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Silva JBB, Riester MR, Zullo AR. Antibiotic Prescribing Patterns for Urinary Tract Infections and Pneumonia by Prescriber Type and Specialty in Nursing Home Care, 2016-2018. J Am Med Dir Assoc 2024; 25:769-773.e9. [PMID: 38428833 DOI: 10.1016/j.jamda.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE To identify whether differences in antibiotic prescribing practices by prescriber type and specialization in nursing home (NH) care exist for urinary tract infection (UTI) and pneumonia. DESIGN Retrospective cohort. SETTING AND PARTICIPANTS This national study included antibiotic dispensings to traditional Medicare beneficiaries aged ≥65 years with UTI or pneumonia infections residing long-term (≥100 days) in US NHs between 2016 and 2018. METHODS Minimum Data Set assessment data were linked to Medicare data [Part D prescription drug, inpatient hospital (MedPAR), prescriber characteristics, and enrollment]. We compared antibiotic prescribing patterns by prescriber type [physician vs advanced practice practitioner (AP)] and NH specialization (≥90% vs <90% of all associated medication dispensings to NH residents). Antibiotic dispensing measures included the total number of dispensings and duration of therapy (median number of days supplied) by antibiotic class. RESULTS There were 264,735 antibiotic dispensings prescribed by 32,437 prescribers for 140,360 residents in 14,035 NHs. NH specialists were less likely to prescribe fluoroquinolones for UTI (22.9% NH specialist physician, 23.9% non-NH specialist physician, 21.3% NH specialist AP, 24.2% non-NH specialist AP), but more likely to prescribe fluoroquinolones for pneumonia (38.9%, 37.8%, 38.8%, 37.3%, respectively). Over time, NH specialists reduced fluoroquinolone prescribing for pneumonia to a greater extent than non-NH specialists. The duration of therapy was similar across prescriber groups for UTI, but longer among non-NH specialist APs for several antibiotic classes for pneumonia, including tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole. CONCLUSIONS AND IMPLICATIONS There were differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Understanding how antibiotic prescribing differs based on prescriber characteristics is essential to inform antibiotic stewardship efforts. Tailoring antibiotic stewardship efforts to prescribers by NH specialization is rational given differences in antibiotic prescribing patterns based on NH specialization.
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Affiliation(s)
- Joe B B Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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König E, Kriegl L, Pux C, Uhlmann M, Schippinger W, Avian A, Krause R, Zollner-Schwetz I. Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study. Antimicrob Resist Infect Control 2024; 13:43. [PMID: 38627795 PMCID: PMC11020885 DOI: 10.1186/s13756-024-01397-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Widespread inappropriate use of antimicrobial substances drives resistance development worldwide. In long-term care facilities (LTCF), antibiotics are among the most frequently prescribed medications. More than one third of antimicrobial agents prescribed in LTCFs are for urinary tract infections (UTI). We aimed to increase the number of appropriate antimicrobial treatments for UTIs in LTCFs using a multi-faceted antimicrobial stewardship intervention. METHODS We performed a non-randomized cluster-controlled intervention study. Four LTCFs of the Geriatric Health Centers Graz were the intervention group, four LTCFs served as control group. The main components of the intervention were: voluntary continuing medical education for primary care physicians, distribution of a written guideline, implementation of the project homepage to distribute guidelines and videos and onsite training for nursing staff. Local nursing staff recorded data on UTI episodes in an online case report platform. Two blinded reviewers assessed whether treatments were adequate. RESULTS 326 UTI episodes were recorded, 161 in the intervention group and 165 in the control group. During the intervention period, risk ratio for inadequate indication for treatment was 0.41 (95% CI 0.19-0.90), p = 0.025. In theintervention group, the proportion of adequate antibiotic choices increased from 42.1% in the pre-intervention period, to 45.9% during the intervention and to 51% in the post-intervention period (absolute increase of 8.9%). In the control group, the proportion was 36.4%, 33.3% and 33.3%, respectively. The numerical difference between intervention group and control group in the post-intervention period was 17.7% (difference did not reach statistical significance). There were no significant differences between the control group and intervention group in the safety outcomes (proportion of clinical failure, number of hospital admissions due to UTI and adverse events due to antimicrobial treatment). CONCLUSIONS An antimicrobial stewardship program consisting of practice guidelines, local and web-based education for nursing staff and general practitioners resulted in a significant increase in adequate treatments (in terms of decision to treat the UTI) during the intervention period. However, this difference was not maintained in the post-intervention phase. Continued efforts to improve the quality of prescriptions further are necessary. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov NCT04798365.
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Affiliation(s)
- Elisabeth König
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Christian Pux
- Geriatric Health Centers of the City of Graz, Graz, Austria
| | | | | | - Alexander Avian
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Ines Zollner-Schwetz
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.
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Conlin M, Hamard M, Agrinier N, Birgand G. Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review. Clin Microbiol Infect 2024; 30:431-444. [PMID: 38141820 DOI: 10.1016/j.cmi.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context. OBJECTIVES This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness. DATA SOURCES Electronic databases until April 2022. STUDY ELIGIBILITY CRITERIA Articles covering implementation of AMS interventions in LTCFs. ASSESSMENT OF RISK OF BIAS Mixed Methods Appraisal Tool for empirical studies. METHODS OF DATA SYNTHESIS Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study. RESULTS Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation. CONCLUSIONS The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.
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Affiliation(s)
- Michèle Conlin
- Regional Center for Infection Prevention and Control Pays de la Loire, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marie Hamard
- Unité de gériatrie Aiguë, Hôpital Bichat-Claude Bernard, Paris, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, F-54000 Nancy, France; CHRU-Nancy, Inserm, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, France.
| | - Gabriel Birgand
- Regional Center for Infection Prevention and Control Pays de la Loire, Centre Hospitalier Universitaire de Nantes, Nantes, France; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London, London, UK
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Jain S, Patel RB, Vala L, Kinthada S, Patel N, Jain S, Khan T, Nanjundappa A, Sirekulam V, Naik N, Siripuram C, Gill H. Missing Renal Stone Diagnosis in Dementia Patients With Recurrent Urinary Tract Infections: A Case Report and Literature Review. Cureus 2024; 16:e58908. [PMID: 38800185 PMCID: PMC11117170 DOI: 10.7759/cureus.58908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
In older adults, diagnosing, treating, and preventing urinary tract infections (UTIs) can be challenging. This case is of an 82-year-old female of white descent, who was admitted to a post-acute care facility following hospitalization for delirium and a UTI. Hypoactive delirium may be the only clinical manifestation of recurrent UTI. Due to challenges in obtaining a history from this patient with dementia, she had to be admitted multiple times for sepsis. During her final hospitalization, a CT scan of the abdomen and pelvis was ordered, which revealed an obstructed kidney stone as the cause of her recurrent UTIs. Recurrent UTIs especially in patients with dementia should prompt further imaging to look for kidney stones. Factors like dehydration and poor oral intake are risk factors for kidney stones, which patients with dementia are susceptible to.
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Affiliation(s)
- Sakshi Jain
- Department of Geriatrics, Hackensack University Medical Center, Hackensack, USA
| | | | - Lovekumar Vala
- Department of Anatomy, Shantabaa Medical College, Amreli, IND
| | - SudhaRani Kinthada
- Department of Obstetrics and Gynecology, Rangaraya Medical College, Kakinada, IND
| | - Neel Patel
- Department of Medical Education, GMERS Medical College Gotri, Vadodara, IND
| | - Shikha Jain
- Department of Medicine, MVJ Medical College and Research Hospital, Bengaluru, IND
| | - Tanzina Khan
- Department of Internal Medicine, Bangladesh Medical College, Dhaka, BGD
| | | | - Vaishnavi Sirekulam
- Department of Medicine, Vijayanagar Institute of Medical Sciences, Ballari, IND
| | - Nishthaben Naik
- Department of Health & Family Welfare, Primary Health Center, Bigri, Navsari, IND
| | - Chandu Siripuram
- Department of Hospital Medicine, Geisinger Medical Center, Scranton, USA
| | - Harmeet Gill
- Department of Medicine, HopeHealth, Florence, USA
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Halonen K, van der Kooi T, Hertogh C, Haenen A, de Greeff SC. Prevalence of healthcare-associated infections in Dutch long-term care facilities from 2009 to 2019. J Hosp Infect 2024; 143:150-159. [PMID: 37321412 DOI: 10.1016/j.jhin.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/02/2023] [Accepted: 06/04/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We assessed trends in the prevalence of healthcare-associated infections (HCAIs) and associated resident and facility characteristics in a national network of long-term care facilities (LTCFs) in the Netherlands from 2009 to 2019. METHODS Participating LTCFs registered the prevalence of urinary tract infection (UTI), lower respiratory tract infection (LRTI), gastrointestinal infection (GI), bacterial conjunctivitis, sepsis and skin infection, using standardized definitions, in biannual point-prevalence surveys (PPSs). In addition, resident and LTCF characteristics were collected. Multi-level analyses were performed to study changes in the HCAI prevalence over time and to identify resident and LTCF-related risk factors. Analyses were performed for HCAIs overall and for UTI, LRTI and GI combined as these were recorded throughout the period. RESULTS Overall, 1353 HCAIs were registered in 44,551 residents with a prevalence of 3.0% (95% confidence interval: 2.8-3.1; range between years 2.3-5.1%). When including only UTI, LRTI and GI the prevalence decreased from 5.0% in 2009 to 2.1% in 2019. Multi-variable regression analyses for UTI, LRTI and GI combined indicated that both prolonged participation and calendar time were independently associated with HCAI prevalence; in LTCFs that participated ≥4 years, the HCAI risk was decreased (OR 0.72 (0.57-0.92)) compared with the first year, and the OR per calendar year was 0.93 (0.88-0.97). CONCLUSIONS Over 11 years of PPS in LTCFs the HCAI prevalence decreased over time. Prolonged participation further reduced the HCAI prevalence, in particular UTIs, despite the increasing age and associated frailty of the LTCF population, illustrating the potential value of surveillance.
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Affiliation(s)
- K Halonen
- National Institute for Public Health and the Environment, Centre for Infectious Disease Research, Epidemiology and Surveillance, Bilthoven, the Netherlands.
| | - T van der Kooi
- National Institute for Public Health and the Environment, Centre for Infectious Disease Research, Epidemiology and Surveillance, Bilthoven, the Netherlands
| | - C Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
| | - A Haenen
- National Institute for Public Health and the Environment, Centre for Infectious Disease Research, Epidemiology and Surveillance, Bilthoven, the Netherlands
| | - S C de Greeff
- National Institute for Public Health and the Environment, Centre for Infectious Disease Research, Epidemiology and Surveillance, Bilthoven, the Netherlands
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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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Chahine EB, Clifford KM, Ladikos N, Milito DA, Morris L, Ranucci S, Dilworth TJ, Pagels CM, Wagner JL, Witsken C, Phillips DC. The Essential Role of Senior Care Pharmacists in Antimicrobial Stewardship: An Updated Position Statement on Behalf of the American Society of Consultant Pharmacists and the Society of Infectious Diseases Pharmacists. Sr Care Pharm 2023; 38:452-456. [PMID: 37885096 DOI: 10.4140/tcp.n.2023.452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Senior care pharmacists are well-positioned to lead and drive antimicrobial stewardship (AMS) initiatives, not only through audit and data collection, but also through communication, collaboration, and cooperation with prescribers and nurses to influence prescribing behaviors. Senior care pharmacists are in a unique position to take a leadership role within the interprofessional team to achieve AMS goals. They should engage with the interprofessional team to promote the judicious and appropriate use of antimicrobials at their practice sites. This position statement is an update of the 2017 version by the American Society of Consultant Pharmacists (ASCP) Antimicrobial Stewardship and Infection and Prevention Control Committee and the Society of Infectious Diseases Pharmacists (SIDP).
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Affiliation(s)
- Elias B Chahine
- Professor of Pharmacy Practice, Palm Beach Atlantic University Gregory School of Pharmacy
| | - Kalin M Clifford
- Associate Professor of Pharmacy Practice Texas Tech University Health Sciences Center
| | - Nicholas Ladikos
- Clinical Pharmacist, Optum Serve/World Trade Center Health Program
| | - Deborah A Milito
- Director of Clinical and Consultant Services-LTC Division, Chief Antimicrobial Stewardship Officer, Diamond Pharmacy Services, ASCP President (2023-2024)
| | - Lisa Morris
- Executive Director, Clinical Services, Consana Health, ASCP President (2018-2019)
| | - Stacey Ranucci
- Director of Clinical Pharmacy Services, RI Primary Care Physician Corporation/Integra
| | | | - Courtney M Pagels
- Clinical Pharmacy Specialist, Infectious Diseases, Clement J. Zablocki VA Medical Center
| | - Jamie L Wagner
- Clinical Associate Professor, University of Mississippi School of Pharmacy
| | - Carmen Witsken
- Executive Fellow in Association Leadership and Management ASCP
| | - David C Phillips
- Director, Pharmacy Services, Julian F. Keith Alcohol & Drug Abuse Treatment Center
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Gillespie C, Sitter K, McConeghy KW, Strymish J, Gupta K, Hartmann CW, Borzecki AM. Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2848-2854.e3. [PMID: 37352930 DOI: 10.1016/j.jaip.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.
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Affiliation(s)
- Chris Gillespie
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass.
| | - Kailyn Sitter
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass
| | - Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI; Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI
| | - Judith Strymish
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass
| | - Kalpana Gupta
- Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass; Center for Healthcare Organization and Implementation Research (CHOIR), Boston Campus, VA Boston Healthcare System, Boston, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Zuckerberg College of Health Sciences, Department of Public Health, University of Massachusetts Lowell, Lowell, Mass
| | - Ann M Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass; School of Public Health, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston University, Boston, Mass
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Azzini AM, Be G, Naso L, Lambertenghi L, Salerno ND, Coledan I, Bazaj A, Mirandola M, Miotti J, Mazzaferri F, Accordini S, Lo Cascio G, Tacconelli E. Risk factors for colonization with multidrug-resistant Gram-negative bacteria and Clostridioides difficile in Long Term Care Facilities (LTCFs) residents: the evidence from 27 facilities in a high endemic setting. Front Cell Infect Microbiol 2023; 13:1155320. [PMID: 37377644 PMCID: PMC10292821 DOI: 10.3389/fcimb.2023.1155320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for C. difficile colonization. Methods A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of C. difficile was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models. Results In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (E. coli 65%, K. pneumoniae 14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant K. pneumoniae, and 3% in a carbapenem-resistant E. coli. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by C. difficile was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with C. difficile colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%). Conclusion Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.
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Affiliation(s)
- Anna Maria Azzini
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giorgia Be
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Disease Unit, Mater Salutis Hospital - ULSS 9 Scaligera, Legnago, Italy
| | - Laura Naso
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
| | - Lorenza Lambertenghi
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nicola Duccio Salerno
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ilaria Coledan
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- SerT Suzzara, SC Ser.D. Mantova, ASST Mantova, Suzzara, Italy
| | - Alda Bazaj
- Microbiology Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Massimo Mirandola
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jessica Miotti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giuliana Lo Cascio
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
- Microbiology Unit, AUSL Piacenza, Piacenza, Italy
| | - Evelina Tacconelli
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Archbald-Pannone L. How do we best manage Clostridioides difficle infections in the elderly? Expert Rev Anti Infect Ther 2023; 21:499-501. [PMID: 36522295 DOI: 10.1080/14787210.2023.2158814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Laurie Archbald-Pannone
- Department of Medicine, Division of General, Geriatric, Hospital & Palliative Medicine and Division of Infectious Diseases and International Health University of Virginia, Charlottesville, VA, USA
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Dickinson DT, Gouin KA, Neuhauser MM, Benedict K, Cincotta S, Kabbani S. Evaluation of antifungal use in long-term care facilities using pharmacy dispensing data in the USA, 2019. J Antimicrob Chemother 2022; 78:309-311. [PMID: 36385559 PMCID: PMC10950041 DOI: 10.1093/jac/dkac384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Drew T. Dickinson
- University of California San Francisco School of Pharmacy, San Francisco, CA, USA
| | - Katryna A. Gouin
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Melinda M. Neuhauser
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kaitlin Benedict
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Samuel Cincotta
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarah Kabbani
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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12
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Sine K, Appaneal H, Dosa D, LaPlante KL. Antimicrobial Prescribing in the Telehealth Setting: Framework for Stewardship During a Period of Rapid Acceleration Within Primary Care. Clin Infect Dis 2022; 75:2260-2265. [PMID: 35906829 PMCID: PMC9384578 DOI: 10.1093/cid/ciac598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 01/19/2023] Open
Abstract
Antibiotic resistance is a global public health threat. The use of telehealth in primary care presents unique barriers to antimicrobial stewardship, including limited physical examination and changes to the patient-provider relationship. Since the coronavirus disease 2019 (COVID-19) pandemic, there is a need to identify novel antimicrobial stewardship strategies with an explosion in the use of telehealth within primary care. Our review proposes a tailored, sustainable approach to antimicrobial prescribing in the telehealth setting based on the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship: commitment, action for policy and practice; tracking and reporting; and education and expertise. The rapid growth of telehealth for all types of primary care visits (not just antibiotic use) is outpacing knowledge associated with strategies for antimicrobial stewardship. Improving antibiotic use within primary care settings is critical as telehealth will remain a priority whether the COVID-19 pandemic recedes, particularly within patient populations with limited access to healthcare.
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Affiliation(s)
- Kathryn Sine
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Haley Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA,Department is College of pharmacy, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - David Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA,Department is College of pharmacy, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA,Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI School of Public Health, Brown University, Providence, RI, USA
| | - Kerry L LaPlante
- Correspondence: K. L. LaPlante, University of Rhode Island College of Pharmacy, 7 Greenhouse Road, Suite 255A-C, Kingston, RI 02881, USA ()
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13
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Krzyzaniak N, Forbes C, Clark J, Scott AM, Mar CD, Bakhit M. Antibiotics versus no treatment for asymptomatic bacteriuria in residents of aged care facilities: a systematic review and meta-analysis. Br J Gen Pract 2022; 72:BJGP.2022.0059. [PMID: 35940886 PMCID: PMC9377352 DOI: 10.3399/bjgp.2022.0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/25/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Asymptomatic bacteriuria (ASB) is common among residents of residential aged care facilities (RACFs). However, differentiating between an established urinary tract infection and ASB in older adults is difficult. As a result, the overuse of dipstick urinalysis, as well as the subsequent initiation of antibiotics, is common in RACFs. AIM To find, appraise, and synthesise studies that reported the effectiveness, harms, and adverse events associated with antibiotic treatment for older patients with ASB residing in RACFs. DESIGN AND SETTING A systematic review using standard Cochrane methods of RACF residents with ASB using antibiotics against placebo, or no treatment. METHOD Three electronic databases (PubMed, EMBASE, and CENTRAL), clinical trial registries, and forward-backward reference checks of included studies were searched. RESULTS Nine randomised controlled trials, comprising 1391 participants were included; two of which used a placebo comparator, and the remaining seven used no therapy control groups. There was a relatively small number of studies assessed per outcome and an overall moderate risk of bias. Outcomes related to mortality, development of ASB, and complications were comparable between the two groups. Antibiotic therapy was associated with a higher number of adverse effects (four studies; 303 participants; risk ratio [RR] 5.62, 95% confidence interval [CI] = 1.07 to 29.55, P = 0.04) and bacteriological cure (nine studies; 888 participants; RR 1.89, 95% CI = 1.08 to 3.32, P = 0.03). CONCLUSION Overall, although antibiotic treatment was associated with bacteriological cure, it was also associated with significantly more adverse effects. The harms and lack of clinical benefit of antibiotic use for older patients in RACFs may outweigh the benefits.
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Affiliation(s)
- Natalia Krzyzaniak
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Connor Forbes
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Chris Del Mar
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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14
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Katz MJ, Tamma PD, Cosgrove SE, Miller MA, Dullabh P, Rowe TA, Ahn R, Speck K, Gao Y, Shah S, Jump RLP. Implementation of an Antibiotic Stewardship Program in Long-term Care Facilities Across the US. JAMA Netw Open 2022; 5:e220181. [PMID: 35226084 PMCID: PMC8886516 DOI: 10.1001/jamanetworkopen.2022.0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown. OBJECTIVES To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019. INTERVENTIONS Fifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate. MAIN OUTCOMES AND MEASURES The primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10 000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time. RESULTS Of a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was -0.41 (95% CI, -0.76 to -0.07; P = .02), with fluoroquinolones showing the greatest decrease at -0.21 starts per 1000 resident-days (95% CI, -0.35 to -0.08; P = .002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (-3.05; 95% CI, -6.34 to 0.23; P = .07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, -1.75 to -0.49; P < .001) and 9.97 per 1000 resident-days (95% CI, -15.4 to -4.6; P < .001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, -0.61 to -0.15; P = .001). There was no significant change in facility-onset C difficile laboratory-identified events. CONCLUSIONS AND RELEVANCE Participation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings.
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Affiliation(s)
- Morgan J. Katz
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D. Tamma
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara E. Cosgrove
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa A. Miller
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | | | - Roy Ahn
- NORC at the University of Chicago, Chicago, Illinois
| | - Kathleen Speck
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yue Gao
- NORC at the University of Chicago, Bethesda, Maryland
| | | | - Robin L. P. Jump
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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15
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Tandan M, Thapa P, Maharjan P, Bhandari B. Impact of Antimicrobial Stewardship Program on Antimicrobial Resistant and Prescribing in Nursing Home: A Systematic Review and Meta-analysis. J Glob Antimicrob Resist 2022; 29:74-87. [DOI: 10.1016/j.jgar.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/25/2022] [Accepted: 02/06/2022] [Indexed: 11/29/2022] Open
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16
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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17
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Daneman N, Lee SM, Bai H, Bell CM, Bronskill SE, Campitelli MA, Dobell G, Fu L, Garber G, Ivers N, Lam JMC, Langford BJ, Laur C, Morris A, Mulhall C, Pinto R, Saxena FE, Schwartz KL, Brown KA. Population-Wide Peer Comparison Audit and Feedback to Reduce Antibiotic Initiation and Duration in Long-Term Care Facilities with Embedded Randomized Controlled Trial. Clin Infect Dis 2021; 73:e1296-e1304. [PMID: 33754632 DOI: 10.1093/cid/ciab256] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents. METHODS We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter. RESULTS Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference -2.65%, 95% confidence interval [CI]: -4.93 to -.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports. CONCLUSIONS Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466.
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Affiliation(s)
- Nick Daneman
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Public Health Ontario, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samantha M Lee
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Heming Bai
- Ontario Health, Toronto, Ontario, Canada
| | - Chaim M Bell
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Susan E Bronskill
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | - Longdi Fu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Gary Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Noah Ivers
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | - Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Andrew Morris
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Ruxandra Pinto
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Farah E Saxena
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Kevin A Brown
- Public Health Ontario, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
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18
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Langford BJ, Brown KA, Diong C, Marchand-Austin A, Adomako K, Saedi A, Schwartz KL, Johnstone J, MacFadden DR, Matukas LM, Patel SN, Garber G, Daneman N. The Benefits and Harms of Antibiotic Prophylaxis for Urinary Tract Infection in Older Adults. Clin Infect Dis 2021; 73:e782-e791. [PMID: 33595621 DOI: 10.1093/cid/ciab116] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The role of antibiotics in preventing urinary tract infection (UTI) in older adults is unknown. We sought to quantify the benefits and risks of antibiotic prophylaxis among older adults. METHODS We conducted a matched cohort study comparing older adults (≥66 years) receiving antibiotic prophylaxis, defined as antibiotic treatment for ≥30 days starting within 30 days of a positive culture, with patients with positive urine cultures who received antibiotic treatment but did not receive prophylaxis. We matched each prophylaxis recipient to 10 nonrecipients based on organism, number of positive cultures, and propensity score. Outcomes included (1) emergency department (ED) visit or hospitalization for UTI, sepsis, or bloodstream infection within 1 year; (2) acquisition of antibiotic resistance in urinary tract pathogens; and (3) antibiotic-related complications. RESULTS Overall, 4.7% (151/3190) of UTI prophylaxis patients and 3.6% (n = 1092/30 542) of controls required an ED visit or hospitalization for UTI, sepsis, or bloodstream infection (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.12-1.57). Acquisition of antibiotic resistance to any urinary antibiotic (HR, 1.31; 95% CI, 1.18-1.44) and to the specific prophylaxis agent (HR, 2.01; 95% CI, 1.80-2.24) was higher in patients receiving prophylaxis. While the overall risk of antibiotic-related complications was similar between groups (HR, 1.08; 95% CI, .94-1.22), the risk of Clostridioidesdifficile and general medication adverse events was higher in prophylaxis recipients (HR [95% CI], 1.56 [1.05-2.23] and 1.62 [1.11-2.29], respectively). CONCLUSIONS Among older adults with UTI, the harms of long-term antibiotic prophylaxis may outweigh their benefits.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Kevin A Brown
- Public Health Ontario, ICES, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | | | | | | | - Kevin L Schwartz
- Public Health Ontario, ICES, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Jennie Johnstone
- Public Health Ontario, Sinai Health, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Larissa M Matukas
- Unity Health Toronto, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Samir N Patel
- Public Health Ontario, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Gary Garber
- Public Health Ontario, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Sunnybrook Health Sciences Center, ICES, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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19
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Appaneal HJ, Shireman TI, Lopes VV, Mor V, Dosa DM, LaPlante KL, Caffrey AR. Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study. BMC Geriatr 2021; 21:436. [PMID: 34301192 PMCID: PMC8299613 DOI: 10.1186/s12877-021-02378-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA. .,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Vincent Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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20
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Simon M, Pereira O, Hulscher MEJL, Schouten J, Thilly N, Pulcini C. Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data. Clin Infect Dis 2021; 72:e493-e500. [PMID: 32822471 DOI: 10.1093/cid/ciaa1221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/20/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotic resistance is an increasing threat to public health globally. Indicators on antibiotic prescribing are required to guide antibiotic stewardship interventions in nursing homes. However, such indicators are not available in the literature. Our main objective was to provide a set of quantity metrics and proxy indicators to estimate the volume and appropriateness of antibiotic use in nursing homes. METHODS Recently published articles were first used to select quantity metrics and proxy indicators, which were adapted to the French nursing home context. A cross-sectional observational study was then conducted based on reimbursement databases. We included all community-based nursing homes of the Lorraine region in northeastern France. We present descriptive statistics for quantity metrics and proxy indicators. For proxy indicators, we also assessed performance scores, clinimetric properties (measurability, applicability, and room for improvement), and conducted case-mix and cluster analyses. RESULTS A total of 209 nursing homes were included. We selected 15 quantity metrics and 11 proxy indicators of antibiotic use. The volume of antibiotic use varied greatly between nursing homes. Proxy indicator performance scores were low, and variability between nursing homes was high for all indicators, highlighting important room for improvement. Six of the 11 proxy indicators had good clinimetric properties. Three distinct clusters were identified according to the number of proxy indicators for which the acceptable target was reached. CONCLUSIONS This set of 15 quantity metrics and 11 proxy indicators may be adapted to other contexts and could be used to guide antibiotic stewardship programs in nursing homes.
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Affiliation(s)
- Maïa Simon
- Université de Lorraine, APEMAC, Nancy, France
| | - Ouarda Pereira
- Direction Régionale du Service Médical Grand Est, Strasbourg, France
| | - Marlies E J L Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Jeroen Schouten
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France.,Département Méthodologie, Promotion, Investigation, Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, APEMAC, Nancy, France.,Département de Maladies Infectieuses, Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
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21
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Clark MD, Halford Z, Herndon C, Middendorf E. Evaluation of Antibiotic Initiation Tools in End-of-Life Care. Am J Hosp Palliat Care 2021; 39:274-281. [PMID: 34169763 DOI: 10.1177/10499091211027806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hospice patients are frequently confronted with potentially infectious complications necessitating antibiotic consideration. Information regarding the appropriate use of antibiotics and their impact on symptom management in hospice patients are unknown. OBJECTIVES This study aimed to evaluate and describe the use of an antibiotic initiation tool in patients admitted to outpatient hospice services. The primary outcome assessed the percentage of antibiotics that were appropriately initiated based on Loeb's Minimum Criteria (LMC) for Antibiotic Initiation Tool. Secondary outcomes included the number of patients with documented symptom resolution following antibiotic completion, the number of antibiotic courses that were successfully completed, and treatment-related adverse events. METHODS This was a retrospective, multisite, descriptive analysis of hospice patients treated with antibiotics between April 2019 and September 2020. RESULTS Two hundred and thirty patients were assessed for inclusion, with 172 meeting eligibility criteria and receiving a total of 201 antibiotic courses. Based on LMC, 84 of the 201 (42%) antibiotics ordered were appropriate, with 60% of these LMC-approved courses resulting in symptom resolution. Out of 201 total courses, 99 (49%) resulted in symptom resolution. Overall, 160 (80%) antibiotic courses were successfully completed. CONCLUSION In this study, antibiotic initiation in hospice patients frequently did not meet LMC. Less than half of the antibiotics prescribed led to symptom resolution despite antibiotic course completion in most patients. There is no consensus or guidelines directing appropriate antibiotic decision-making in hospice patients. The appropriate use of antibiotics in terminally ill patients warrants additional research.
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Affiliation(s)
- Matthew D Clark
- Pharmacy Clinical Programs, 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zachery Halford
- Department of Pharmacy Practice, 4107Union University College of Pharmacy, Jackson, TN, USA
| | - Chris Herndon
- Department of Pharmacy Practice, 33140Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, USA.,Department of Community and Family Medicine, St. Louis School of Medicine, Edwardsville, IL, USA
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22
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Belan M, Thilly N, Pulcini C. Antimicrobial stewardship programmes in nursing homes: a systematic review and inventory of tools. J Antimicrob Chemother 2021; 75:1390-1397. [PMID: 32108883 DOI: 10.1093/jac/dkaa013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/05/2020] [Accepted: 01/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available. METHODS We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts. RESULTS A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement. CONCLUSIONS Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.
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Affiliation(s)
- Martin Belan
- Université de Lorraine, CHRU-Nancy, Département de maladies infectieuses, Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France.,Université de Lorraine, CHRU-Nancy, Département Méthodologie Promotion Investigation, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, CHRU-Nancy, Département de maladies infectieuses, Nancy, France.,Université de Lorraine, APEMAC, Nancy, France
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23
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Song S, Wilson BM, Marek J, Jump RLP. Use of electronic pharmacy transaction data and website development to assess antibiotic use in nursing homes. BMC Med Inform Decis Mak 2021; 21:148. [PMID: 33952239 PMCID: PMC8097250 DOI: 10.1186/s12911-021-01509-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2017, the Centers for Medicare and Medicaid Services required all long-term care facilities, including nursing homes, to have an antibiotic stewardship program. Many nursing homes lack the resources, expertise, or infrastructure to track and analyze antibiotic use measures. Here, we demonstrate that pharmacy invoices are a viable source of data to track and report antibiotic use in nursing homes. METHODS The dispensing pharmacy working with several nursing homes in the same healthcare corporation provided pharmacy invoices from 2014 to 2016 as files formatted as comma separated values. We aggregated these files by aligning elements into a consistent set of variables and assessed the completeness of data from each nursing home over time. Data cleaning involved removing rows that did not describe systemic medications, de-duplication, consolidating prescription refills, and removing prescriptions for insulin and opioids, which are medications that were not administered at a regular dose or schedule. After merging this cleaned invoice data to nursing home census data including bed days of care and publicly available data characterizing bed allocation for each nursing home, we used the resulting database to describe several antibiotic use metrics and generated an interactive website to permit further analysis. RESULTS The resultant database permitted assessment of the following antibiotic use metrics: days of antibiotic therapy, length of antibiotic therapy, rate of antibiotic starts, and the antibiotic spectrum index. Further, we created a template for summarizing data within a facility and comparing across facilities. https://sunahsong.shinyapps.io/USNursingHomes/ . CONCLUSIONS Lack of resources and infrastructure contributes to challenges facing nursing homes as they develop antibiotic stewardship programs. Our experience with using pharmacy invoice data may serve as a useful approach for nursing homes to track and report antibiotic use.
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Affiliation(s)
- Sunah Song
- Cleveland Institute for Computational Biology, Cleveland, OH, USA.,Department of Computer and Data Sciences, School of Engineering, Case Western Reserve University, Cleveland, OH, USA.,Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Brigid M Wilson
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs (VA) Northeast Ohio Healthcare System, 10701 East Blvd., Cleveland, OH, 44106, USA
| | - Joseph Marek
- CommuniCare Health Services, Cincinnati, OH, USA
| | - Robin L P Jump
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA. .,Division of Infectious Diseases and HIV Medicine in the Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA. .,Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs (VA) Northeast Ohio Healthcare System, 10701 East Blvd., Cleveland, OH, 44106, USA.
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24
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Chambers A, Chen C, Brown KA, Daneman N, Langford B, Leung V, Adomako K, Schwartz KL, Moore JE, Quirk J, MacFarlane S, Cronsberry T, Garber GE. Virtual learning collaboratives to improve urine culturing and antibiotic prescribing in long-term care: controlled before-and-after study. BMJ Qual Saf 2021; 31:94-104. [PMID: 33853868 PMCID: PMC8785008 DOI: 10.1136/bmjqs-2020-012226] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/16/2021] [Accepted: 04/05/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urine culturing practices are highly variable in long-term care and contribute to overprescribing of antibiotics for presumed urinary tract infections. The purpose of this study was to evaluate the use of virtual learning collaboratives to support long-term care homes in implementing a quality improvement programme focused on reducing unnecessary urine culturing and antibiotic overprescribing. METHODS Over a 4-month period (May 2018-August 2018), 45 long-term care homes were self-selected from five regions to participate in virtual learning collaborative sessions, which provided an orientation to a quality improvement programme and guidance for implementation. A process evaluation complemented the use of a controlled before-and-after study with a propensity score matched control group (n=127) and a difference-in-difference analysis. Primary outcomes included rates of urine cultures performed and urinary antibiotic prescriptions. Secondary outcomes included rates of emergency department visits, hospital admission and mortality. An 18-month baseline period was compared with a 16-month postimplementation period with the use of administrative data sources. RESULTS Rates of urine culturing and urinary antibiotic prescriptions per 1000 resident days decreased significantly more among long-term care homes that participated in learning collaboratives compared with matched controls (differential reductions of 19% and 13%, respectively, p<0.0001). There was no statistically significant changes to rates of emergency department visits, hospital admissions or mortality. These outcomes were observed with moderate adherence to the programme model. CONCLUSIONS Rates of urine culturing and urinary antibiotic prescriptions declined among long-term care homes that participated in a virtual learning collaborative to support implementation of a quality improvement programme. The results of this study have refined a model to scale this programme in long-term care.
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Affiliation(s)
| | - Cynthia Chen
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Kevin Antoine Brown
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | | | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Gary E Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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25
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Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes. Prim Health Care Res Dev 2021; 22:e12. [PMID: 33818336 PMCID: PMC8101078 DOI: 10.1017/s1463423621000025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Aim: The aim was to determine the association between healthcare workers’ (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention. Background: Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important. Methods: This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ2 test and a linear mixed regression model were applied. Findings: Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (−7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (−5.64, P < 0.01). Native HCWs’ mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs’ mean change in knowledge-of-antibiotic score. Conclusion: Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.
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26
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Felsen CB, Dodds Ashley ES, Barney GR, Nelson DL, Nicholas JA, Yang H, Aydelotte ME, Karlic A, Nicholas NC, Petrone KK, Pine RD, Schabel SL, Medina-Walpole A, Dumyati GK. Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration. J Am Med Dir Assoc 2021; 21:55-61.e2. [PMID: 31888865 DOI: 10.1016/j.jamda.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS Six NHs in Monroe County, NY. METHODS A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.
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Affiliation(s)
- Christina B Felsen
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC
| | - Grant R Barney
- Emerging Infections Program, New York State Department of Health, Albany, NY
| | - Dallas L Nelson
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Joseph A Nicholas
- Department of Medicine and Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | | | - Alexander Karlic
- Unity Living Center and Unity Hospital, Rochester Regional Health, Rochester, NY
| | - Nirmala C Nicholas
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | | | | | - Scott L Schabel
- Division of Long Term Care, Rochester Regional Health, Rochester, NY
| | - Annette Medina-Walpole
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Ghinwa K Dumyati
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY; Department of Medicine, Division of Infectious Disease, University of Rochester Medical Center, Rochester, NY.
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27
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Gouin KA, Creasy S, Beckerson M, Wdowicki M, Hicks LA, Lind JN, Geller AI, Budnitz DS, Kabbani S. Trends in Prescribing of Antibiotics and Drugs Investigated for COVID-19 Treatment in U.S. Nursing Home Residents During the COVID-19 Pandemic. Clin Infect Dis 2021; 74:74-82. [PMID: 33693607 PMCID: PMC7989581 DOI: 10.1093/cid/ciab225] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Trends in prescribing for nursing home (NH) residents, which may have been influenced by the COVID-19 pandemic, have not been characterized. METHODS Long-term care pharmacy data from 1,944 U.S. NHs were used to evaluate trends in prescribing of antibiotics and drugs that were investigated for COVID-19 treatment, including hydroxychloroquine, famotidine, and dexamethasone. To account for seasonal variability in antibiotic prescribing and decreased NH occupancy during the pandemic, monthly prevalence of residents with a prescription dispensed per 1,000 residents serviced was calculated from January - October and compared as relative percent change from 2019 to 2020. RESULTS In April 2020, prescribing was significantly higher in NHs for drugs investigated for COVID-19 treatment than 2019; including hydroxychloroquine (+563%, 95% confidence interval (CI) 5.87, 7.48) and azithromycin (+150%, 95% CI 2.37, 2.63). Ceftriaxone prescribing also increased (+43%, 95% CI 1.34, 1.54). Prescribing of dexamethasone was 36% lower in April (95% CI 0.55, 0.73) and 303% higher in July (95% CI 3.66, 4.45). Although azithromycin and ceftriaxone prescribing increased, total antibiotic prescribing among residents was lower from May (-5%, 95% CI 0.94, 0.97) through October (-4%, 95% CI 0.94, 0.97) in 2020 compared to 2019. CONCLUSIONS During the pandemic, large numbers of residents were prescribed drugs investigated for COVID-19 treatment, and an increase in prescribing of antibiotics commonly used for respiratory infections was observed. Prescribing of these drugs may increase the risk of adverse events, without providing clear benefits. Surveillance of NH prescribing practices is critical to evaluate concordance with guideline-recommended therapy and improve resident safety.
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Affiliation(s)
- Katryna A Gouin
- Chenega Corporation, contractor on assignment to the National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, U.S.A
| | - Stephen Creasy
- PharMerica, a BrightSpring Health Services company, Louisville, KY, U.S.A
| | - Mary Beckerson
- PharMerica, a BrightSpring Health Services company, Louisville, KY, U.S.A
| | - Martha Wdowicki
- PharMerica, a BrightSpring Health Services company, Louisville, KY, U.S.A
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, U.S.A
| | - Jennifer N Lind
- CDC COVID-19 Response, U.S. Centers for Disease Control and Prevention, Atlanta, GA, U.S.A
| | - Andrew I Geller
- CDC COVID-19 Response, U.S. Centers for Disease Control and Prevention, Atlanta, GA, U.S.A
| | - Daniel S Budnitz
- CDC COVID-19 Response, U.S. Centers for Disease Control and Prevention, Atlanta, GA, U.S.A
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, U.S.A
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28
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Cohen CC, Dick AW, Agarwal M, Gracner T, Mitchell S, Stone PW. Trends in antibiotics use among long-term US nursing-home residents. Infect Control Hosp Epidemiol 2021; 42:311-317. [PMID: 32935657 PMCID: PMC7960578 DOI: 10.1017/ice.2020.422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Antibiotics are overly prescribed in nursing homes. Recent antibiotic stewardship efforts attempt to reduce inappropriate use. Our objective was to describe antibiotic use from 2012 to 2016 among nursing-home residents with various health conditions. DESIGN Retrospective, repeated cross-sectional analysis. SETTING AND PARTICIPANTS All long-term residents in a random 10% sample of national nursing homes: 2,092,809 assessments from 319,615 nursing-home residents in 1,562 nursing homes. MEASUREMENTS We calculated a 1-day antibiotic prevalence using all annual and quarterly clinical assessments in the Minimum Data Set (MDS) from April 2012 through December 2016. We calculated prevalence of antibiotic use overall and within conditions of interest: Alzheimer's disease and related dementias (ADRD), advanced cognitive impairment (ACI), and infections likely to be treated with antibiotics. We applied logistic regressions with nursing-home cluster, robust standard errors to assess changes in conditions and antibiotic use 2012-2016. RESULTS Overall, antibiotic use did not change (2012 vs 2016, adjusted odds ratio [AOR], 1.00; 95% CI, 0.97-1.03). Antibiotic use was higher in 2016 versus 2012 among assessments with any infection (AOR, 1.10; 95% CI, 1.04-1.16), urinary tract infection (AOR, 1.18; 95% CI, 1.12-1.25), and no infection (AOR, 1.13; 95% CI, 1.09-1.17). Results were similar by cognitive status. CONCLUSIONS The increased proportion of assessments recording antibiotics but no infection may not be clinically appropriate. Higher antibiotic use among infected residents with advanced cognitive impairment is also concerning. Further efforts to understand mechanisms driving these trends and to promote antibiotic stewardship in nursing homes are warranted.
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Affiliation(s)
- Catherine C Cohen
- Behavioral & Policy Sciences, RAND Corporation, Santa Monica, California
| | - Andrew W Dick
- Economics, Sociology & Statistics, RAND Corporation, Boston, Massachusetts
| | - Mansi Agarwal
- Center for Health Policy, Columbia University School of Nursing, New York, New York
| | - Tadeja Gracner
- Economics, Sociology & Statistics, RAND Corporation, Washington, DC
| | - Susan Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York
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29
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Valmadrid LC, Schwei RJ, Maginot E, Pulia MS. The impact of health care provider relationships and communication dynamics on urinary tract infection management and antibiotic utilization for long-term care facility residents treated in the emergency department: A qualitative study. Am J Infect Control 2021; 49:198-205. [PMID: 32653562 PMCID: PMC7348612 DOI: 10.1016/j.ajic.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND For older adults, over diagnosis of urinary tract infections (UTI) is a primary driver of inappropriate antibiotic use. This risk is increased for patients in long-term care facilities (LTCF), especially as they transition back and forth to emergency departments (ED). In this study, we aimed to understand how health care provider communication and relationship dynamics affect LTCF residents treated in the ED to identify barriers to antibiotic stewardship for UTIs. METHODS We conducted semi-structured interviews with nurses and physicians from LTCFs and EDs, guided by the Systems Engineering Initiative for Patient Safety framework. Data were systematically coded and underwent iterative, conventional, content analysis. RESULTS We interviewed 16 LTCF and 16 ED providers across Wisconsin. ED and LTCF nurses have a critical role in both intrafacility and interfacility communication. Fragmented communication and interprofessional power dynamics were identified barriers to optimal antibiotic prescribing for UTIs. Identified strategies to overcome these issues included using objective diagnostic criteria, development of communication scripts, and nurse-to-nurse education. CONCLUSIONS Our qualitative approach revealed important insights about how communication and relationship dynamics influence UTI diagnosis and optimal antibiotic stewardship for LTCF residents evaluated in the ED. Future interventions should strengthen communications between settings and across provider types, and address standardization of diagnostic and treatment communication pathways for LTCF residents with suspected infections transitioning between EDs and LTCFs.
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Affiliation(s)
- Luke Carmichael Valmadrid
- University of North Carolina at Chapel Hill, Chapel Hill, NC; University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Rebecca J Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Elizabeth Maginot
- University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI.
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30
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Laur C, Sribaskaran T, Simeoni M, Desveaux L, Daneman N, Mulhall C, Lam J, Ivers NM. Improving antibiotic initiation and duration prescribing among nursing home physicians using an audit and feedback intervention: a theory-informed qualitative analysis. BMJ Open Qual 2021; 10:e001088. [PMID: 33547157 PMCID: PMC7871236 DOI: 10.1136/bmjoq-2020-001088] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/25/2020] [Accepted: 01/13/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In nursing homes, 25%-75% of antibiotic days of treatment are inappropriate or unnecessary and are often continued for longer durations than necessary. In Ontario, physicians can receive a provincial audit and feedback report that provides individualised, confidential, data about their antibiotic prescribing. Objectives of this study were to explore antibiotic prescribing of nursing home physicians and the influence of the report. METHODS All physicians who received a personalised MyPractice: Long-Term Care report from Ontario Health (Quality) (OH(Q)) in January 2019 (n=361) were eligible to participate in semistructured telephone interviews that were recorded then transcribed verbatim. Recruitment emails were sent from OH(Q) until saturation of ideas. Analysis was conducted by two team members inductively, then deductively using the theoretical domains framework, a comprehensive, theory-informed framework to classify determinants of specific behaviours. RESULTS Interviews were conducted with n=18 physicians; 78% (n=14) were men, practising for an average of 27 years, with 18 years of experience working in nursing homes. Physicians worked in a median of 2 facilities (range 1-6), with 72% (n=13) in an urban setting. 56% (n=10) were medical directors for at least one home. Professional role and identity impacted all aspects of antibiotic prescribing. Key roles included being an 'Appropriate prescriber', an 'Educator' and a 'Change driver'. For antibiotic initiation, these roles interacted with Knowledge, Skills, Beliefs about consequence, Beliefs about capabilities, and Social influence to determine the resulting prescribing behaviour. When considering the impact of interacting with the report, participants' perceived roles interacted with Reinforcement, Social influence, and Intention. Environmental context and resources was an overarching domain. CONCLUSION This theory-informed approach is being used to inform upcoming versions of existing audit and feedback initiatives. Appealing to the role that prescribers see themselves offers a unique opportunity to encourage desired changes, such as providing tools for physicians to be Educators and facilitating, particularly medical directors, to be Change drivers.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Thivja Sribaskaran
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Michelle Simeoni
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Noah Michael Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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31
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Fornaro R, Heil E, Claeys K, Sheikh F, Naqvi F, Chou J, Oketch E, Mansour D, Zarowitz B, Brandt N. Identifying and Bridging the Gaps in Antimicrobial Stewardship in Post-Acute and Long-Term Care. J Gerontol Nurs 2021; 46:8-13. [PMID: 31895956 DOI: 10.3928/00989134-20191211-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
National organizations have developed guidelines and tools for antimicrobial stewardship (AMS) in post-acute and long-term care (PALTC), but there is a need to effectively translate these into actionable, measurable, and impactful programs. An electronic needs assessment survey was developed and distributed to health care providers and administrators involved with AMS activities in PALTC facilities in Maryland. The results of this survey were used to develop a statewide initiative to improve AMS in nursing facilities. The survey revealed that barriers to implementing AMS include limited access or poor utilization of experts in AMS and infectious disease, adverse event data collection tools, and locally developed protocols and guidelines. Strategies to improve AMS included the provision of free continuing education to a multidisciplinary audience and improved access to individuals with expertise in infectious disease and the development of an adverse drug event tool. Continuing to provide meaningful tools and resources that address the specific needs of nursing facilities should lead to improved compliance with regulations and ultimately improved resident outcomes. [Journal of Gerontological Nursing, 46(1), 8-13.].
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Description of antibiotic use variability among US nursing homes using electronic health record data. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e58. [PMID: 36168476 PMCID: PMC9495428 DOI: 10.1017/ash.2021.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022]
Abstract
Abstract
Background:
Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders.
Methods:
A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models.
Results:
In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5–10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software).
Conclusions:
Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.
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Sibani M, Mazzaferri F, Carrara E, Pezzani MD, Arieti F, Göpel S, Paul M, Tacconelli E, Mutters NT, Voss A. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in long-term care facilities-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2020; 75:ii33-ii41. [PMID: 33280047 PMCID: PMC7719406 DOI: 10.1093/jac/dkaa427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In long-term care facilities (LTCFs) residents often receive inappropriate antibiotic treatment and infection prevention and control practices are frequently inadequate, thus favouring acquisition of MDR organisms. There is increasing evidence in the literature describing antimicrobial stewardship (AMS) activities in LTCFs, but practical guidance on how surveillance data should be linked with AMS activities in this setting is lacking. To bridge this gap, the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks joined their efforts to provide practical guidance for linking surveillance data with AMS activities. MATERIALS AND METHODS Considering the three main topics [AMS leadership and accountability, antimicrobial usage (AMU) and AMS, and antimicrobial resistance (AMR) and AMS], a literature review was performed and a list of target actions was developed. Consensus on target actions was reached through a RAND-modified Delphi process involving 40 experts from 18 countries and different professional backgrounds adopting a One Health approach. RESULTS From the 25 documents identified, 25 target actions were retrieved and proposed for expert evaluation. The consensus process produced a practical checklist including 23 target actions, differentiating between essential and desirable targets according to clinical relevance and feasibility. Flexible proposals for AMS team composition and leadership were provided, with a strong emphasis on the need for well-defined and adequately supported roles and responsibilities. Specific antimicrobial classes, AMU metrics, pathogens and resistance patterns to be monitored are addressed. Effective reporting strategies are described. CONCLUSIONS The proposed checklist represents a practical tool to support local AMS teams across a wide range of care delivery organization and availability of resources.
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Affiliation(s)
- Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Mical Paul
- Diseases Institute, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Nico T Mutters
- Institute for Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Pezzani MD, Mazzaferri F, Compri M, Galia L, Mutters NT, Kahlmeter G, Zaoutis TE, Schwaber MJ, Rodríguez-Baño J, Harbarth S, Tacconelli E. Linking antimicrobial resistance surveillance to antibiotic policy in healthcare settings: the COMBACTE-Magnet EPI-Net COACH project. J Antimicrob Chemother 2020; 75:ii2-ii19. [PMID: 33280049 PMCID: PMC7719409 DOI: 10.1093/jac/dkaa425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To systematically summarize the evidence on how to collect, analyse and report antimicrobial resistance (AMR) surveillance data to inform antimicrobial stewardship (AMS) teams providing guidance on empirical antibiotic treatment in healthcare settings. METHODS The research group identified 10 key questions about the link between AMR surveillance and AMS using a checklist of 9 elements for good practice in health research priority settings and a modified 3D combined approach matrix, and conducted a systematic review of published original studies and guidelines on the link between AMR surveillance and AMS. RESULTS The questions identified focused on AMS team composition; minimum infrastructure requirements for AMR surveillance; organisms, samples and susceptibility patterns to report; data stratification strategies; reporting frequency; resistance thresholds to drive empirical therapy; surveillance in high-risk hospital units, long-term care, outpatient and veterinary settings; and surveillance data from other countries. Twenty guidelines and seven original studies on the implementation of AMR surveillance as part of an AMS programme were included in the literature review. CONCLUSIONS The evidence summarized in this review provides a useful basis for a more integrated process of developing procedures to report AMR surveillance data to drive AMS interventions. These procedures should be extended to settings outside the acute-care institutions, such as long-term care, outpatient and veterinary. Without proper AMR surveillance, implementation of AMS policies cannot contribute effectively to the fight against MDR pathogens and may even worsen the burden of adverse events from such interventions.
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Affiliation(s)
- Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Monica Compri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Nico T Mutters
- Bonn University Hospital, Institute for Hygiene and Public Health, Bonn, Germany
| | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Växjö Central Hospital, Växjö, Sweden
| | - Theoklis E Zaoutis
- Perelman School of Medicine at the University of Pennsylvania, Infectious Diseases Division, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mitchell J Schwaber
- National Centre for Infection Control, Israel Ministry of Health and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jesús Rodríguez-Baño
- Division of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena/Department of Medicine, University of Seville/Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Stephan Harbarth
- Infection Control Program, World Health Organization Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
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Adre C, Jump RLP, Spires SS. Recommendations for Improving Antimicrobial Stewardship in Long-Term Care Settings Through Collaboration. Infect Dis Clin North Am 2020; 34:129-143. [PMID: 32008695 DOI: 10.1016/j.idc.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antimicrobial stewardship is a collaborative venture and antimicrobial stewardship in long-term care (LTC) settings is no exception. There are many barriers to implementing effective antimicrobial stewardship programs in LTC settings, including constrained financial resources, limited access to physicians and pharmacists with antimicrobial stewardship training, minimal on-site infectious syndrome diagnostics and laboratory expertise, and high rates of staff turnover. This article suggests that collaboration at the level of health care facilities and systems, with public health departments, with laboratory partners, and among personnel, including nursing staff, prescribers, and pharmacists, can lead to effective antimicrobial stewardship programs in LTC settings.
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Affiliation(s)
- Cullen Adre
- Tennessee Department of Health, Andrew Johnson Tower, 3.417C, 710 James Robertson Parkway, Nashville, TN 37243, USA.
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC); Specialty Care Center of Innovation at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Steven Schaeffer Spires
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, DUMC PO Box 102359, Durham, NC 27710, USA
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"There is no one to pick up the pieces": Sustainability of antibiotic stewardship programs in nursing homes. Infect Control Hosp Epidemiol 2020; 42:440-447. [PMID: 33100251 DOI: 10.1017/ice.2020.1217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe nursing home staff experiences and perceptions of the factors that impact the sustainability of an antibiotic stewardship program (ASP). METHODS Using a qualitative descriptive design, semistructured interviews with staff at 9 not-for-profit nursing homes with an established ASP were conducted and audio recorded. De-identified transcriptions of the interviews were coded using a sustainability framework and were analyzed to identify themes. RESULTS Interviews were conducted with 48 clinical and administrative staff to elicit their perceptions of the ASPs, and 7 themes were identified. ASPs were perceived to be resource intensive and "data driven," requiring access to and interpretation of data that are not readily available at many nursing homes. Though motivated and committed, ASP champions felt that they could not single-handedly sustain the program. Attending to daily clinical needs (ie, "fires") made it hard to progress beyond implementation and to reach step 2 of sustainability. Longstanding treatment habits by external prescribers and regulations were believed to impede ASP efforts. Partnerships with an external consultant with antibiotic stewardship expertise were considered important, as was the need for internal leadership support and collaboration across disciplinary boundaries. Participants felt that consistent and ongoing education on antibiotic stewardship at all staff levels was important. CONCLUSIONS Although many interconnected factors impact the sustainability of an ASP, nursing homes may be able to sustain an ASP by focusing on 3 critical areas: (1) explicit support by nursing home leadership, (2) external partnerships with professionals with antibiotic stewardship expertise and internal interprofessional collaborations, and (3) consistent education and training for all staff.
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Song S, Wilson BM, Bej T, Gravenstein S, Carter RR, Marek J, Jump RLP. Antibiotic Use Among Residents Receiving Skilled Nursing Care in 29 U.S. Nursing Homes. J Am Geriatr Soc 2020; 69:399-406. [PMID: 33037613 DOI: 10.1111/jgs.16856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Data describing antibiotic use in U.S. nursing homes remain limited. We report antibiotic use among skilled nursing facility residents from 29 U.S. nursing homes and assessed correlations between antibiotics prescribed to residents in skilled care and nursing home characteristics. DESIGN Retrospective cohort study. SETTING Twenty-nine U.S. nursing homes in the same healthcare corporation. PARTICIPANTS Residents receiving skilled care in 2016. MEASUREMENTS We used pharmacy invoice and nursing home census data to calculate the days of antibiotic therapy per 1,000 days of skilled care (1,000 DOSC), the rate of antibiotic starts per 1,000 DOSC, the length of antibiotic therapy, and the average antibiotic spectrum index. We also assessed correlations between antibiotic use and nursing home characteristics. RESULTS Antibiotics accounted for an average of 9.6% (±0.6%) of systemic medications prescribed among residents receiving skilled care. On average, 26.8% (±2.9%) of antibiotics were intravenous. Fluoroquinolones were prescribed at the highest rates (19% across all facilities), followed by beta-lactam/beta-lactamase inhibitors (11%), first- and second-generation cephalosporins, sulfonamides, and oral tetracyclines (each at 9%). Both the proportion of residents using enrolled in Medicare and number of unique prescribers responsible for systemic prescriptions positively correlated with the rate of antibiotic starts. CONCLUSIONS Our study demonstrates that pharmacy invoices represent a useful and preexisting source of data for assessing antibiotic prescriptions among individuals receiving skilled nursing care. The correlation between the number of unique prescribers and antibiotic starts suggests that prescribers are central to efforts to improve antibiotic use in nursing homes.
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Affiliation(s)
- Sunah Song
- Cleveland Institute for Computational Biology, Cleveland, Ohio, USA.,Department of Computer and Data Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Taissa Bej
- Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Stefan Gravenstein
- Brown University Alpert Medical School and School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence VA Medical Center, Providence, Rhode Island, USA
| | - Rebecca R Carter
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Center for the Advancement of Team Science, Analytics, and Systems Thinking, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph Marek
- CommuniCare Health Services, Cincinnati, Ohio, USA
| | - Robin L P Jump
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
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Beeber AS, Kistler CE, Zimmerman S, Dictus C, Ward K, Farel C, Chrzan K, Wretman CJ, Boyton-Hansen M, Pignone M, Sloane PD. Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse. J Am Med Dir Assoc 2020; 22:156-163. [PMID: 32839125 DOI: 10.1016/j.jamda.2020.06.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents. DESIGN Web-based discrete choice experiment with 19 clinical scenarios. SETTING AND PARTICIPANTS Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel. METHODS Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non-evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression. RESULTS For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16-5.65], obvious blood in urine (OR 4.66, 95% CI 3.99-5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28-4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53-7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53-5.47) had highest odds for the forced-deliberation group. CONCLUSIONS AND IMPLICATIONS This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.
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Affiliation(s)
- Anna Song Beeber
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA; The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.
| | - Christine E Kistler
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA; School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | - Cassandra Dictus
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Claire Farel
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Crayton E, Richardson M, Fuller C, Smith C, Liu S, Forbes G, Anderson N, Shallcross L, Michie S, Hayward A, Lorencatto F. Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review. BMC Geriatr 2020; 20:237. [PMID: 32646382 PMCID: PMC7350746 DOI: 10.1186/s12877-020-01564-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities’ antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes. Method A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as ‘very promising’ (all outcomes statistically significant), ‘quite promising’ (some outcomes statistically significant), or ‘not promising’ (no outcomes statistically significant). ‘Promise ratios’ (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2. Results Twenty studies (of19 interventions) were included. Seven interventions (37%) were ‘very promising’, eight ‘quite promising’ (42%) and four ‘not promising’ (21%). Most promising intervention types were ‘persuasion’ (n = 12; promise ratio (PR) = 5.0), ‘enablement’ (n = 16; PR = 4.33) and ‘education’ (n = 19; PR = 3.75). Most promising behaviour change techniques were ‘feedback on behaviour’ (n = 9; PR = 8.0) and ‘restructuring the social environment’ (e.g. staff role changes; n = 8; PR = 7.0). Conclusion Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.
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Affiliation(s)
- Elise Crayton
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Michelle Richardson
- Institute of Education (IOE), University College London, London, WC1H 0NS, UK
| | - Chris Fuller
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Catherine Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Sunny Liu
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Gillian Forbes
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Niall Anderson
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.,Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.,Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| | - Andrew Hayward
- Institute of Epidemiology & Health, University College London, London, WC1E 7HB, UK
| | - Fabiana Lorencatto
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.,Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
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40
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Smith CM, Williams H, Jhass A, Patel S, Crayton E, Lorencatto F, Michie S, Hayward AC, Shallcross LJ. Antibiotic prescribing in UK care homes 2016-2017: retrospective cohort study of linked data. BMC Health Serv Res 2020; 20:555. [PMID: 32552886 PMCID: PMC7301534 DOI: 10.1186/s12913-020-05422-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older people living in care homes are particularly susceptible to infections and antibiotics are therefore used frequently for this population. However, there is limited information on antibiotic prescribing in this setting. This study aimed to investigate the frequency, patterns and risk factors for antibiotic prescribing in a large chain of UK care homes. METHODS Retrospective cohort study of administrative data from a large chain of UK care homes (resident and care home-level) linked to individual-level pharmacy data. Residents aged 65 years or older between 1 January 2016 and 31 December 2017 were included. Antibiotics were classified by type and as new or repeated prescriptions. Rates of antibiotic prescribing were calculated and modelled using multilevel negative binomial regression. RESULTS 13,487 residents of 135 homes were included. The median age was 85; 63% residents were female. 28,689 antibiotic prescriptions were dispensed, the majority were penicillins (11,327, 39%), sulfonamides and trimethoprim (5818, 20%), or other antibacterials (4665, 16%). 8433 (30%) were repeat prescriptions. The crude rate of antibiotic prescriptions was 2.68 per resident year (95% confidence interval (CI) 2.64-2.71). Increased antibiotic prescribing was associated with residents requiring more medical assistance (adjusted incidence rate ratio for nursing opposed to residential care 1.21, 95% CI 1.13-1.30). Prescribing rates varied widely by care home but there were no significant associations with the care home-level characteristics available in routine data. CONCLUSIONS Rates of antibiotic prescribing in care homes are high and there is substantial variation between homes. Further research is needed to understand the drivers of this variation to enable development of effective stewardship approaches that target the influences of prescribing.
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Affiliation(s)
- Catherine M Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK.
| | - Haydn Williams
- Four Seasons Health Care, Norcliffe House, Station Road, Wilmslow, Cheshire, SK9 1BU, UK
| | - Arnoupe Jhass
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK
| | - Selina Patel
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Elise Crayton
- Centre for Behaviour Change, University College London, WC1E 7HB, London, UK
| | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, WC1E 7HB, London, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, WC1E 7HB, London, UK
| | - Andrew C Hayward
- Institute of Epidemiology and Health Care, University College London, WC1E 7HB, London, UK
| | - Laura J Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
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Rowan-Nash AD, Araos R, D'Agata EMC, Belenky P. Antimicrobial Resistance Gene Prevalence in a Population of Patients with Advanced Dementia Is Related to Specific Pathobionts. iScience 2020; 23:100905. [PMID: 32106056 PMCID: PMC7044522 DOI: 10.1016/j.isci.2020.100905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/10/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
Long-term care facilities are significant reservoirs of antimicrobial-resistant organisms, and patients with advanced dementia are particularly vulnerable to multidrug-resistant organism (MDRO) acquisition and antimicrobial overuse. In this study, we longitudinally examined a group of patients with advanced dementia using metagenomic sequencing. We found significant inter- and intra-subject heterogeneity in microbiota composition, suggesting temporal instability. We also observed a link between the antimicrobial resistance gene density in a sample and the relative abundances of several pathobionts, particularly Escherichia coli, Proteus mirabilis, and Enterococcus faecalis, and used this relationship to predict resistance gene density in samples from additional subjects. Furthermore, we used metagenomic assembly to demonstrate that these pathobionts had higher resistance gene content than many gut commensals. Given the frequency and abundances at which these pathobionts were found in this population and the underlying vulnerability to MDRO of patients with advanced dementia, attention to microbial blooms of these species may be warranted.
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Affiliation(s)
- Aislinn D Rowan-Nash
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Rafael Araos
- Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina Clinica Alemana Universidad del Desarrollo, Santiago, Chile; Millenium Nucleus for Collaborative Research on Bacterial Resistance (MICROB-R), Santiago, Chile; Advanced Center for Chronic Diseases (ACCDiS), Facultad de Medicina Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Erika M C D'Agata
- Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Peter Belenky
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA.
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42
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Fu CJ, Mantell E, Stone PW, Agarwal M. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey. Am J Infect Control 2020; 48:13-18. [PMID: 31447117 PMCID: PMC6935405 DOI: 10.1016/j.ajic.2019.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.
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Affiliation(s)
| | | | | | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY.
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Furuno JP, Mody L. Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes. J Am Geriatr Soc 2019; 68:11-14. [PMID: 31825520 DOI: 10.1111/jgs.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Detroit, Michigan.,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Detroit, Michigan
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44
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Kuper KM, Hamilton KW. Collaborative Antimicrobial Stewardship: Working with Information Technology. Infect Dis Clin North Am 2019; 34:31-49. [PMID: 31836327 DOI: 10.1016/j.idc.2019.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Information technology (IT) is vitally important to making antimicrobial stewardship a scalable endeavor in modern health care systems. Without IT, many antimicrobial interventions in patient care would be missed. Clinical decision support systems and smartphone apps, either stand-alone or integrated into electronic health records, can all be effective tools to help augment the work of antimicrobial stewardship programs and support the management of infectious diseases in any health care setting.
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Affiliation(s)
- Kristi M Kuper
- Vizient Center for Pharmacy Practice Excellence; DoseMe/Tabula Rasa HealthCare, 228 Strawbridge Drive, Moorestown, NJ 08057, USA
| | - Keith W Hamilton
- Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor South Pavilion, Philadelphia, PA 19426, USA.
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45
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Salem‐Schatz S, Griswold P, Kandel R, Benjamin‐Bothwell S, DeMaria A, McElroy N, Bolstorff B, McHale E, Doron S. A Statewide Program to Improve Management of Suspected Urinary Tract Infection in Long‐Term Care. J Am Geriatr Soc 2019; 68:62-69. [DOI: 10.1111/jgs.16261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/18/2019] [Accepted: 09/21/2019] [Indexed: 02/05/2023]
Affiliation(s)
| | - Paula Griswold
- Massachusetts Coalition for the Prevention of Medical Errors Burlington MA
| | | | | | - Alfred DeMaria
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Nora McElroy
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Barbara Bolstorff
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Eileen McHale
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health Boston Massachusetts
| | - Shira Doron
- Division of Infectious DiseaseTufts Medical Center Boston Massachusetts
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46
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Quigley DD, Dick A, Stone PW. Quality Innovation Networks Share Varied Resources for Nursing Homes on Mostly User-Friendly Websites. J Am Geriatr Soc 2019; 67:2376-2381. [PMID: 31675106 PMCID: PMC8173537 DOI: 10.1111/jgs.16201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Quality innovation networks' (QINs') support of nursing homes (NHs) is a national strategy to systematically improve the quality of care experienced by residents. QINs have been tasked with providing NHs with information, resources, tools, and training to assist in developing best practices and to support quality improvement efforts in infection prevention (including joining the National Healthcare Safety Network [NHSN]), avoid unnecessary hospitalizations, and increase use of hospice and palliative care. Our objective was to examine QIN online resources provided to NHs to support best practices and improvement efforts. DESIGN An environmental scan was conducted. SETTING/MEASUREMENT Each QIN website was evaluated on (1) usability, (2) accessibility and prominence, (3) website design, (4) availability of training materials, (5) recency of update, (6) identification of key personnel, and (8) quality focus areas (ie, infection prevention, NHSN, antibiotic stewardship, reducing unnecessary or avoidable hospitalizations, and palliative and hospice care). RESULTS QIN websites varied dramatically in design and resources offered to NHs as well as in the content and ease of finding information. Antibiotic stewardship and NHSN resources were widely available. Information (ie, fact sheets) on reducing avoidable hospitalizations was commonly available, while resources, such as tool kits, webinars, training, and contact information for personnel on reducing avoidable hospitalizations, were available to 23 states. Infection prevention resources were varied and limited to 34 states. Both palliative care and hospice resources were available through only a few QINs (13 states and 20 states, respectively). CONCLUSIONS Given that much of the information, tool kits, and resources are standardized and in the public domain, centralized resources with tailored or specialized links to unique local resources, like in-person trainings and state-specific contact information, could be more beneficial for NHs. J Am Geriatr Soc 67:2376-2381, 2019.
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47
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Dylis A, Boureau AS, Coutant A, Batard E, Javaudin F, Berrut G, de Decker L, Chapelet G. Antibiotics prescription and guidelines adherence in elderly: impact of the comorbidities. BMC Geriatr 2019; 19:291. [PMID: 31664914 PMCID: PMC6819552 DOI: 10.1186/s12877-019-1265-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Although the interest of antibiotics is well known, antibiotics prescription is associated with side effect, especially in patients with multiples comorbidities. One way to reduce the incidence of side effects is to respect antibiotics prescriptions guidelines. Our objective was to investigated the factors associated with guidelines adherence in elderly patients with multiples comorbidities. Methods From October 2015 to December 2016, antibiotics prescription and guidelines adherence were analyzed in two post-acute care and rehabilitation services of a 2600-bed, university-affiliated center. Results One hundred and twenty-eight patients were included, fifty-nine (46%) patients had antibiotics prescription according to guidelines. In Multivariable logistic regression analysis, prescription of 2 antibiotics or more (OR = 0.168, 95% IC = 0.037–0.758, p < 0.05), 85 years of age and more (OR = 0.375, 95% IC = 0.151–0.931, p < 0.05) and the Charlson comorbidity index score (OR = 0.750, 95% IC = 0.572–0.984, p < 0.05) were negatively associated with antibiotics prescriptions according to guidelines. Conclusions High comorbidity in the elderly was negatively associated with the guidelines adherence of antibiotiсs prescriptions. These criteria should be considered to optimize antibiotics prescriptions in elderly patients. Electronic supplementary material The online version of this article (10.1186/s12877-019-1265-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anthony Dylis
- Clinical Gerontology Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France
| | - Anne Sophie Boureau
- Clinical Gerontology Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France
| | - Audrey Coutant
- Clinical Gerontology Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France
| | - Eric Batard
- Université de Nantes, EE MiHAR (Microbiotes, Hôtes, Antibiotiques et Résistance bacterienne), Institut de Recherche en Santé (IRS2), 22 Boulevard bénoni-Goullin, F-44200, Nantes, France.,Emergency Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France
| | - François Javaudin
- Université de Nantes, EE MiHAR (Microbiotes, Hôtes, Antibiotiques et Résistance bacterienne), Institut de Recherche en Santé (IRS2), 22 Boulevard bénoni-Goullin, F-44200, Nantes, France.,Emergency Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France
| | - Gilles Berrut
- Clinical Gerontology Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France
| | - Laure de Decker
- Clinical Gerontology Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France.,Université de Nantes, EE MiHAR (Microbiotes, Hôtes, Antibiotiques et Résistance bacterienne), Institut de Recherche en Santé (IRS2), 22 Boulevard bénoni-Goullin, F-44200, Nantes, France
| | - Guillaume Chapelet
- Clinical Gerontology Department, Centre Hospitalier Universitaire de Nantes, 1 place Alexis-Ricordeau, F-44000, Nantes, France. .,Université de Nantes, EE MiHAR (Microbiotes, Hôtes, Antibiotiques et Résistance bacterienne), Institut de Recherche en Santé (IRS2), 22 Boulevard bénoni-Goullin, F-44200, Nantes, France.
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48
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Kullar R, Yang H, Grein J, Murthy R. A Roadmap to Implementing Antimicrobial Stewardship Principles in Long-term Care Facilities (LTCFs): Collaboration Between an Acute-Care Hospital and LTCFs. Clin Infect Dis 2019; 66:1304-1312. [PMID: 29182743 DOI: 10.1093/cid/cix1041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/18/2017] [Indexed: 12/14/2022] Open
Abstract
Effective 28 November 2017, the Centers for Medicare & Medicaid Services (CMS) mandated long-term care facilities (LTCFs) to have antimicrobial stewardship programs (ASPs) in place. Although guidance exists for establishing ASPs in LTCFs, limited data exist on the "how." As comprehensive ASPs already exist in many acute-care hospitals (ACHs) and with the known "sharing of patients" between both settings, extending ACH ASP expertise to LTCFs will not only aid LTCFs in complying with the CMS mandate but will likely also facilitate in decreasing multidrug-resistant organisms and Clostridium difficile infection rates in patients at both organizations. Here, we provide a roadmap on how to implement ASPs in LTCFs, using examples from our own ACH's collaboration with local LTCFs to develop and sustain LTCF ASPs. We discuss critical elements to achieving successful LTCF ASPs, including the potential barriers and how to overcome them.
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Affiliation(s)
- Ravina Kullar
- Global Center for Scientific Affairs, Merck & Co., Inc., Kenilworth, New Jersey
| | - Haoshu Yang
- Department of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles
| | - Jonathan Grein
- Department of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles
| | - Rekha Murthy
- David Geffen School of Medicine, University of California, Los Angeles
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49
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Stepan D, Ušaj L, Petek Šter M, Smolinger Galun M, Smole H, Beović B. Antimicrobial prescribing in long-term care facilities: a nationwide point-prevalence study, Slovenia, 2016. ACTA ACUST UNITED AC 2019; 23. [PMID: 30458914 PMCID: PMC6247456 DOI: 10.2807/1560-7917.es.2018.23.46.1800100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Residents in long-term care are at high risk of infections because of their old age and many related health problems that lead to frequent antibiotic prescribing. The aim of the study was to assess antibiotic use in Slovenian long-term care facilities (LTCFs). The point-prevalence study was conducted between April and June 2016. Online questionnaires were sent to all Slovenian LTCFs. Eighty (68.4%) of the 117 LTCFs contacted, caring for 13,032 residents (70.6% of all Slovenian LTCF residents), responded to the survey. On the day of the study, the mean antibiotic prevalence per LTCF was 2.4% (95% confidence interval: 1.94-2.66). Most (70.2%) of the residents taking antibiotics were female. Most residents were being treated for respiratory tract (42.7%) or urinary tract (33.3%) infections. Co-amoxiclav and fluoroquinolones were the most frequently prescribed antibiotics (41.0% and 22.3% respectively). Microbiological tests were performed for 5.2% of residents receiving antibiotics. Forty nine (19.8%) residents receiving antibiotics were colonised with multidrug-resistant bacteria (MDR). Antibiotic use in Slovenian LTCFs is not very high, but most prescribed antibiotics are broad-spectrum. Together with low use of microbiological testing and high prevalence of colonisation with MDR bacteria the situation is worrisome and warrants the introduction of antimicrobial stewardship interventions.
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Affiliation(s)
- Dora Stepan
- Department of Infectious Diseases, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lea Ušaj
- Department of Infectious Diseases, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marija Petek Šter
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Hermina Smole
- Long-term care facility for the elderly Trebnje, Trebnje, Slovenia
| | - Bojana Beović
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Infectious Diseases, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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50
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Hughes MSA, Dosa DM, Caffrey AR, Appaneal HJ, Jump RLP, Lopes V, LaPlante KL. Antibiograms Cannot Be Used Interchangeably Between Acute Care Medical Centers and Affiliated Nursing Homes. J Am Med Dir Assoc 2019; 21:72-77. [PMID: 31537479 DOI: 10.1016/j.jamda.2019.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether antibiograms for Veterans Affairs (VA) nursing homes (NHs), termed Community Living Centers, are similar to those from their affiliated acute care medical centers. DESIGN Descriptive study. SETTING AND PARTICIPANTS We compared the 2017 antibiograms for VA NHs to their affiliated VA medical centers (VAMCs). Antibiograms included antibiotic susceptibility rates for commonly observed bacteria in this setting (Staphylococcus aureus, Enterococcus spp, Escherichia coli, Klebsiella spp, Proteus mirabilis, and Pseudomonas aeruginosa). METHODS Antibiograms were considered to be in complete agreement when the overall susceptibility rate between the NH and affiliated VAMC was either at or above 80% or below 80% across all bacteria and antibiotics. Average percentage of bacteria-antibiotic comparisons in disagreement per facility pair, and number of facilities with agreement for specific bacteria-antibiotic comparisons were also assessed. The chi-square test was used to compare disagreement between NH-VAMC facilities based on geographic proximity of the NH to the VAMC, culture source, and bed size. RESULTS A total of 119 NH-VAMC affiliate pairs were included in this analysis, with 71% (84/119) on the same campus and 29% (35/119) on geographically distinct campuses. None of the NH-VAMC pairs demonstrated complete agreement (all bacteria vs all antibiotics) between their antibiograms. On average, 20% of the bacteria-antibiotic comparisons from the antibiogram disagreed clinically per NH-VAMC pair, and almost twice as often the nursing home had lower susceptibility (higher resistance) than the acute care facility. Some bacteria-antibiotic comparisons agreed in all facilities (eg, E coli-imipenem; S aureus-linezolid; S aureus-vancomycin), while others showed greater disagreement (eg, Klebsiella spp-cefazolin; Klebsiella spp-ampicillin-sulbactam; P aeruginosa-ciprofloxacin). Rates of clinical disagreement were similar by geographic proximity of the NH to the VAMC, culture source, and bed size. CONCLUSIONS AND IMPLICATIONS Overall, this study showed a moderate lack of agreement between VA NH antibiograms and their affiliate VAMC antibiograms. Our data suggest that antibiograms of acute care facilities are often not accurate approximations of the nursing home resistance patterns and therefore should be used with caution (if at all) in guiding empiric antibiotic therapy.
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Affiliation(s)
- Maria-Stephanie A Hughes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; School of Public Health, Brown University, Providence, RI
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; School of Public Health, Brown University, Providence, RI
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; School of Public Health, Brown University, Providence, RI
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) and the Specialty Care Center of Innovation, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Vrishali Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI.
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