In the last 20 years, the US health care continuum has grown encompassing many additional care settings outside of the hospital. We continue to provide care and acute care hospitals, but have expanded to ambulatory care settings, long term acute care hospitals, long term care settings, and the home. In this presentation, we will focus on residents in long term care facilities. Resistant organisms are common in long term care facilities. In one long term care facility, 14-25 percent of residents were colonized with Methicillin-resistant staphylococcus aureus, ESPL producing Klebsiella, ESBL producing E.coli or Vancomycin-resistant enteroccoci. Studies have shown one of the strongest predictors of developing an antibiotic resistant infection is being a resident of a long term care facility. A study published in 2013, long term care facility residents had eight times the risk of contracting antibiotic resistant E.coli compared with non long term care facility residents. The reasons for high rates of drug resistant organisms and long term care facilities are multifaceted. Including the frequent transfer of patients with multi-drug resistant organisms from acute care hospitals to long term care facilities. Increased opportunities for horizontal transmission of drug resistant organisms and the widespread and often unnecessary use of antibiotics first, patients with multi-drug resistant organisms are often too sick to go home and therefore, must be discharged to long term care second, there is a propensity for horizontal transmission of resistant organisms within long term care facilities given largely poor infection control practices and an increase in invasive devices and procedures. Today, the long term care facility population includes more acute and sub-acute resonance with central lines, chronic respiratory therapy, feeding tubes, dialysis and IV antibiotics whom were previously treated in hospitals. In addition, staff and long term care facilities have not been given appropriate education to treat these more acutely ill residents. Antimicrobials are frequently prescribed long term care settings. Ascending from the 1980s, it was reported that at any one time eight percent of residents are on antimicrobial therapy, and each resident has a 50-70 percent likelihood of receiving at least one course of antimicrobials during a given year. Resistant organisms may also develop in a long-term care facility due to antibiotic treatment initiated in the hospital. In this study, residents who had received Levofloxacin in the hospital were 1.6 times more likely to develop MRSA in the long term care facility. If they had received a third-generation cephalosporin in the hospital, they were two times more likely to develop MRSA in the long term care facility. It is estimated that 25-75 percent of the systemic antimicrobial use and 60 percent of topical antimicrobial use in the long-term care setting is inappropriate and suboptimal. The take-home message from this is that antibiotic exposures and infection control measures in the hospital influence a long-term care facility residents health and vice versa. So, we must make every attempt to improve antibiotic use in both the acute care setting as well as long-term care setting. It is widely accepted that antimicrobial use optimization should occur in the acute care settings. The Joint Commission has now established criteria for a hospital antibiotic stewardship program. Programs that promote the appropriate use of antimicrobials by selecting appropriate agents, dose, duration, and route of administration. The objectives of an antibiotic stewardship program are to optimize the utilization of antimicrobial agents in order to minimize acquired resistance, improve patient outcomes, decrease patient toxicities, and reduce treatment costs. Many acute care hospitals have developed antibiotic stewardship programs due to an increase in prevalence of healthcare-associated infections, coupled with decreased reimbursement for healthcare associated infections and public reporting of these infections. They also recognize a lack of new antimicrobials that are in development. So, having an antibiotic stewardship program is fiscally responsible. But there is limited literature to support antimicrobial use optimization in long term care facilities. It is agreed upon that efforts are necessary to improve antimicrobial use in the long-term care setting and the Centers for Medicare and Medicaid Services has established the development and maintenance of antibiotic stewardship programs as a condition of participation for long term care facilities. These facilities have been slower to adopt antibiotic stewardship programs, due to a lack of necessary personnel. Usually, no infectious diseases trained personnel at the long term care facility nor an on-site pharmacist, lack of funding, and a paucity of well-validated strategies specific to long term care facilities that can be easily implemented. The clinical diagnosis of infection in this population is also in precise. Symptoms are often not expressed or misinterpreted because there are hearing and cognition and pyramids and many comorbidities. The febrile response maybe relatively impaired and fever without a source is quite frequent in this setting and there may be limitations and resources to support an appropriate clinical assessment of the resonant. For example, there may not be an advanced licensed practitioner on-site to evaluate a fever in a resonant. Evidence-based recommendations on the use of antimicrobials in long term care residents, are also limited. When there are recommendations, they are often based on clinical criteria targeted for younger populations with less complex problems and optimal treatment regimens have not been well-defined. The Centers for Disease Control and Prevention has developed the core elements for antibiotic stewardship and nursing homes to provide guidance. This chart shows an antimicrobial stewardship strategy hierarchy for use in long term care. At the bottom of the chart, are the least intrusive strategies and at the top of the chart, the most intrusive. Passive monitoring includes measuring types and quantities of antibiotics used. In understanding the presence of antimicrobial resistant organisms in the facility based on laboratory data, these activities may be implemented by a non-pharmacists nor IT trained health care provider. So, the suggestion is that passive monitoring can occur in any long term care facility. Education is the next strategy that is suggested. That may take a little more time and effort in organizing a group of health care providers and providing them with the appropriate education on improving antimicrobial use. The Front End passive approach is essentially limiting the types of antibiotics that are available in the facility. Essentially, implementing a formulary based on facility-specific susceptibility patterns. Then there is the more active front end approach, which is requiring pre-authorization of antibiotics based upon predetermine criteria. Lastly, the most intrusive strategy is post prescriptive review and feedback. When a team or expert antimicrobial prescribers provide feedback to the primary prescriber on their choice of antibiotics. So, how do you select the cases for review? Selection criteria should be tailored to the problems in the facility and may include targeting residence on high use agents, double coverage of anaerobes or optimizing management of one infectious syndrome. The syndromic approach, is one option which I believe is quite useful in the long term care setting such as focusing on asymptomatic bacteriuria. Asymptomatic bacteriuria is defined as positive urine cultures in the absence of clinical signs and symptoms. Treatment for asymptomatic bacteriuria is indicated in pregnancy and after the general urinary tract is manipulated only. However, multiple treatments are often given for asymptomatic bacteriuria in the elderly. Trial after trial have shown that there is no real benefit from treating patients with asymptomatic bacteriuria. As therapy does not decrease the occurrence of symptomatic infection or chronic symptoms nor alter mortality. A major consequence of treating patients with antibiotics for asymptomatic bacteriuria is unnecessary adverse drug effects and colonization with multi-drug resistant organisms. Five to 50 percent of elderly patients and long term care facilities have bacteriuria, and over 90 percent of elderly with bacteriuria have pyuria. There is no evidence of poor clinical outcomes for patients with high levels of pyuria. In fact, some individuals have levels of pyuria greater than a thousand white blood cells per millimeter cubed of urine persisting for months or years. Asymptomatic bacteriuria with or without pyuria should not be treated and the elderly are residents of long-term care facilities with asymptomatic bacteriuria, we suggest removal the indwelling catheter and replacing it with a straight or condom catheter along with other prevention measures. This study looked at an educational intervention targeting the diagnosis and treatment of asymptomatic bacteriuria. Study investigators educated nurses on when to send a urine culture and doctors on asymptomatic bacteriuria on when it was appropriate to treat a urinary tract infection. This educational intervention was effective in decreasing total urine culture sent, decreasing inappropriate cultures, and decreasing number of residents treated for asymptomatic bacteriuria. Another study that I was involved with, implemented a formal antibiotic stewardship programs in three community long term care facilities utilizing post prescriptive review and feedback with an ID pharmacist and an ID physician. Qualitatively, we found urinary catheters were quite uncommon. Residents rarely had signs and symptoms consistent with UTI. An empiric therapy was rarely used. There was a lot of pressure from nurses and families to send urine analyses and urine cultures for sought applications even if the physician did not want to test. There was also significant pressure to treat positive cultures regardless of symptoms, which perpetuated treatment of asymptomatic bacteriuria. Antibiotic use in this study, was most often inappropriate and only indicated in 18 percent of the cases evaluated. In summary, antibiotic stewardship programs are essential in long term care facilities. Because there is a high rate of resistant organisms in this setting, variable infection control oversight, and unnecessary utilization of antimicrobials. CMS has established regulatory guidance to prioritize the development of antibiotic stewardship programs in long term care facilities. However, implementation of antibiotic stewardship programs in long term care facilities is obviously quite difficult given the elderly population and there are complexities with clinical assessment and diagnosis as well as limited treatment guideline availability. The syndromic approach may be used as low-hanging fruit to target syndromes such as pneumonia or UTI. Educational strategies have demonstrated utility, but must include nurses, residents, and their families. ASP interventions must be tailored to the specific environment. One size does not fit all, especially in long term care facilities. Our recommendations are that acute care and long-term care settings should partner together and improve inter-facility communication and share resources such as ID expertise, infection control, and pharmacy expertise. The goal should be a standardized regional approach to antimicrobial stewardship implementation and infection control. Because that strategy will be the most beneficial for our patients and residents.
