end of 2006. In 2009, Bo­ero be­gan con­tact­ing doc­tors who showed up as out­liers. He faced some push­back.

In Septem­ber, the Cen­ters for Dis­ease Con­trol and Preven­tion is­sued rec­om­men­da­tions to fight su­per­bugs in nurs­ing homes. It said that up to 75% of an­tibi­otics pre­scribed in longterm-care fa­cil­i­ties are given un­neces- sar­ily. In re­cent years, pub­lic health lead­ers have urged use of an­tibi­otic ste­ward­ship pro­grams to com­bat overuse in health­care set­tings.

The push arises from the grow­ing num­ber of bac­te­ria re­sis­tant to mul­ti­ple an­tibi­otic ther­a­pies. In 2014, Pres­i­dent Barack Obama de­scribed the prob­lem as a threat to na­tional se­cu­rity; in Jan­uary, he pro­posed $993 mil­lion in fund­ing for 2016 to tackle the is­sue.

A study in the Jour­nal of In­fec­tion Con­trol and Hospi­tal Epi­demi­ol­ogy in May linked an­tibi­otic overuse to di­ag­nos­tic chal­lenges. It’s a prob­lem in cor­rectly treat­ing uri­nary tract in­fec­tions, one of the key driv­ers of an­tibi­otic use in long-term-care fa­cil­i­ties, said Dr. David Gif­ford, se­nior vice pres­i­dent at the Amer­i­can Health Care As­so­ci­a­tion, which rep­re­sents nurs­ing homes.

When a uri­nary tract in­fec­tion is sus­pected, nurs­ing home res­i­dents are tested. About half of el­derly peo­ple have ex­cess bac­te­ria, but that’s not al­ways in­dica­tive of an in­fec­tion, Gif­ford said. It still re­sults in more fre­quent an­tibi­otic pre­scrib­ing, he added. “You could have ev­ery fa­cil­ity in the coun­try im­ple­ment preven­tion meth­ods, but if we don’t change how we test, we will not see much change,” he said.

In 2014, Park Manor started ap­ply­ing cri­te­ria that lim­ited when nurses could re­quest tests for uri­nary and res­pi­ra­tory tract in­fec­tions. While a to­tal of 291 UTI tests were or­dered in 2006, only 85 were or­dered last year. “When the tests go down, an­tibi­otic use goes down,” Bo­ero said.

The ef­forts paid off: In 2014, Park Manor logged 212 to­tal an­tibi­otic pre­scrip­tions, for an av­er­age 6.04 per 1,000 pa­tient days. That was more than a 40% re­duc­tion in the an­tibi­otic pre­scrip­tion rate since the pro­gram started in 2006.

There’s a push for sim­i­lar an­tibi­otic ste­ward­ship ef­forts across the coun­try. The CDC, So­ci­ety for Health­care Epi­demi­ol­ogy of Amer­ica and Amer­i­can Geri­atrics So­ci­ety have re­leased tools to help long-term-care fa­cil­i­ties track health­care-as­so­ci­ated in­fec­tions and drive down an­tibi­otic overuse rates.

In July, the CMS pro­posed re­quir­ing 15,000 long-term-care fa­cil­i­ties serv­ing Medi­care and Med­i­caid pa­tients to each hire an in­fec­tion preven­tion and con­trol of­fi­cer and in­sti­tute an an­tibi­otic ste­ward­ship pro­gram.

But Cr­nich cau­tioned against “sim­ply re­duc­ing an­tibi­otics at all costs and un­der­treat­ing in­fec­tions.”

Gif­ford noted that there are pow­er­ful fac­tors work­ing against re­duc­ing an­tibi­otic use, such as med­i­cal liability con­cerns, pa­tients and fam­i­lies de­mand­ing an­tibi­otic treat­ment, and fed­eral read­mis­sion penal­ties re­lated to po­ten­tially pre­ventable blad­der in­fec­tions.

“Fa­cil­i­ties are try­ing to im­prove, but you’ve also got all th­ese forces,” he said. “It’s kind of like swim­ming up­stream.”

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