Hostname: page-component-78c5997874-94fs2 Total loading time: 0 Render date: 2024-11-10T06:15:59.524Z Has data issue: false hasContentIssue false
  • English
  • Français

Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel

Published online by Cambridge University Press:  22 June 2020

Shaul Z. Kruger ,
Susan E. Bronskill ,
Lianne Jeffs ,
Marilyn Steinberg ,
Andrew M. Morris  and
Chaim M. Bell Open the ORCID record for Chaim M. Bell [Opens in a new window]
Shaul Z. Kruger
Affiliation:
Department of Medicine, University of Toronto, Toronto, Ontario, Canada
Susan E. Bronskill
Affiliation:
ICES, Toronto, Ontario, Canada Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
Lianne Jeffs
Affiliation:
Department of Nursing, Sinai Health, Toronto, Ontario, Canada Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
Marilyn Steinberg
Affiliation:
Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
Andrew M. Morris
Affiliation:
Department of Medicine, University of Toronto, Toronto, Ontario, Canada Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
Chaim M. Bell*
Affiliation:
Department of Medicine, University of Toronto, Toronto, Ontario, Canada ICES, Toronto, Ontario, Canada Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada Division of General Internal Medicine, Sinai Health, Toronto, Ontario, Canada
*
Author for correspondence: Chaim M. Bell, E-mail: Chaim.Bell@sinaihealth.ca
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited.

Objective:

To support nursing home providers with the selection and adoption of ASP interventions.

Design and Setting:

A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting.

Participants:

A 16-member multidisciplinary panel of experts and resident representatives.

Results:

From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions.

Conclusions:

Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 9 , September 2020 , pp. 1028 - 1034
Check for updates
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Daneman, N, Gruneir, A, Newman, A, et al.Antibiotic use in long-term care facilities. J Antimicrob Chemother 2011;66:2856–2863.CrossRefGoogle ScholarPubMed
Friedrich, MJ. Antibiotic consumption increasing globally. JAMA 2018;319:1973.Google ScholarPubMed
Klein, EY, Van Boeckel, TP, Martinez, EM, et al.Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci U S A 2018;115:E3463–E3470.CrossRefGoogle ScholarPubMed
Nicolle, LE. Urinary tract infection in long-term care facility residents. Clin Infect Dis 2000;31:757–761.CrossRefGoogle ScholarPubMed
Peron, EP, Hirsch, AA, Jury, LA, Jump, RL, Donskey, CJ. Another setting for stewardship: high rate of unnecessary antimicrobial use in a veterans affairs long-term care facility. J Am Geriatr Soc 2013;61:289–290.Google Scholar
Katz, PR, Beam, TR, Brand, F, Boyce, K. Antibiotic use in the nursing home: physician practice patterns. Arch Gen Intern Med 1990;150:1465–1468.CrossRefGoogle ScholarPubMed
Loeb, M. Antibiotic use in long-term–care facilities: many unanswered questions. Infect Control Hosp Epidemiol 2000;21:680–683.CrossRefGoogle ScholarPubMed
Van Buul, LW, van der Steen, JT, Veenhuizen, RB, et al.Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc 2012;13:568.e1–e13.CrossRefGoogle ScholarPubMed
Dyar, OJ, Pagani, L, Pulcini, C. Strategies and challenges of antimicrobial stewardship in long-term care facilities. Clin Microbiol Infect 2015;21:10–19.CrossRefGoogle ScholarPubMed
O’Brien-Pallas, LG, Tomblin, M, Shamian, J. Final report: understanding the costs and outcomes of nurses’ turnover in Canadian hospitals. University of Toronto Nursing Health Services Research Unit: Toronto, ON, Canada, 2008.Google Scholar
Crnich, CJ, Jump, R, Trautner, B, Sloane, PD, Mody, L. Optimizing antibiotic stewardship in nursing homes: a narrative review and recommendations for improvement. Drugs Aging 2015;32:699–716.CrossRefGoogle ScholarPubMed
Schwartz, DN, Abiad, H, DeMarais, PL, Armeanu, E, Trick, WE, Wang, Y, Weinstein, RA. An educational intervention to improve antimicrobial use in a hospital-based long-term care facility. J Am Geriatr Soc 2007;55:1236–1242.CrossRefGoogle Scholar
Field, TS, Gurwitz, JH, Avorn, J, et al.Risk factors for adverse drug events among nursing home residents. Arch Intern Med 2001;161:1629–1634.CrossRefGoogle ScholarPubMed
Dellit, TH, Owens, RC, McGowan, JE, et al.Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.10.1086/510393CrossRefGoogle Scholar
Kaki, R, Elligsen, M, Walker, S, Simor, A, Palmay, L, Daneman, N. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Chemother 2011;66:1223–1230.Google ScholarPubMed
Sloane, PD, Huslage, K, Kistler, CE, Zimmerman, S. Optimizing antibiotic use in nursing homes through antibiotic stewardship. N C Med J 2016;77:324–329.Google ScholarPubMed
Malani, AN, Brennan, BM, Collins, CD, Finks, J, Pogue, JM, Kaye, KS. Antimicrobial stewardship practices in Michigan long-term care facilities. Infect Control Hosp Epidemiol 2016;37:236–237.CrossRefGoogle ScholarPubMed
Strausbaugh, LJ, Joseph, CL. The burden of infection in long-term care. Infect Control Hosp Epidemiol 2000;21:674–679.Google ScholarPubMed
Hughes, JM. Preserving the lifesaving power of antimicrobial agents. JAMA 2011;305:1027–1028.CrossRefGoogle ScholarPubMed
Jump, RL, Olds, DM, Seifi, N, et al.Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012;33:1185–1192.CrossRefGoogle Scholar
Barlam, TF, Cosgrove, SE, Abbo, LM, et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51–e77.CrossRefGoogle Scholar
Loeb, M, Bentley, DW, Bradley, S, et al.Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol 2001;22:120–124.CrossRefGoogle ScholarPubMed
Centers for Disease Control and Prevention (CDC). Antibiotic resistance threats in the United States, Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2013.Google Scholar
Antimicrobial stewardship strategies. Public Health Ontario website. https://www.publichealthontario.ca/en/health-topics/antimicrobial-stewardship/acute-care/asp-strategies. Accessed October 1, 2019.Google Scholar
Ilić, D, Bukumirić, Z, Janković, S. Impact of educational intervention on prescribing inappropriate medication to elderly nursing homes residents. Srp Arh Celok Lek 2015;143:174–179.CrossRefGoogle ScholarPubMed
Katz, MJ, Gurses, AP, Tamma, PD, Cosgrove, SE, Miller, MA, Jump, RLP. Implementing antimicrobial stewardship in long-term care settings: an integrative review using a human factors approach. Clin Infect Dis 2017;65:1943–1951.CrossRefGoogle ScholarPubMed
Harbarth, S, Harris, AD, Carmeli, Y, Samore, MH. Parallel analysis of individual and aggregated data on antibiotic exposure and resistance in gram-negative bacilli. Clin Infect Dis 2001;33:1462–1468.CrossRefGoogle ScholarPubMed
High, KP, Bradley, SF, Gravenstein, S, et al.Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48:149–171.CrossRefGoogle ScholarPubMed
Nicolle, LE. Antimicrobial stewardship in long-term care facilities: what is effective? Antimicrob Resist Infect Control 2014;3:6.CrossRefGoogle ScholarPubMed
Fleming, A, Browne, J, Byrne, S. The effect of interventions to reduce potentially inappropriate antibiotic prescribing in long-term care facilities: a systematic review of randomised controlled trials. Drugs Aging 2013;30:401–408.CrossRefGoogle ScholarPubMed
Schulz, L, Hoffman, RJ, Pothof, J, Fox, B. Top ten myths regarding the diagnosis and treatment of urinary tract infections. J Emerg Med 2016;51:25–30.CrossRefGoogle ScholarPubMed
Fink, A, Kosecoff, J, Chassin, M, Brook, RH. Consensus methods: characteristics and guidelines for use. Am J Public Health 1984;74:979–983.CrossRefGoogle ScholarPubMed
Morris, AM, Brener, S, Dresser, L, Daneman, N, Dellit, TH, Avdic, E, Bell, CM. Use of a structured panel process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2012;33:500–506.CrossRefGoogle ScholarPubMed
Dresser, LD, Bell, CM, Steinberg, M, et al.Use of a structured panel process to define antimicrobial prescribing appropriateness in critical care. J Antimicrob Chemother 2017;73:246–249.CrossRefGoogle Scholar
Fitch, K, Bernstein, SJ, Aguilar, MS, et al.The RAND/UCLA appropriateness method user’s manual. Santa Monica, CA: The RAND Corporation; 2001.Google Scholar
Zabarsky, TF, Sethi, AK, Donskey, CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control 2008;36:476–480.CrossRefGoogle Scholar
McElligott, M, Welham, G, Pop–Vicas, A, Taylor, L, Crnich, CJ. Antibiotic stewardship in nursing facilities. Infect Dis Clin North Am 2017;31:619–638.CrossRefGoogle ScholarPubMed
Gurwitz, JH, Field, TS, Avorn, J, McCormick, D, et al.Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000;109:87–94.CrossRefGoogle ScholarPubMed
Moehring, RW, Anderson, DJ, Cochran, RL, et al.Expert consensus on metrics to assess the impact of patient-level antimicrobial stewardship interventions in acute-care settings. Clin Infect Dis 2017;64:377–383.CrossRefGoogle ScholarPubMed
Wu, JH, Langford, BJ, Daneman, N, Friedrich, JO, Garber, G. Antimicrobial stewardship programs in long-term care settings: a meta-analysis and systematic review. J Am Geriatr Soc 2019;67:392–399.CrossRefGoogle ScholarPubMed
Davey, P, Marwick, CA, Scott, CL, et al.Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017;2:CD003543.Google ScholarPubMed