National Center for Emerging and Zoonotic Infectious Diseases Antibiotic Stewardship in Nursing Homes � Great Plains Quality Innovation Network � October 19th 2017 � Sarah Kabbani, MD, MSc Medical Officer, Office of Antibiotic Stewardship Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention
Objectives � Highlight the importance of antibiotic stewardship in nursing home and in new regulations � � Define the Core Elements of antibiotic stewardship for nursing homes � Discuss actions that can be taken to promote stewardship activities
Antibiotics are frequently prescribed in nursing homes.
A large number of Americans with increasing medical complexity reside in nursing homes. � Around 4 million Americans are admitted to or reside in a nursing home during a year 1 � 35% age ≥ 65 will receive nursing home care in their lifetime 2 � By 2060 the number of Americans ≥ 65 will double 3 � Residents at NH have increasingly more complex medical conditions 4 1. https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx 2. https://assets.aarp.org/rgcenter/il/fs10r_homes.pdf 3. http://www.prb.org/pdf16/aging-us-population-bulletin.pdf1http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age 4. http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age
Antibiotics are frequently prescribed in nursing homes. � Estimated 50-70% of residents will be prescribed an antibiotic in a year 1,2 – Based on limited data � One day point prevalence survey of antibiotic use in U.S. nursing homes 3 – December 2013-May 2014, 9 U.S. NH, 1,272 residents Median age 85 years (range 21-91), 70% were female, 14% were short stay – – Total AU was 11.1% (95% CI 9.4-12.9%) • 23% of AU was for prophylaxis • The most common indication for treatment was UTI (32%) • AU was more common in short stay residents (21.2%) and � residents with devices (23.5%%) p-value < 0.0001 � 1. Lim et al. Clin Interven Aging. 2014 Jan 13;9:165-77. 2. Nicolle et al. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45. 3. Thompson et al. J Am Med Dir Assoc. 2016 Dec 1;17(12):1151-1153.
Antibiotic prescribing in nursing homes is frequently inappropriate. � Estimated 40-75% of antibiotic use in nursing homes is inappropriate 1,2 – Diagnosis: treatment may not be indicated – Drug: antibiotic selection may not be correct – Dose: dosing may be inappropriate or not adjusted – Duration: longer than recommended guidelines – De-escalation: not adjusted based on clinical condition or laboratory results – Documentation: should reflect all D’s above 1. Lim et al. Clin Interven Aging. 2014 Jan 13;9:165-77. 2. Nicolle et al. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45
Testing and antibiotic prescribing for urinary tract infections in nursing homes is frequently inappropriate. � Asymptomatic bacteriuria is common in nursing home residents 1,2 � Up to half of antibiotics prescribed to treat urinary tract infection in older adults are unnecessary or inappropriate 3,4 – Appropriateness of AU for UTI ranged from 15-45% depending on appropriateness criteria applied 5 � Overtesting could lead to incorrectly diagnosing urinary tract infections, inappropriate treatment, adverse drug events and delays in diagnosis 6 1. Nicolle et al. Int J Antimicrob Agents. 2006 Aug;28 Suppl 1:S42-8. 2. Nicolle et al. Infect Control Hosp Epidemiol. 2001 Mar;22(3):167-75. 3. Crnich et a,. J Am Geriatr Soc. 2017 Aug;65(8):1661-1663. 4. Trautner. Nat Rev Urol. 2012;9(2):85-93. 5. Eure et al, Infect Control Hosp Epidemiol 2017 Aug;38(8):998-1001. 6. Hald. JAMA Intern Med. 2016 May 1;176(5):587-8.
Antibiotics save lives but increase the risk of adverse events in older adults. � Antibiotics were the second most common drug class causing outpatient ADEs in older adults 1 � Polypharmacy is associated with an increased risk of ADEs in older adults: 2 – The odds of adverse events increases with the number of regularly scheduled medications in residents in nursing homes � Antibiotics contribute to clinically significant drug interactions – Antibiotic prescribing increases the risk of bleeding in patients on warfarin. 3 1. Gurwitz et al. JAMA. 2003 Mar 5;289(9):1107-16. 2. Gurwitz et al. Am J Med. 2005 Mar;118(3):251-8. 3. Zhang et al. J Manag Care Pharm. 2006 Oct;12(8):640-8.
Antibiotics are a common cause of adverse drug events in nursing homes. � 13% of adverse drug events are secondary to antibiotic use 1 � Residents of high antibiotic use nursing homes had a 24% greater risk of antibiotic-related adverse events compared to low antibiotic use nursing homes 2 – Each additional day of antibiotic use leads to a 0.4% increased risk of antibiotic-related harm � Risk of acquiring Clostridium difficile infection and subsequent complications including death are greatest in older adults 3 – Up to 25% of patients can have recurrent disease after treatment � In Ohio 2006, >50% of healthcare-associated C. difficile infection with onset likely in nursing homes 5 1. Gurwitz et al. Am J Med. 2005 Mar;118(3):251-8. 2. Daneman et al. JAMA Intern Med. 2015 Aug;175(8):1331-1339. 3. Zilberberg et al. Emerg Infect Dis. 2008 Jun;14(6):929-31. 4. Kelly et al, Clin Microbial Infect. 2012 Dec;18 Suppl 6:21-7. 5. Campbell et al. Infect Control Hosp Epidemiol. 2009 Jun;30(6):526-33.
Nursing home residents can spread antibiotic resistant bacteria to other residents in the nursing home and in other health care settings. � Antibiotic exposure is one of the most important risk factors associated with the � development of antibiotic resistance 1,2 � � Residents who develop colonization with antibiotic resistant bacteria can spread these organisms to other residents 3,4 � Nursing homes are a key part of our interconnected healthcare system – Genetic and epidemiological studies of MRSA and carbapenem-resistant � Acute care hospital Gram-negatives highlighted transmission and interconnectedness of nursing � homes to acute hospitals and other sites 5 � 1. Bronzwaer et al, Emerg Infect Dis 2002 8(3): 278-282. Long-term acute 2. Costelloe et al, BMJ 2010 340: c2096. care hospital Nursing homes 3. O’Fallon et al, Infect Control Hosp Epidemiol. 2010;31:1148–1153. (LTACH) 4. Furuno et al, Infect. Control Hosp. Epidemiol. 2011;32:244–249. 5. Dumyati et al, Curr Infect Dis Rep 2017 Apr;19(4):18.
The antibiotic prescribing process in nursing homes is challenging. � Antibiotic prescribing in nursing home is frequently made off site and influenced by nursing staff communication. � The process of antibiotic prescribing in NH is complex and faces barriers that are different from the acute care and ambulatory settings 1 – Clinical uncertainty related to resident factors and limited resources – Decision to initiate antibiotics • 66% of antimicrobial prescriptions were started by telephone orders 2 • Transitions in care – Limited documentation of assessment and decision making process • For 38% of antibiotics administered , key prescribing information were not documented 3 – High staff turnover – Family preferences influence treatment decisions 1. Crnich et al. Drugs Aging. 2015 Sep;32(9):699-716. 2. Richards et al, J Am Med Dir Assoc. 2005 Mar-Apr;6(2):109-12. 3. Thompson et al. J Am Med Dir Assoc. 2016 Dec 1;17(12):1151-1153.
Antibiotic Stewardship Core Elements provide a framework to improve antibiotic prescribing in nursing homes.
Antibiotic stewardship is a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. � Antimicrobial stewardship includes: – Measuring antibiotic prescribing – Improving antibiotic prescribing – Minimizing misdiagnoses or delayed diagnoses – Ensure that the right drug, dose, and duration are selected � Antimicrobial stewardship interventions can lead to: – Improved individual resident outcomes – Prevention of the emergence of antibiotic resistance – Saving healthcare dollars
Infection Prevention and Antibiotic Stewardship Drivers in Nursing � Homes 2015 2015 � 2013 2014 White House CDC Core Elements of � HHS National Action Plan Office of Inspector Stewardship Forum Antibiotic Stewardship in � to Prevent Healthcare General Report Nursing Homes � Associated Infections 2015 2015 2016 2013 National Action Plan for CMS New Regulatory CMS Regulatory CDC Antibiotic Resistant Combating Antibiotic Proposal for Long Term Threats Report Requirements Finalized Resistant Bacteria Care Facilities
Centers for Medicare and Medicaid services reformed requirements of participation for long term care facilities. � On October 4 th 2016 CMS finalized long term care requirements of participation that would require antibiotic stewardship to become part of infection prevention and control programs (IPC) and pharmacy services – Antibiotic Use Protocols and monitoring included in IPC programs- effective Nov 2017 https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf
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