Antibiotic Stewardship an Uphill Battle

Nursing homes have the greatest need … but the fewest resources

January 2022 – The Journal of Healthcare Contracting

Since the mass production of penicillin began in the 1940s, antimicrobials have drastically improved human health, preventing death from bacterial infection and lowering the risk associated with surgery and other lifesaving medical procedures, point out the authors of a recent report from the National Academy of Medicine, “Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine.”

But almost as quickly as the first family of antibacterials was introduced, its usefulness declined. Within six years of the introduction of penicillin, roughly a quarter of staphylococcal infections in hospitals (where the drug was often used) were no longer susceptible to it. Penicillin resistance continued to spread, and by the 1970s was as common in community-acquired infections as in hospitals.

Hospitals still face an uphill battle against antimicrobial resistance today, but post-acute and long-term-care facilities even more. That’s because unlike hospitals, nursing homes typically lack the expertise of a full-time infection prevention staff or an onsite medical director. Nor do they have the information systems that could help staff identify potential misuse of antibiotics. 

Foggy guidelines

Sadly, antibiotic resistance is a fact of life. In its report, the NAM points out that microbes are constantly responding to selective pressures, including the pressures from antimicrobial medicines. “One response is a classic, Darwinian evolution wherein beneficial traits are passed from one generation to another. … The genetic adaptability of microbes contributes to the emergence of resistance.”

The misuse or overuse of antibiotics exacerbates the problem. Claims data suggest that roughly 17% of antibiotic prescriptions in the United States are made in the absence of any diagnosis of infection, while another 20% to 30% are not associated with any clinical visit at all, according to the NAM.

Confusion over treatment guidelines is another problem. Long treatment regimens with antimicrobials were common historically, driven partly by a limited understanding of their effectiveness. The optimal duration of antibiotic therapy even for common infections, such as community-acquired pneumonia, was not established for decades, according to the NAM authors.

And the results?

In 2019, the Centers for Disease Control and Prevention estimated that every year, 2.8 million resistant infections in the United States lead to 35,900 deaths, with C difficile infection killing another 12,800 people. The Organisation for Economic Co-operation and Development estimates that 1.75 million years of healthy life are lost to antimicrobial-resistant infections every year among its 33 European member countries.

Urinary tract infections

Older Americans make up 15% of the U.S. population but account for more than one-third of the deaths from antibiotic-resistant bacterial infections, according to a recent study from The Pew Charitable Trusts, University of Utah, and Infectious Diseases Society of America. In nursing homes – which accommodate an estimated 1.3 million Americans, about 80% of whom are over age 65 – antibiotic usage is common, according to the NAM researchers.

Suspected urinary tract infection (UTI) could be the most common indication for antibiotics in U.S. nursing homes, a group of researchers reported in August 2021. But some of those prescriptions are, at best, unnecessary, and at worst, contributory to antibiotic resistance.

“The clinical suspicion of UTI among nursing home residents is most often triggered by subjective changes in behavior or falls, which can also be caused by many noninfectious conditions common to older adults,” according to the NAM researchers. Accordingly, NAM recommends that in the absence of fever or symptoms localized to the urinary tract, providers avoid urine cultures and antibiotic treatment.

“Automatically reaching for that antibiotic isn’t a benign decision,” Christopher Crnich, M.D., PhD, Infectious Diseases Faculty, Veterans Administration Hospital in Madison, Wisconsin, told Repertoire. (Crnich was one of two authors of an editorial in JAMA in April 2021 titled “Opportunities to Improve Antimicrobial Use in US Nursing Homes.”)

“There has been a lot of misinformation in clinical training, particularly around the presentation of infection in older adults, and that has led to or promoted overutilization of antibiotics for nonspecific geriatric manifestations,” he says. “That’s a tough nut to crack because you have to ‘de-implement’ decades of training. Building systems that force clinicians to consider alternative explanations for a resident’s condition or situation is necessary.” The good news, he says, is that a new generation of clinicians is learning that subtle behavior changes among nursing home residents don’t necessarily point to UTI.

Antibiotic stewardship programs

Most experts believe that healthcare providers – including long-term-care facilities – need to address antibiotic resistance with antibiotic stewardship programs, intended to measure and improve how antibiotics are prescribed by clinicians and used by patients. Among those experts are the federal government.

In 2015, the CDC released its “Core Elements of Antibiotic Stewardship for Nursing Homes,” and in 2016, the Centers for Medicare & Medicaid Services finalized a rule requiring that nursing homes have antimicrobial stewardship programs in place by late 2017. In addition, The Joint Commission standards require nursing care centers to develop antimicrobial stewardship programs based on the core principles published by the CDC.

But it’s not clear how many nursing homes have such programs in place, or how well-developed those programs are. The Joint Commission reports that, based on its survey of accredited organizations, only 2% were scored for non-compliance related to the requirement. However, in 2020 researchers reported in the American Journal of Infection Control that among 861 nursing homes surveyed, just 33% had “comprehensive” antibiotic stewardship programs and 41% had “moderately comprehensive” plans.

Crnich believes that those figures – particularly the 33% with comprehensive programs – “are probably a best-case estimate, given how the sampling was conducted,” as those surveyed were in the CDC’s National Healthcare Safety Network, a widely used healthcare-associated infection tracking system. “But it’s premature to criticize nursing homes, given this is a relatively new regulatory requirement, even though the clinical need has been longstanding.”

Hospitals – where stewardship programs began – have a leg up on long-term-care because they have onsite expertise in infectious diseases and pharmacy, as well as automated data systems to help them monitor and improve their stewardship activities, he says. It’s true that every nursing home is required by regulation to have a medical director, but not every medical director is engaged in facility operations in a meaningful way. Similarly, every nursing home has a consultant pharmacist, but again, whether that person is engaged in antibiotic stewardship is variable, depending on the facility. In many cases, it is up to the director of nursing or infection preventionist – who are often one and the same, given staffing challenges facing long-term-care – to implement an antibiotic stewardship program.

Nevertheless, Crnich sees progress. “The fact that CMS in collaboration with other public health agencies decided to explicitly incorporate stewardship into the regulatory language will help drive change,” he says. And, if there is a silver lining to COVID, it may be growing recognition that infection prevention in long-term care is a serious issue. Crnich also believes that information technology infrastructure in nursing homes is improving, which should help staff direct their efforts toward antibiotic resistance more precisely.

Up and running

“High staff turnover and challenges in training staff on antibiotic stewardship protocols may present obstacles to comprehensive stewardship programs in [the long-term-care] setting,” says Sarah Kabbani, M.D., medical officer at the CDC in the National Center for Emerging and Zoonotic Infectious Diseases, Office of Antibiotic Stewardship. Another barrier is limited access to facility antibiotic use data. “Tracking and reporting antibiotic use are important to identify opportunities for improving antibiotic use and engaging healthcare professionals to improve prescribing practices.”

Nevertheless, Kabbani sees increasing awareness of the importance of antibiotic stewardship in nursing homes, and points to a recently published study by the CDC’s Office of Antibiotic Stewardship that reflects growing usage of its “Core Elements” program.

Nursing homes around the country are engaged with academic partners in innovative programs to identify residents at risk for multidrug-resistant pathogens and reduce the spread of these germs, she says. Two examples:

  • The Targeted Infection Prevention program led by Lona Mody from the University of Michigan, which is focused on improving care of residents with indwelling-medical devices at risk for antibiotic-resistant infections.
  • The SHIELD Orange County quality improvement project led by Susan Huang, University of California-Irvine in collaboration with Orange County Public Health, to evaluate use of an anti-bacterial bathing strategy to reduce prevalence of antibiotic-resistant organisms in nursing homes, long-term acute care hospitals and hospitals caring for patients and residents in the same community.

“Through these experiences, there is a growing body of evidence to inform practices in nursing homes that will protect residents from the harms due to antibiotic resistance,” she says.

CDC is investing $2.1 billion to improve infection prevention and control activities across the U.S. public health and healthcare sectors, a portion of which will be dedicated to antibiotic stewardship. Funds will support state data analyses of antibiotic use and programs to improve antibiotic prescribing across communities and address health disparities related to antibiotic use, including in long-term care settings.

Bringing hospitals into the picture

Long-term-care facilities can’t do it alone, wrote Crnich in his JAMA editorial. To have any chance of reducing antibiotic resistance among the post-acute-care nursing home population, they must work with referring hospitals.

Researchers in the JAMA study found that higher antimicrobial usage was observed among short-stay residents admitted for post-acute skilled nursing or rehabilitation care, and among residents most recently admitted to the nursing home. They found that residents receiving antimicrobials during days 1 and 2 of their stay were most likely initiated before nursing home admission.

“It definitely is an area that requires focused attention,” says Crnich. “We are collaborating with investigators at Oregon Health and Science University to identify opportunities and targets for intervention. Whether those are identified prior to the patient’s discharge from the hospital or during post-discharge monitoring by the acute-care provider is not entirely clear. My initial bias is that there will have to be ongoing post-discharge monitoring by acute care, but that can only be accomplished through collaboration between acute and post-acute care. I hope we see these types of models emerging.”