The recent data regarding antibiotic stewardship Programs (ASPs) has demonstrated that programs dedicated to improving antibiotic use can enhance the treatment of infections as well as reduce adverse events associated with antibiotic use. Skilled nursing facilities are required to have an ASP in place by October 1, 2017 as published in the 2016 Mega Rule.

Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year.

Why is antibiotic/ antimicrobial stewardship important in your facility?

• Up to 75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate.
• Patients who are unnecessarily exposed to antibiotics are placed at risk for serious adverse events with no clinical benefit.
• The misuse of antibiotics has also contributed to the growing problem of antibiotic resistance, which has become one of the most serious and growing threats to public health.
• Unlike other medications, the potential for spread of resistant organisms means that the misuse of antibiotics can adversely impact the health of patients who are not even exposed to them.
• The Centers for Disease Control and Prevention (CDC) estimates more than two million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually.
• Improving the use of antibiotics is an important patient safety and public health issue as well as a national priority.
• Stewardship programs can result in significant annual drug cost savings and even larger savings when other costs are included. These savings have been helpful in garnering support for antibiotic stewardship programs. However, it is important to continue support for stewardship to maintain gains as costs can increase if programs are terminated.

So how do you implement an ASP in your facility? There are seven core elements that will help you begin your ASP:

1) Leadership Commitment. Components include:

• Dedicating the necessary human, financial and information technology resources to the task.
• Developing formal statements that the facility supports efforts to improve and monitor antibiotic use.
• Adding stewardship-related duties in job descriptions and annual performance reviews.
• Ensuring staff from relevant departments are given sufficient time to contribute to stewardship activities.
• Supporting training and education.
• Ensuring participation from the many groups that can support stewardship activities.

 2) Accountability. Components include:

• Appointing an infection prevention program coordinator.
• Engaging a consultant laboratory.
• Working with state and local health departments.

 3) Drug Expertise. Components include:

• Identifying a single consultant pharmacy leader who will co-lead the program.
• Implementing automatic changes from intravenous to oral antibiotic therapy.

• Implementing dose adjustments in cases of organ dysfunction.
• Reviewing antibiotic prescriptions as part of the drug regimen review.
• Reviewing microbiology culture results by the consultant pharmacist.
• Implementing dose optimization, including dose adjustments based on therapeutic drug monitoring.
• Instituting automatic alerts in situations where therapy might be unnecessarily duplicative.
• Instituting time-sensitive automatic stop orders for specified antibiotic prescriptions.
• Detection and prevention of antibiotic-related drug-drug interactions.
• Partnering with ASP leads at the hospitals within your referral network.

4) Taking Action. This entails taking action through policy and practice change—specifically, implementing at least one policy or practice to improve antibiotic use. Policies should also support optimal antibiotic use. Other elements include:

• Broad interventions to improve antibiotic use.
• Antibiotic “time outs.”
• Establishment of best practices for use of microbiology testing.
• Pharmacy interventions to improve antibiotic use.
• Development of facility-specific treatment recommendations.
• Development and implementation of algorithms for the assessment of residents suspected of having an infection using evidence-based guidance.
• Utilization of a communication tool for residents suspected of having an infection.
• Infection-specific interventions to improve antibiotic use.
• Reduction of antibiotic prophylaxis for prevention of UTI.
• Optimized management of nursing home-associated pneumonia.
• Optimized use of superficial cultures for management of chronic wounds.

 5) Tracking antibiotic use/outcomes. This entails:

• Process measures.
• Antibiotic use measures.
• Antibiotic outcome measures.
• Development and implementation of facility-specific treatment recommendations.
• Implementation of policies that apply in all situations to support optimal antibiotic prescribing.

 6) Reporting. This entails:

• Measurement, which is critical to identify opportunities for improvement and assess the impact of improvement efforts.
• Reporting/providing regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff.

 7) Education. This entails:

• Antibiotic stewardship education to clinicians nursing staff, residents and families.
• Providing regular updates on antibiotic prescribing, antibiotic resistance, and infectious disease management that address both national and local issues.
• by incorporating both education and feedback to providers.
• Engaging residents and their family members in antibiotic use and stewardship.
• The integration of information technology (IT) into the clinical data presentation and decision-making.

If you haven’t started your ASP, this is the time to get started. There are additional reference materials available from the CDC.

Contact Richter Healthcare Consultants

Do you have questions about antibiotic stewardship programs (ASPs) or need help understanding how they can positively impact your skilled nursing facility? Call Richter's clinical healthcare consultants at 866-806-0799 to schedule a free consultation. 

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Jennifer Leatherbarrow, RN BSN, RAC-CT, QCP, CIC is a Clinical Consultant with Richter Healthcare Consultants.