Antibiotic Stewardship Programs: Why They’re More Critical Than Ever

By: Laura Ditz, Clinical Consultant, PointClickCare and Stanley Wang, Data Scientist, PointClickCare

The impact antibiotics have in preventing bacterial infections is undeniable. However, their use in long-term care settings can have adverse effects when administered inappropriately or too often. Consider the following:

• It is estimated that between 40-75% of antibiotics administered in nursing homes are inappropriate.^{1, 2}
• A cohort study of nursing homes in Canada showed that diarrhea, gastroenteritis, and Clostridium difficile (C. difficile) infections were the most common antibiotic-related adverse events.³
• There are more than 100,000 cases of difficile infections in nursing home residents annually, with up to 75% having had recent exposure to antibiotics.⁴

This growing concern has resulted in a regulatory push for antibiotic stewardship programs, which are sets of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

In 2015, with growing concerns related to overuse and misuse of antibiotics, the Centers for Disease Control and Prevention (CDC) issued a recommendation that all nursing homes implement an antibiotic stewardship program.

Additionally, the Centers for Medicare & Medicaid Services mandated that participating care facilities adhere to a three-phase stewardship implementation process. Currently, the plan is in Phase 2, which requires protocols and a system to monitor antibiotic use. Phase 3, which begins November 2019, states that facilities must designate one or more individuals to oversee its infection prevention and control program.

To better understand the current level of antibiotic stewardship taking place in long-term care facilities, the CDC and PointClickCare collaborated to research the state of antibiotic stewardship programs, which attempted to accomplish three goals:

• Understand antibiotic prescribing data elements captured within electronic records.
• Identify data elements, which can be used to track antibiotic use in a facility.
• Describe antibiotic use in a subset of nursing homes to identify targets for improving antibiotic use.

Methodology
Because PointClickCare users are required to enter information related to the prescription of antibiotics, researchers were positioned to uncover insightful data that could inform a baseline understanding of where many long-term care facilities stood in terms of stewardship.

From 2015-2017, more than 2.8 million antibiotic orders and admission records from 2,538 skilled nursing facilities were analyzed. Further details of research included:

• Combined generic and brand name drugs
• Utilized therapeutic class information from Medi-Span
• Data-mined indications to create common groups
• Measured antibiotic days of therapy (DOT)
• Considered the rate of antibiotic using DOT per 1,000 resident days

Findings
Antibiotics Use

• 43% of all residents had at least one antibiotic order during their stay.
• The average DOT was 139 days per 1,000 resident days.
• At a facility level, the average DOT was 165 days per 1,000 resident days (60-208 IQR).

Indications
Between 2015-2017, the frequency of ailments for which antibiotics were administered remained relatively the same, free of wide variances. 2017 statistics included:

• 24% of administrations were for urinary tract infections
• 13% for respiratory issues
• 12% for skin infection
• 5% for prophylaxis
• 5% for GI (including C. difficile)

Short-stay vs. Long-stay

• 85% of residents were short-stays (fewer than 100 days, no more than a three-day gap).
• Short-stay: 40% were on antibiotics, with an average DOT of 319 days per 1,000 resident days.
• Long-stay: 61% were on antibiotics, with an average DOT of 78 days per 1,000 resident days.

Antibiotic Administration

• 80% of residents prescribed an antibiotic received administration within the first 10 days of admission in 2017, which is up from 69% in 2015.
• 42% of residents prescribed an antibiotic were administered at least two of them during their stay in 2017, which is down from 50% in 2015.

Enabling Antibiotic Stewardship
While necessary, implementing an antibiotic stewardship program is no simple task. It often requires a significant culture shift for many care providers, which includes physicians adjusting prescribing patterns, pharmacists diligently monitoring prescription data and nurses closely observing changes in condition.

In addition to a change in processes, it is just as critical to have systems in place to ensure collected data is accurate to empower the changes necessary to improve care. This requires a list of “Must-Have’s” and “Must-Do’s”:

Must-Haves:

• Standardized list of Medical Indications or Diagnosis Code
• Standard list of antibiotic drug classes
• Duration and stop dates

Must-Dos:

• Investigate and clean up unclear data
• Understand broader implications
• Train staff to be accountable

To curtail the adverse effects of antibiotic overuse and misuse, it is more critical than ever for long-term care facilities to have an effective stewardship program. This requires having the technology in place to easily capture, access, and analyze data, the processes necessary to ensure the data is accurate, and the proper training to position everyone on staff to play their parts in promoting an effective antibiotic stewardship program.

Stanley Wang, Laura Ditz, and Sarah Kabbani (infectious disease specialist at the CDC) will present, “Antibiotic Drug Usage and Clinical Indications to Understand Antibiotic Prescribing Practices,” today at AHCA, based on these findings. Learn more about their presentation.

1. Lim et al. Clin Interven Aging. 2014 Jan 13;9:165-77
2. Nicolle et al. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45
3. Daneman et al. JAMA Intern Med. 2015 Aug;175(8):1331-1339
4. Hunter et al. Open Forum Infect Dis. 2016 18;3(1):ofv196