Antibiotic Resistance and Stewardship in Long-Term Care

Decades of suboptimal prescribing patterns and misuse of antibiotics by health care providers and agricultural producers have produced multidrug resistant organisms (MDROs) at a quickening pace - and faster than our progress in developing replacement agents. Thus, the rise of MDROs is largely a self-inflicted casualty born of a cavalier approach to their use. David A. Nace, MD, MPH, and his team are working on ways to help.

While bacterial organisms will develop resistance over time, a judicious, evidence-based approach to antibiotic use will slow and sometimes reverse resistance patterns, as well as other adverse outcomes. Changes to how, when, and why antibiotics are used is a global health imperative. To maintain the efficacy of antimicrobial agents for the long term, these changes in usage must occur now.

The misuse of antibiotics has consequences beyond the rise of MDROs, particularly in frail, older adult populations, especially those who reside in long-term care facilities (LTCs). A full 20 percent of adverse drug events (ADEs) in long term care residents are related to antibiotic use. Inappropriate or unwarranted courses of antibiotics can also lead to Clostridium difficile infections. "Research by Dr. Nick Daneman's group in Canada has actually shown that in facilities with high antibiotic use, there is a 24 percent increase in ADEs, and the risk extends even to residents who do not receive the antibiotics. In the LTC environment, the overuse of antibiotics affects everyone, whether they receive an antibiotic or not. This is some.thing that providers and facilities must come to understand,"says Dr. Nace, associate professor and director of Long-Term Care and Influenza Programs at UPMC.

A Stewardship Template for LTCs

Dr. Nace leads the antibiotic stewardship efforts for the Division of Geriatric Medicine, and he has been an active researcher into antibiotic use and misuse and the consequences for many years. He is also part of a work group for the Society for Post-Acute and Long-Term Care Medicine (AMDA) that has developed a template to assist LTCs with developing their own antibiotic stewardship program.¹ These programs are required for phase II implementation of the Centers for Medicare and Medicaid Services (CMS) participation requirements that went into effect on November 28, 2017.

The new CMS guidelines mandate that stewardship programs be developed and implemented by LTCs, and include use protocols and monitoring systems, among other requirements. Ostensibly, these systems will facilitate visibility of patterns of resistance, monitoring of usage patterns, the development of facility antibiograms, and other key metrics. This should allow for greater transparency and characterization of the use of antibiotic medications, theoretically leading to reduction of inappropriate uses, lower infection rates, lower rates of MDRO infections, and fewer adverse drug events attributable to antibiotics.

The impetus for Dr. Nace and his colleagues to develop such templates is an under.standing that facilities have long struggled with antibiotic stewardship. The reasons are multifactorial - limited expertise, insufficient resources and training, and a lack of evidence on what good models of stewardship look like in the LTC setting. "What works for acute-care hospitals or in an outpatient setting does not necessarily translate well into the unique setting of the LTC facility with its two major populations: post-acute patients and long-term care residents," says Dr. Nace.

The template that Dr. Nace and his colleagues have produced is meant to be tailored by, and adapted to, the individual needs of a facility. "Our intent is to provide facilities with an understanding of what actions and plans make strategic sense, along with the rationale for their adoption. This includes things like the formation and function of antibiotic stewardship committees, creation of antibiotic use and monitoring protocols, measuring resistance rates and developing facility antibiograms, implementing antibiotic 'time-outs,' and training to promote best practices," says Dr. Nace.

Better Antibiotic Use in UTIs, Bladder Infections, and Beyond

Urinary tract infections (UTIs) are a particularly problematic area in the use of antibiotics. Mistreatment and over-treatment are common and lead to all manner of complications. An international project led from the Netherlands has been working to develop better guidelines for the diagnosis of UTI, an initiative that Dr. Nace has been part of locally. The guidelines are currently in draft form and will be published in the near future.

Related work by Dr. Nace has involved a multiyear study, the IOU project - Improving Outcomes in UTI Management. Funded by the AHRQ, this $1.5 million cluster randomized controlled trial started in June 2015. Its goal is to improve treatment and reduce antibiotic use in suspected urinary tract infections. UTI (or suspected UTI) is the poster child for poor antibiotic use. Research indicates that many suspected UTIs are in fact instances of asymptomatic bacteriuria, for which treatment with antibiotics is generally not needed and may in cases prove harmful. Increasing the appropriateness of antibiotic use through an effective, multifaceted intervention will lessen the risk of adverse drug events, help reduce the growing threat of antimicrobial resistance, and diminish the risk of Clostridium difficile infection.

Influenza Vaccine Response and Sarcopenia

Dr. Nace's clinical and research work also focuses on influenza prevention and management. Currently, Dr. Nace is collaborating with Richard Zimmerman, MD, MPH, who leads the Pittsburgh Vaccine Research Group, on a study investigating markers of immune response in frail, pre-frail, and non-frail older adults. The Pittsburgh Vaccine Research Group is one of five centers that make up the Centers for Disease Control and Prevention's (CDC) Influenza Vaccine Effectiveness Network, which evaluates influenza vaccine effectiveness. Dr. Nace and other colleagues in the Division of Geriatric Medicine have received additional funding to conduct a related pilot study, the first such study to assess the relationship between sarcopenia and vaccine response.

References and Further Reading

1. Jump RLP, Gaur S, Katz MJ, Crnich CJ, Dumyati G, Ashraf MS, Frentzel E, Schweon SJ, Sloane P, Nace DA, on Behalf of the Infection Advisory Committee for AMDA Ð The Society of Post-Acute and Long-Term Care Medicine. Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings. JAMDA. 2017; 18: 913-920.

2. Dumyati G, Stone ND, Nace DA, Crnich CJ, Jump RL. Challenges and Strategies for Prevention of Multidrug-Resistant Organism Transmission in Nursing Homes. Curr Infect Dis Rep. 2017; 19: 18. Epub ahead of print.

3. Crnich CJ, Jump RL, Nace DA. Improving Management of Urinary Tract Infections in Older Adults: A Paradigm Shift or Therapeutic Nihilism? J Am Geriatr Soc. 2017; 65(8): 1661-1663.

4. Nace DA, Drinka PJ, Crnich CJ. Clinical Uncertainties in the Approach to Long Term Care Residents With Possible Urinary Tract Infection. J Am Med Dir Assoc. 2014; 15(2): 133-139.

5. Drinka PJ, Crnich CJ, Nace DA. An Antibiotic Prescription Induces Resistance at the Individual Level More Than the Group Level.J Am Med Dir Assoc. 2013; 14(9): 707-708.