Scope of the Problem
Antibiotics are among the most prescribed medications in skilled nursing facilities across the country. Up to 70% of residents take one or more courses of antibiotics every year. According to the CDC “Similar to the findings in hospitals, studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate”. There are many potential harms from antibiotics, including serious diarrheal infections, C diff, and increased adverse drug events and drug interactions. Colonization and/or infection with antibiotic-resistant organisms may also be a serious negative outcome of overuse of antibiotics.
Antibiotic Stewardship
The Centers for Disease Control and Prevention (CDC) provide core elements of antibiotic stewardship that are aimed to improve the use of antibiotics in healthcare, protect residents and reduce the overall threat of antibiotic resistance in the United States. Antibiotic stewardship refers to a set of commitments and actions that are designed to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use” (CDC). The Centers for Disease Control and Prevention recommends that all nursing facilities implement an antibiotic stewardship program (ASP) and use the seven core elements for implementing it.
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According to the CDC, “Nursing homes are encouraged to work in a step-wise fashion, implementing one or two activities to start and gradually adding new strategies from each element over time”. The CDC also states that “Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting”.
Seven Core Elements of Antibiotic Stewardship
The CDC provides seven core elements that nursing facilities can implement one-by-one. They include leadership commitment, accountability, drug expertise, action, tracking, reporting and education. Like most good programs, leadership must make a commitment to develop, manage and sustain the antibiotic stewardship program. Leadership must support safe and appropriate antibiotic use, develop written statements in support of improving antibiotic use and share it with staff, residents and families. Leadership must also communicate with nurses and physicians their expectations about the use of antibiotics and the monitoring and enforcement of stewardship policies.
In terms of accountability, individuals in the care community should be identified and held accountable for the antibiotic stewardship activities and have support from leadership. The medical director, director of nursing, nurses and nursing assistants should all be on the same page concerning the program. Drug expertise in antibiotic use is necessary to implement this program and should involve someone with a clinical background within the care community, a hired consultant or attending pharmacist.
Action refers to policies and procedures regarding antibiotic use within the care setting. Staff should become familiar with any new policy or procedure regarding antibiotic use and misuse. Ultimately, policies should support optimal antibiotic use. Tracking of how often and why antibiotics are prescribed is another important core element of the stewardship program. Reporting on issues like outcomes and costs is equally important. Lastly, education must be ongoing, updated and recurring in order for staff to stay on top of antibiotic use and misuse in senior living communities.
Final Thoughts on Antibiotic Stewardship
Taken all together, these seven core elements of an antibiotic stewardship program can help reduce inappropriate prescribing and use of antibiotics, improve the overall health and well-being of residents and maintain a safe and healthy living environment.
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