Antibiotics: LTC’s double-edged sword

The clinical and environmental challenges of infection control are getting tougher as long-term care (LTC) organizations simultaneously try to reduce healthcare-associated infections (HAIs) and combat the rise of drug-resistant bacteria.

Skilled nursing facilities (SNFs) experience between 765,000 and 2.8 million HAIs nationwide, the Department of Health and Human Services reports. As SNF resident acuity continues to rise, urinary tract infections/Catheter Associated Urinary Tract Infections (UTIs/CAUTIs), respiratory tract infections, methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile infections are becoming more prevalent and increasingly difficult to treat.

But when it comes to the antibiotics used to treat these infections, more is not necessarily better. Recent research reveals the concern of antibiotic overprescribing and the dangerous road of creating more and more virulent multidrug-resistant organisms (MDROs).

A study published in Monday’s online edition of JAMA Internal Medicine notes that in LTC, antibiotics are likely to be prescribed for long periods of time, seemingly whether or not they’re needed. The study involved 66,901 LTC residents across 630 facilities in Ontario, Canada, in 2010. Nearly 80 percent of these residents took an antibiotic during the year, and the most common treatment course lasted for seven days.

But, almost 45 percent of the prescribed antibiotics' courses were longer than seven days. More importantly, the study concluded, the length of the antibiotic course appeared to be related more to physician preference than to the clinical characteristics of the bacterial infection.

“Future trials should evaluate antibiotic stewardship interventions targeting prescriber preferences to systematically shorten average treatment durations to reduce the complications, costs, and resistance associated with antibiotic overuse,” the Canadian study urges.

In July 2012, the U.S. National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Eliminationhad discussed the problem of overuse of antibiotics in LTC facilities, noting that almost half of the drugs administered in SNFs are antibiotics. “Studies estimate that 25% to 75% of systemic antibiotic use may be inappropriate in the LTC setting,” the LTC chapter explains. “All this antibiotic exposure carries the risk of adverse drug reactions, complications such as CDI, and promotes the emergence of MDROs.”

SNFs must maintain infection control protocols (F Tag 441) to remain in compliance with federal regulations, of course. But in the 2012 HAI Action Plan, Health & Human Services estimated that few SNFs (<10 percent) had personnel specifically trained in infection control. Even physicians may not know as much as they should, and organizations such as the American Medical Directors Association—Dedicated to Long Term Care Medicineand the Association for Professionals in Infection Control and Epidemiology (APIC)have created guidelines for infection control in the LTC setting.

SNFs are strongly encouraged to implement antimicrobial stewardship programs to help staffers—and physicians—to increase their knowledge of the infections and illnesses most common to LTC and the most up-to-date clinical protocols on how to treat them, said Phenelle Segal, RN, CIC, president of Infection Control Consulting Services, Delray Beach, Fla., at last week’s APIC educational conference.The best strategy is a team-based, facility-wide approach, she added: “Teams should include housekeeping, administration and pharmacists as well as nurses and physicians. The best approach is a group of healthcare workers who are experts in different areas united as a team.”

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