Interventions to modifying antibiotic treatment may be beneficial to reducing antibiotic therapy in nursing homes, according to a new study presented at The Society for Healthcare Epidemiology of American Spring Conference (SHEA 2019
) in Boston.
Noting that up to 75% of antibiotics prescribed in nursing homes are unnecessary or prescribed inappropriately, the study examined an intervention called Optimizing Antibiotic Stewardship in Skilled nursing facilities (OASIS).
“One of the things we really wanted to address with our intervention is making sure that the information that providers are getting when they make their antibiotic decisions is of the highest possible quality,” Christopher J. Crnich, MD, PhD, chief of medicine at Madison VA Hospital and associate professor of medicine at the University of Wisconsin, told Contagion®
. “So, we designed the intervention around improving the assessment of a resident experiencing a change in condition and making sure that the information they’re collecting is being conveyed in standardized way to providers and also trying to encourage nursing staff to be more active participants in decisions to test and treat residents that have a change in condition that may be related to an infection.”
The study involved 12 nursing homes in 2 states divided between an intervention group and a control group. Days of antibiotic therapy per 1000 residents declined more significantly in the OASIS intervention group than in the control group. Antibiotic starts per 1000 residents also declined in the OASIS group, but not at a statistically significant rate. The study also found that reducing antibiotic use didn’t appear to have any adverse effects on resident outcomes and saw no impact on death rates or unplanned transfers.
“At the end of the day, what we were trying to do on the front end was get providers to delay testing of residents and treating residents with empiric antibiotics when they have a low-risk change in condition,” Crnich told Contagion®
. “We tried to develop decision aids that helped nursing staff and providers put residents into these different buckets: high risks of infection versus a low risk of infection.”
The study focused on assessment and communication related to change in condition, antibiotics avoidance in change of condition determined low risk, and treatment review to reduce duration or switch to alternative treatment. The study promoted the use of antibiotic timeouts, a practice advocated by the US Centers for Disease Control and Prevention (CDC) that isn’t widely used in nursing homes.
“In vast majority of cases, I think most providers are taking a prescribe and forget perspective. We really wanted to move providers to prescribe and follow up with this timeout,” Crnich said.
Although he couldn’t say for sure why antibiotic starts declined at an insignificant rate, diagnostic uncertainty and risk aversion are two factors that likely play a role.
“You have to understand you’re dealing with a patient population that has high levels of cognitive impairment, so diagnostic uncertainty is very high in this population. And they’re frail and they can get sick very quickly, and so levels of risk aversion are very high,” Crnich told Contagion®
. “It’s part of the reason why we knew we wanted to put some emphasis on the timeout with the understanding that getting providers to withhold the antibiotic treatment in this particular setting with these types of patients I think is asking a lot. They’re a lot more amenable to circling back and modifying therapy to a narrow spectrum alternative or using a shorter duration of therapy than completely withholding antibiotic therapy.”
High rates of staff turnover in nursing homes also affect antibiotic stewardship programs, and the study found a wide variation in turnover among nursing homes.
“If I was to pick just 1, I’d say leadership stability is the biggest key to achieving quality improvements in nursing homes,” Crnich said. “I think you can design systems to account for turnover in frontline staff, but when you lose leadership like your director of nursing or your infection preventionist, that’s really tough for a facility to deal with.”
Crnich said the investigators have a few more pieces of analysis to complete their research, and they hope to have a report ready to submit to peer-reviewed literature in the next couple of months.
“I’m generally optimistic about our ability to have a positive impact on antibiotic prescribing in nursing homes on the basis of our work and certainly the work of others in this space,” Crnich told Contagion®
. “I think it’s still an area where more work needs to continue.”
Antimicrobial Stewardship Programs (ASPs) have been a focus
for many providers since the Centers for Medicare & Medicaid Services issued a mandate in October 2016 stating that all LTCFs must fully implement an ASP by November 2019. That mandate has led to initiatives, including the CDC-grant-funded establishment of the Antimicrobial Stewardship Collaborative of South Carolina (ASC-SC)
, a collaborative aiming to improve antimicrobial stewardship among 44 acute care hospitals and 12 long-term care facilities.
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