Annals of Long Term Care

Key words: Antibiotic resistance, antibiotic stewardship, infectious diseases, nursing home, quality of life. 

An estimated 1.6 million to 3.8 million nursing home residents are treated for infections annually, and approximately 400,000 infection-related deaths occur in long-term care (LTC) facilities every year.¹ According to the Society for Healthcare Epidemiology of America (SHEA), antibiotics constitute up to 40% of all prescribed medications in LTC facilities, with as many as 70% of residents having at least one antibiotic prescription in any given year.² According to various studies, however, 25% to 75% of the antibiotic use in nursing homes is inappropriate.^2,3 This not only puts residents at increased risk of drug-related complications, but because the majority of these residents are elders, adverse effects due to the decreased kidney, liver, and cerebral function that occurs with aging are also more likely.² In addition, because many LTC residents take several medications daily, they also have an increased likelihood of experiencing drug-drug interactions.²

Another important issue surrounding inappropriate antibiotic use is the development of bacterial resistance. Because LTC residents live in close proximity to one another, there is a greater risk of spreading antibiotic-resistant organisms.² More complications arise with antibiotic-resistant infections, which make them harder to treat.⁴ Antibiotic resistance in these patients increases the likelihood of and the need for hospitalization, increasing mortality and cost.⁴ The Figure illustrates the trend in antibiotic-resistant infections between 2000 and 2004.¹ Although these data are more than 8 years old, and no more recent longitudinal data are available, based on our experience, the trend demonstrated by the Figure is increasing.

The effort to improve antibiotic use has been focused primarily in inpatient settings.^5-7 Most US hospitals have some type of antibiotic management program, and these have been shown to be an effective tool for combating drug resistance and for improving prescribing practices in hospitals.^8,9 However, little progress has been made in implementing such programs in LTC settings. Our successful hospital antibiotic stewardship program led our pharmacy team to seek a way to translate that success to our hospital’s LTC facility.

The Pharmacist’s Role 

We reviewed the literature on antibiotic stewardship programs that included pharmacists and that were set in both hospitals and in LTC facilities. We found that studies exploring the effectiveness of antibiotic stewardship initiatives often actively involved pharmacists on the program’s team. In many instances, pharmacists assumed leadership roles, because optimal antibiotic use directly relates to the major objectives of pharmacy practice: safe and effective use of medications and cost-effective care.⁷

The positive impact of including clinical pharmacists trained in infectious diseases (ID) on antibiotic stewardship teams has been well documented.^8-12 One such study compared antibiotic recommendations made by ID pharmacists versus ID fellows.¹² Pharmacists in this study were backed up as needed by the ID physician. Recommendations were later evaluated and compared in a blinded manner by the ID physician who directed the antibiotic stewardship program. This study focused on evaluating the appropriateness of therapy, patient outcomes, and cost of hospitalization. The authors found that antibiotic choice was deemed appropriate in 87% of pharmacist recommendations versus 47% of fellow recommendations, with cure rates of 64% and 42%, respectively. The median cost of the hospital stay was $6468 for patients with antibiotic recommendations from the ID pharmacist and $7864 for patients of ID fellows; the median cost of antibiotics was $79 versus $122, respectively.¹²

The Infectious Diseases Society of America (IDSA) has also recognized the value of the pharmacist’s expertise and recommends the inclusion of these healthcare professionals on antibiotic stewardship teams.⁶ The guidelines note “Core members of a multidisciplinary antimicrobial stewardship team include an infectious diseases physician and a clinical pharmacist with infectious diseases training (A-II) who should be compensated for their time (A-III), with the inclusion of a clinical microbiologist, an information system specialist, an infection control professional, and hospital epidemiologist being optimal (A-III).”

Antibiotic Stewardship in Long-Term Care Facilities  

In contrast, little progress has been made in establishing antibiotic stewardship programs in LTC facilities, despite evidence of the continuing increase in antibiotic resistance in this setting and support for antibiotic stewardship programs from the Centers for Disease Control and Prevention, SHEA, the Association for Professionals in Infection Control and Epidemiology (APIC), the American Society of Health-System Pharmacists, and other healthcare societies.^1,13,14

Although the concept has widespread support, developing a viable and effective model of antibiotic stewardship for LTC facilities presents a major challenge. For example, the APIC and SHEA recommendation supporting the implementation of such programs in LTC facilities has an evidence rating of level I B (strong recommendation, moderate evidence), which indicates a paucity of actual practical experience.¹³

Some of the barriers to implementing antibiotic stewardship programs in nursing homes are the lack of ID physicians and pharmacists, a deficit in knowledge regarding current guidelines, the lack of an antibiogram, and limited pharmacist access to patient records.⁵

The Memorial Health Center Antibiotic Stewardship Program

The Memorial Health Center Hospital in Medford, WI, has a successful antibiotic stewardship program that is led by pharmacists. Our program consists of a clinical pharmacist with training in ID, supported by an internal medicine physician (as needed), staff pharmacists, and an infection control coordinator. Based on the success and popularity of the program among the hospital physicians, we expanded the program to Memorial Health Center Nursing Home, the LTC facility associated with the hospital. Because the nursing home is owned by the hospital, pharmacists have full access to nursing home patients’ electronic medical records, physicians’ progress notes, laboratory results, and other data. Our goals were as follows: (1) to evaluate the need for antibiotic stewardship; (2) to reduce the inappropriate use of antibiotics; and (3) to determine whether pharmacists could improve antibiotic prescribing practices in the nursing home.

Study Design

Our study was constructed in two phases. The first phase was observational, with the goal of performing a needs assessment. The second phase was interventional and included an evaluation of the efficacy of the antibiotic stewardship program. The head of the pharmacy department at Memorial Health Center approved the study design.

Methods. We included only those patients who had cultures collected (N=29). Phase 1 of the study lasted for 3 months before implementation of the antibiotic stewardship program. During this phase, pharmacists did not interfere with antibiotic prescribing, but collected data on antibiotics prescribed, duration of therapy, laboratory tests, signs and symptoms of infection, and culture and sensitivity results. Antibiotic use was assessed retrospectively and classified as inappropriate if one or more of several predefined conditions were met, as outlined in Table 1.^3,15

Phase 2 of the study lasted for 3 months following the implementation of the antibiotic stewardship program. During this time, pharmacists evaluated the appropriateness of therapy by determining if antibiotic therapy was warranted (if empiric antibiotic choice corresponded with current guidelines). They also received and analyzed culture and sensitivity reports and examined antibiotic dosing for every patient included in phase 2 of the study (N=24). These measures enabled pharmacists to identify areas that required intervention, and they made recommendations by contacting prescribers.

Results. During phase 1 of the antibiotic stewardship program (this was the 3-month period that preceded implementation of the program), we found that 40% of the antibiotics in the nursing home were prescribed inappropriately, supporting the need for the program. Some of the prescriptions met more than one of the criteria for inappropriate antibiotic prescribing (Table 1).

In phase 2 of the study, we found that the involvement of pharmacists resulted in a reduction in inappropriate prescribing of antibiotics from 40% to 21% (about a 50% reduction) within the first 3 months after implementation (Table 2). During this time, pharmacists made 12 interventions recommending changes in antibiotic therapy, all of which were accepted by prescribers.