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 Antibiotic Stewardship in Practice

It is critically important that providers create committed working teams to implement infection prevention and control procedures.

 

Antibiotic stewardship and a robust infection prevention and control program (IPCP) are key initiatives in the 2016 revision of the federal Requirements of Participation for skilled nursing facilities, and this year health inspectors are really honing in on these areas as part of the survey process.

All staff will be expected to answer questions about their facility’s program, and the medical director is no exception. In fact, the medical director should work closely with the infection preventionist to craft appropriate, evidence-based policies and procedures and monitor the patterns in the facility.

The Interdisciplinary Team

To comply with the new regulations, it is advisable to first review current programs. The second step is to utilize tools to identify potential or actual antibiotic use problems in the facility, with a designated interdisciplinary team (IDT) specifically around infection prevention and control. This usually includes the director of nursing services and the director of staff development, in addition to the medical director and infection preventionist. It’s important to ensure that this task-specific IDT meets regularly to discuss progress and any new issues of concern. Support from facility leadership is essential.

Doing More Harm Than Good

Many clinicians, including physicians, advanced practice nurses, physician assistants, and nursing staff have antiquated ideas about some aspects of diagnosing and treating infections.

For example, it used to be commonplace when a resident had some increased confusion, or experienced a fall, for the nurse to call the physician and receive an order for a urinalysis and urine culture to “rule out an occult urinary tract infection” (UTI). There are still some clinicians who believe that ordering repeat stool studies for Clostridium difficile (C. diff.), or repeat urine cultures after treatment, are indicated as a “test of cure.” Sometimes the physician requests these studies, sometimes the nurse requests them.

These practices are no longer the standard of care, though, and they can do more harm than good. Consensus (including ample research) indicates that urine studies should not be ordered on the basis of a single symptom change.

In fact, the McGeer criteria (which should be considered as a valuable tool for an IPCP) are available online within the Society for Healthcare Epidemiology of America and the Centers for Disease Control and Prevention (CDC) guidelines (http://bit.ly/2CJgGmC). The criteria strongly recommend not routinely doing urine cultures in the absence of multiple specific symptoms.

While positive urine cultures are common in the nursing center population, these are often not indicative of an actual infection, but they represent colonization of the bladder—or what is called asymptomatic bacteriuria. This is now considered to be part of a normal microbiome for some people, and it should not be treated if it does not meet criteria for an actual infection.

Leaving the Past Behind

What if a facility’s medical director is one of the physicians who still seems to be practicing 1990s medicine with respect to antibiotic stewardship? The CDC website has some excellent resources for all long term care (LTC) facility staff, and the medical director should be encouraged to read it carefully. The landing page is at www.cdc.gov/longtermcare/staff/index.html. Attending meetings of AMDA – The Society for Post-Acute and Long-Term Care Medicine and its state affiliates, and achievement of a Certified Medical Director certificate are likely to enhance understanding of these issues.

Ultimately, if the medical director disagrees with all the evidence available, it may be time to consider a new medical director.

Family members can be another driver of inappropriate antibiotic use. A spouse or adult child of a resident may say of the resident, “She always gets like this when she has a UTI” and demand testing and antibiotics. Sometimes it may feel easier just to acquiesce instead of attempting to educate the family member and prevent harm to the patient, but this does not constitute good antibiotic stewardship.

The Harm in Antibiotics

So, where is the harm in a course of antibiotics? Especially when the urine is growing >100,000 colonies per high-power field of Escherichia coli or some other nasty-sounding bug?

Well, there are a number of potential harms. One is that it gives clinicians a false sense of security that they have identified and treated the cause of the original change of condition. This may result in a delay in diagnosing other significant problems such as dehydration or other metabolic derangements.

Second, the antibiotic may interact with multiple other medications the resident is taking, most notably warfarin (Coumadin).

Third, many antibiotics directly cause nausea, anorexia, abdominal pain, and similar side effects. Fourth, antibiotics may significantly disrupt the normal flora or microbiome, resulting in a number of derangements that can include nuisance-type problems like thrush or other candidiasis, all the way to potentially life-threatening C. diff. infections.

The Useful QAPI

The Quality Assurance/Performance Improvement (QAPI) paradigm can be very useful in assessing and fine-tuning an antibiotic stewardship program in nursing centers and should be utilized both for surveillance of prevalent microorganisms and for assessment of appropriate antimicrobial use.

QAPI relies on a rapid-cycle, data-driven process where once a gap is identified, a performance improvement project is designed and implemented. This may be as simple as tracking all new antimicrobial orders in the facility, then doing a chart review to determine whether accepted criteria were met.

If antibiotics are being ordered repeatedly in clinically inappropriate circumstances (like the ones listed above), it is time to do a deeper dive into the data. Is there one particular prescriber or nurse who seems to be involved in more of these incidents? Then specific, tailored action can be implemented with education and, if need be, specific peer-to-peer contact between the medical director and the inappropriate prescriber.

Countering Inappropriate Use

With respect to inappropriate orders for urine studies and inappropriate antibiotic prescriptions for asymptomatic bacteriuria, there is much the medical director can do to assist the nursing center. Providing an in-service to front-line nursing staff that reviews the reasoning behind reserving urine studies for clinical situations that meet McGeer’s criteria, and limiting antibiotics to actual, confirmed UTIs, will help give the nurses language to talk to the attending practitioners when they call about a change of condition.

Sometimes scripting can be helpful, and maintaining a checklist of the McGeer criteria to be able to tell a physician why the urine studies are not indicated, based on facility policy, can be invaluable. Sometimes suggesting alternative measures, such as obtaining blood work (such as a complete blood count and chemistry panel) before doing urine studies, can also help.

Communicating Changes

It is advisable to let practitioners know of changes in facility policy around urine studies, antibiotic use, and the IPCP in general. A written or e-mailed communication to all attending staff from the medical director outlining the changes can often lead to improved understanding and less resistance when a front-line nurse is on the phone with the practitioner. On the CDC nursing facility LTC antibiotic stewardship page (cited above) is a link to a specific Situation/Background/Assessment/Request form that is excellent for use with physicians who may be overutilizing urine studies and antibiotics.

But, ultimately, there are going to be some clinical instances where a physician insists on proceeding in a fashion that is inconsistent with a facility’s IPCP and antibiotic stewardship program. When that occurs only sporadically, or with reasonable documentation of the reason for the deviation, that should not cause significant survey problems. But for habitually noncompliant clinicians, it is advisable to have the medical director contact these clinicians directly for attempts at remediation—and if need be, consider overriding their orders or otherwise limiting their privileges.
 
Karl Steinberg, MD, CMD, HMDC, is a long term care geriatrician in Ocean-side, Calif. He is chief medical officer for Mariner Health Central and medical director of Life Care Center of Vista and Carlsbad by the Sea Care Center. He is chair of AMDA’s Public Policy Committee and editor-in-chief of its monthly periodical, Caring for the Ages. A hospice and nursing home medical director since 1995, Steinberg is probably best known for taking his dogs on rounds in nursing homes and assisted living centers.
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