Stewardship training program reduces antibiotic use in nursing homes
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A safety training program for antibiotic stewardship was associated with reductions in antibiotic use and urine culture collection in long-term care facilities, according to findings published in JAMA Network Open.
“Improving antibiotic use in nursing homes is critically important, both for the individual resident, who may suffer side effects from unnecessary antibiotics, and for public health,” Morgan J. Katz, MD, MHS, an assistant professor of medicine at Johns Hopkins Medicine, told Healio.
“Older individuals are the most susceptible to adverse effects of antibiotic use,” she added. “They are often on multiple medications, which can lead to dangerous interactions such as kidney injury, arrythmias or bleeding issues.”
Older adults are also particularly susceptible to severe infection with Clostridioides difficile, which can occur with antibiotic use, according to Katz. Antibiotic use can lead to bacterial resistance which makes treating infections difficult.
Antibiotic stewardship program
In a quality improvement study, Katz and colleagues investigated outcomes following the implementation of the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, a free resource for developing and sustaining antibiotic stewardship programs in long-term care facilities.
“The goal of the program is to reframe antibiotic use as a patient safety issue, with the understanding that any antibiotic prescription can carry risk to the patient and should be considered,” Katz said.
The AHRQ program was implemented in 439 long-term care facilities in the U.S. between December 2018 and November 2019. The trainings emphasized the “Four Moments of Antibiotic Decision-Making” framework through presentations, posters and pocket cards administered during 15 webinar sessions over a 12-month period. All clinical staff at the long-term care facilities were encouraged to participate; however, the trainings were optional.
In addition to antibiotic use, the researchers also evaluated changes in urine collection.
“The common misperception by direct care staff or family members that changes in the appearance of urine (eg, malodorous, cloudy) indicate a urinary tract infection (UTI) can lead to obtaining unnecessary urine cultures to assess for UTI. Up to 50% of residents in nursing homes will have bacteria in their urine, and prescribers often feel inclined to treat a positive culture even if antibiotics are not indicated,” Katz and colleagues wrote. “We targeted misconceptions about when to test for and treat UTIs by educating direct caregivers about sending urine cultures only when specific signs and symptoms were present.”
Outcomes following the intervention
From baseline to study completion, antibiotic initiation decreased from 7.9 to 7.5 per 1,000 resident-days (mean difference = –0.41; 95% CI, –0.76 to –0.07), according to the researchers. Fluoroquinolones showed the greatest decrease, from 1.5 to 1.3 per 1,000 resident-days (mean difference = –0.21; 95% CI, –0.35 to –0.08).
Although there was no significant difference in the number of days of any antibiotic therapy per 1,000 resident-days (–3.05; 95% CI, –6.34 to 0.23), the researchers found that reductions in antibiotic starts and use were greater in facilities with higher program engagement, which was measured by webinar attendance. Katz and colleagues reported that antibiotic starts and days of antibiotic therapy decreased by 1.12 (95% CI, –1.75 to –0.49) and 9.97 per 1,000 resident-days (95% CI, –15.4 to –4.6;) in high-engagement facilities. Also, urine cultures decreased by 0.38 (95% CI, –0.61 to –0.15) per 1,000 resident-days.
The implications of the findings are significant, according to Katz.
“We have used a top-down approach to antibiotic stewardship for too long and have not placed enough emphasis on involving the entire care team, rather than just prescribers, in the prescribing process,” she said. “In the long-term care setting, nurses and certified nursing assistants are the backbone of the care team; they are the ones at the bedside and often having conversations with families. By taking the time to educate and involve these staff, we can significantly reduce the use of unnecessary diagnostic tests and antibiotics, which can certainly lead to cost-saving for the facility over time.”’
Indeterminate causal relationship
In a related commentary, Lindsay N. Taylor, MD, an infectious disease physician, and Christopher J. Crnich, MD, PhD, an associate professor of infectious disease, both of the University of Wisconsin School of Medicine and Public Health, discussed the implications of the findings as well as the limitations of the study.
They noted that antibiotic starts and antibiotic days of therapy per 1,000 resident-days decreased by about 5% and the number of urine cultures collected decreased by about 13% compared with baseline. However, the study design makes it difficult to establish a causal relationship to the intervention, according to Taylor and Crnich. Additional research involving antibiotic stewardship programs is needed to build on Katz and colleagues’ results, they wrote.
More research “will accelerate our understanding of the needed improvements in nursing home antibiotic stewardship infrastructure and help identify those interventions with the greatest impact on critical antibiotic utilization and outcome measures,” they wrote.
Taylor and Crnich also clarified that antibiotic resistance threatens other health care settings in addition to long-term care facilities. A previous nationwide, 5-year study evaluated the AHRQ initiative in ambulatory care. Healio reported that the findings from this study indicate that antibiotic stewardship programs in ambulatory care settings resulted in nine fewer antibiotic prescriptions for every 100 visits.
Still, “stewardship programs remain immature in most facilities,” Taylor and Crnich wrote.
References:
Katz MJ, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.0181.
Taylor LN, Crnich CJ. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.0211.