From the Guidelines
Antimicrobial stewardship in long-term care facilities should be implemented through a structured program that includes regular review of antibiotic prescriptions, development of facility-specific treatment guidelines, and ongoing education for healthcare providers. The program should establish a multidisciplinary team including physicians, nurses, pharmacists, and infection control specialists who collaborate to optimize antibiotic use 1. Key strategies include requiring documentation of antibiotic indications, dose, and duration for every prescription; implementing "antibiotic time-outs" at 48-72 hours to reassess therapy; and developing facility-specific antibiograms to guide empiric therapy choices. Specific interventions should include avoiding antibiotics for asymptomatic bacteriuria, using shorter courses when appropriate (e.g., 5-7 days for uncomplicated UTIs rather than 10-14 days), and selecting narrow-spectrum antibiotics when possible (e.g., nitrofurantoin for uncomplicated UTIs instead of fluoroquinolones) 1.
Some studies have shown that implementing an antibiotic stewardship program can lead to a decrease in systemic antibiotic use and fewer positive C. difficile tests 1. For example, Jump et al reported a decrease in systemic antibiotic use by 30.1% and fewer positive C. difficile tests after initiating an infectious diseases consultation service at a single Veterans Affairs long-term care facility 1. Schwartz et al conducted an intervention that included physician education, guideline implementation, and presentation of local baseline antibiotic use data, which resulted in a decrease in antibiotic starts by 25.9% and antibiotic DOTs by 29.7% 1.
Regular monitoring of antibiotic use patterns, resistance rates, and C. difficile infections helps measure program effectiveness 1. These efforts are crucial in long-term care settings where residents are particularly vulnerable to both infections and adverse effects of antibiotics, including drug interactions, side effects, and the development of resistant organisms that can spread within the facility.
Key considerations for implementing an antimicrobial stewardship program in long-term care facilities include:
- Establishing a multidisciplinary team to collaborate on optimizing antibiotic use
- Developing facility-specific treatment guidelines and antibiograms
- Implementing "antibiotic time-outs" to reassess therapy
- Avoiding antibiotics for asymptomatic bacteriuria and using shorter courses when appropriate
- Selecting narrow-spectrum antibiotics when possible
- Regularly monitoring antibiotic use patterns, resistance rates, and C. difficile infections.
Overall, implementing an antimicrobial stewardship program in long-term care facilities is crucial to reduce unnecessary antibiotic use, prevent the development of resistant organisms, and improve resident outcomes 1.
From the Research
Strategies for Antimicrobial Stewardship
- Implementing comprehensive and interdisciplinary antimicrobial stewardship programs in long-term care facilities to improve antimicrobial use and combat antimicrobial resistance 2
- Developing guidelines specific to long-term care facilities, as current guidelines are mostly focused on hospitals 3
- Monitoring antibiotic use metrics, such as antibiotic dispensing rates and duration of treatment, to identify areas for improvement 4, 5
- Implementing risk adjustment for interfacility comparisons and quality improvement to develop benchmarks for antibiotic use in long-term care facilities 4
- Focusing on optimizing antibiotic use, including reducing unnecessary or inappropriate use, to minimize antibiotic selective pressure and improve the quality of care received by residents 3, 6
Challenges and Barriers
- Lack of evidence on effective antimicrobial stewardship interventions in long-term care facilities 2
- Variability in antibiotic use across facilities, with some facilities having higher rates of antibiotic use than others 5
- Limited expertise in antimicrobial therapy in long-term care facilities, requiring collaboration with infectious disease-trained physicians or pharmacists 2
- Need for education and training on antimicrobial stewardship for healthcare professionals in long-term care facilities 3
Potential Interventions
- Implementing antibiotic stewardship programs that include monitoring and feedback on antibiotic use, as well as education and training for healthcare professionals 3, 6
- Developing and implementing guidelines for antibiotic use in long-term care facilities, including recommendations for diagnosis, treatment, and duration of therapy 3
- Using metrics, such as antibiotic dispensing rates and duration of treatment, to monitor and evaluate antibiotic use in long-term care facilities 4, 5