Stewardship in the primary care and long-term care settings

Long Term Care ◽

Diagnostic Tools ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Term Care ◽

Care Facilities ◽

This chapter focuses on stewardship in the primary care and long-term care settings. Antibiotic prescribing in the community accounts for 80% total antibiotic prescribing and approximately 75% of this is for acute respiratory tract infections, many of which are viral. There is also significant variation in prescribing practices that is not explained by differences in presenting patients. These factors suggest that antimicrobial stewardship programmes are necessary. This chapter identifies the components of stewardship that have been successful in influencing antibiotic prescribing in primary care and shares local experiences with practical examples. The lack of UK evidence about antimicrobial stewardship in long-term care facilities is discussed, along with successful interventions from overseas. Challenges within these settings are highlighted, including patient demand, lack of access to microbiological and diagnostic tools, competing targets, time pressures, and clinical uncertainty.

2055. Action: A Year in the Lives of Consultant Pharmacists Working on Antimicrobial Stewardship in Long-Term Care Facilities

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1735 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S692-S693

Author(s):

Philip Chung ◽

Alex Neukirch ◽

Rebecca J Ortmeier ◽

Scott Bergman ◽

Mark E Rupp ◽

...

Keyword(s):

First Generation ◽

Long Term Care ◽

Diagnostic Testing ◽

Drug Regimen ◽

Term Care ◽

Clostridioides Difficile ◽

Care Facilities ◽

Abstract Background The CDC recommends consultant pharmacists (CP) support antimicrobial stewardship (AS) activities in long-term care facilities (LTCF) by reviewing antimicrobial appropriateness. We initiated a project training CP from a regional long-term care pharmacy to support AS implementation in LTCF. Methods CP were trained to evaluate the appropriateness of all systemic antimicrobial therapy (AT) and provide prescriber feedback during their monthly drug regimen review (DRR). An electronic database was developed to facilitate data reporting. Antimicrobial use (AU) and adverse events (AE) from 32 LTCF were analyzed for 2018 using descriptive statistics. Results A total of 5327 courses of AT with a median duration of 7 days (IQR 5–10) were reviewed. The majority of AT was started in the LTCF (55%) but was also initiated in hospitals (24%), clinics (11%) and emergency departments (2%). Of 2926 AT started in LTCF, 36% were based on nurse evaluation (NE) while 33% began after prescriber evaluation (PE). Fluoroquinolones (FQ) and first-generation cephalosporins were the most commonly prescribed agents (Table 1). Treatment or prophylaxis of urinary tract infections accounted for 40% of AU (Figure 1). Diagnostic testing was associated with 37% of AT courses. Urine cultures were the most frequent test performed (81%). Overall, 41% of AT was determined to be inappropriate resulting in > 800 feedback letters sent to prescribers. Unnecessary antibiotic starts (based on revised Mc Geer or Loeb’s criteria) were identified as the most common reason (Figure 2). AT appropriateness varied depending on the setting in which it was initiated. A majority (87%) of AT initiated in hospitals was found to be appropriate with 56% and 46% appropriate for ED and clinic starts. Appropriateness of LTCF initiated AT was 49% (59% after PE and 42% after NE). AE were associated with 3% of AT with allergic reactions and Clostridioides difficile infections occurring with 0.4% and 0.7% of AT, respectively. AE were most frequently associated with folate antagonists (5%) and FQ (3%). Conclusion This study demonstrates many AU improvement opportunities exist in LTCF and CP can play an important role in identifying them if trained in AS principles. CP should review all AU for appropriateness and provide data to inform AS efforts in LTCF. Disclosures All authors: No reported disclosures.

A recipe for antimicrobial stewardship success: Using intervention mapping to develop a program to reduce antibiotic overuse in long-term care

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2018.281 ◽

2018 ◽

Vol 40 (1) ◽

pp. 24-31 ◽

Cited By ~ 9

Author(s):

Andrea Chambers ◽

Sam MacFarlane ◽

Rosemary Zvonar ◽

Gerald Evans ◽

Julia E. Moore ◽

...

Keyword(s):

Behavior Change ◽

Long Term Care ◽

Asymptomatic Bacteriuria ◽

Barriers And Facilitators ◽

Antibiotic Prescribing ◽

Term Care ◽

Antibiotic Overuse ◽

AbstractObjectiveTo better understand barriers and facilitators that contribute to antibiotic overuse in long-term care and to use this information to inform an evidence and theory-informed program.MethodsInformation on barriers and facilitators associated with the assessment and management of urinary tract infections were identified from a mixed-methods survey and from focus groups with stakeholders working in long-term care. Each barrier or facilitator was mapped to corresponding determinants of behavior change, as described by the theoretical domains framework (TDF). The Rx for Change database was used to identify strategies to address the key determinants of behavior change.ResultsIn total, 19 distinct barriers and facilitators were mapped to 8 domains from the TDF: knowledge, skills, environmental context and resources, professional role or identity, beliefs about consequences, social influences, emotions, and reinforcements. The assessment of barriers and facilitators informed the need for a multifaceted approach with the inclusion of strategies (1) to establish buy-in for the changes; (2) to align organizational policies and procedures; (3) to provide education and ongoing coaching support to staff; (4) to provide information and education to residents and families; (5) to establish process surveillance with feedback to staff; and (6) to deliver reminders.ConclusionsThe use of a stepped approach was valuable to ensure that locally relevant barriers and facilitators to practice change were addressed in the development of a regional program to help long-term care facilities minimize antibiotic prescribing for asymptomatic bacteriuria. This stepped approach provides considerable opportunity to advance the design and impact of antimicrobial stewardship programs.

Antibiotic prescribing for residents in long-term-care facilities across the UK

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dkz008 ◽

2019 ◽

Vol 74 (5) ◽

pp. 1447-1451 ◽

Cited By ~ 6

Author(s):

Tracey Thornley ◽

Diane Ashiru-Oredope ◽

Andrew Normington ◽

Elizabeth Beech ◽

Philip Howard

Keyword(s):

Long Term Care ◽

Antibiotic Use ◽

Vulnerable Population ◽

Antibiotic Prescribing ◽

Major Public Health Problem ◽

Term Care ◽

Data Set ◽

Care Facilities ◽

Abstract Background Antimicrobial resistance (AMR) is a major public health problem. Elderly residents in long-term-care facilities (LTCFs) are frequently prescribed antibiotics, particularly for urinary tract infections. Optimizing appropriate antibiotic use in this vulnerable population requires close collaboration between NHS healthcare providers and LTCF providers. Objectives Our aim was to identify and quantify antibiotic prescribing in elderly residents in UK LTCFs. This is part of a wider programme of work to understand opportunities for pharmacy teams in the community to support residents and carers. Methods This was a retrospective longitudinal cohort study. Data were extracted from a national pharmacy chain database of prescriptions dispensed for elderly residents in UK LTCFs over 12 months (November 2016–October 2017). Results Data were analysed for 341536 residents in LTCFs across the four UK nations, from which a total of 544796 antibiotic prescriptions were dispensed for 167002 residents. The proportion of residents prescribed at least one antibiotic over the 12 month period varied by LTCF, by month and by country. Conclusions Whilst national data sets on antibiotic prescribing are available for hospitals and primary care, this is the first report on antibiotic prescribing for LTCF residents across all four UK nations, and the largest reported data set in this setting. Half of LTCF residents were prescribed at least one antibiotic over the 12 months, suggesting that there is an opportunity to optimize antibiotic use in this vulnerable population to minimize the risk of AMR and treatment failure. Pharmacy teams are well placed to support prudent antibiotic prescribing and improved antimicrobial stewardship in this population.

2046. A Qualitative Study on Perceived Barriers and Facilitators of Implementing an Antimicrobial Stewardship Intervention in the Management of Urinary Tract Infections in a Long-Term Care Setting

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1726 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S688-S689

Author(s):

April Chan ◽

Denis O’Donnell ◽

Benjamin Kaasa ◽

Annalise Mathers ◽

Nicoleta Paraschiv ◽

...

Keyword(s):

Urinary Tract ◽

Long Term Care ◽

Structured Interview ◽

Barriers And Facilitators ◽

Antibiotic Prescribing ◽

Term Care ◽

Increased Risk ◽

Abstract Background 50% of antibiotic courses in long-term care facilities (LTCFs) are unnecessary, leading to increased risk of harm such as Clostridiodes difficile infection and antibiotic-resistant organisms. Antimicrobial stewardship (AS) interventions play an important role in optimizing antibiotic use. Most studies addressing strategies to improve antibiotic prescribing in LTCFs showed modest and unsustained results. We aimed to identify facilitators, barriers and strategies in implementing a urinary tract infection (UTI)-focused AS intervention at an LTCF in Toronto. Methods A qualitative approach using conventional content analysis was used. Through purposeful sampling, we recruited different LTCF healthcare providers and administrators at Kensington Gardens. Interviewees attended focus groups or one-on-one interviews. Data were collected using a semi-structured interview guide. Data were analyzed inductively using a codebook modified in an iterative analytic process. Barriers and facilitators with potential strategies were summarized and mapped using the COM-B (capability, opportunity, motivation and behavior) model (Mitchie et al.) and emerging themes identified. Results Sixteen participants were interviewed. The most common barriers were family pressure, lack of access and test result delay while the barrier themes were lack of access, inadequate communication, lack of time and lack of knowledge of both HCPs and resident’s families. These can be addressed by the most common facilitators and facilitator themes, which included good communication between healthcare professionals (HCPs), education for HCPs and families and collaboration between HCPs. Most barriers and facilitators were mapped to the opportunities domain of the COM-B model. Conclusion Strategies for improved UTI-focused antimicrobial stewardship intervention in LTC setting should focus on increasing opportunities and innovative formats for education, communication and collaboration among HCPs and with families although barriers and facilitators in all aspects of the COM-B model were identified. Disclosures All authors: No reported disclosures.

1245. Infection Prevention and Control (IP&C) and Antibiotic Stewardship (AS) Practices in Pediatric Long-Term Care Facilities

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1078 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S379-S379

Author(s):

Candace L Johnson ◽

Alexandra Hill-Ricciuti ◽

Lisa Saiman

Keyword(s):

Long Term Care ◽

Infection Prevention And Control ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Term Care ◽

Environmental Cleaning ◽

C Programs ◽

Care Facilities ◽

Feedback Strategies

Abstract Background In November 2017, the Centers for Medicare and Medicaid (CMS) implemented a requirement for long-term care facilities (LTCFs) to incorporate AS into their IP&C programs. The purpose of this study was to describe baseline IP&C and AS practices in pediatric LTCFs. Methods We modified a survey from the CDC to assess IP&C in pediatric LTCFs. The internet-based survey was distributed to the 41 pLTCFs in the Pediatric Complex Care Association from May to June 2017. The 67-question survey included questions to assess IP&C domains and infrastructure such as written policies, hand and respiratory hygiene (HH), personal protective equipment (PPE) use, environmental cleaning, and AS practices. Responses to questions were summarized using frequencies and analyzed using χ2 or Fisher’s exact tests, as appropriate. The characteristics of sites with ≥90% compliance with the CMS rule, as assessed by 14 relevant survey questions, were compared with those of sites with <90% compliance. Results Overall, 25 (61%) facilities nationwide completed the survey. All sites reported having written IP&C policies and most had a person responsible for IP&C (96%); fewer reported reviewing/updating these policies annually (72%). Few sites provided feedback to staff on HH adherence (44%), PPE use (40%), and cleaning/disinfection procedures (44%). Few had written policies on antibiotic prescribing (48%) or provided prescribers with feedback about their prescribing practices (40%). Sites with ≥90% compliance with the CMS rule were more likely to report providing prescribers with feedback (70% vs. 20%, P = 0.03), to have provided AS training to clinical (60% vs. 0%, P < 0.01) and nursing staff (70% vs. 7%, P < 0.01) in the past 12 months, and to provide feedback regarding HH (70% vs. 27%, P = 0.05). Conclusion While most facilities had implemented some IP&C and AS strategies pertaining to the CMS rule before its enforcement, this survey identified several gaps, especially pertaining to staff feedback for IP&C practices and antibiotic prescribing. Facilities should develop feedback strategies and regularly reinforce the importance of IP&C at employment and during regular trainings. Disclosures All authors: No reported disclosures.

Infections and use of antibiotics in residents of long-term care facilities in Hungary

Orvosi Hetilap ◽

10.1556/oh.2014.29876 ◽

2014 ◽

Vol 155 (23) ◽

pp. 911-917 ◽

Cited By ~ 1

Author(s):

Rita Szabó ◽

Karolina Böröcz

Keyword(s):

Urinary Tract ◽

Long Term Care ◽

Soft Tissues ◽

Good Practice ◽

Antibiotic Use ◽

Prevalence Survey ◽

Term Care ◽

Care Facilities ◽

Introduction: Healthcare associated infections and antimicrobial use are common among residents of long-term care facilities. Faced to the lack of standardized data, the European Centre for Disease Prevention and Control funded a project with the aim of estimating prevalence of infections and antibiotic use in European long-term care facilities. Aim: The aim of the authors was to present the results of the European survey which were obtained in Hungary. Method: In Hungary, 91 long-term care facilities with 11,823 residents participated in the point-prevalence survey in May, 2013. Results: The prevalence of infections was 2.1%. Skin and soft tissues infections were the most frequent (36%), followed by infections of the respiratory (30%) and urinary tract (21%). Antimicrobials were mostly prescribed for urinary tract infections (40.3%), respiratory tract infections (38.4%) and skin and soft tissue infections (13.2%). The most common antimicrobials (97.5%) belonged to the ATC J01 class of “antibacterials for systemic use”. Conclusions: The results emphasise the need for a national guideline and education for good practice in long-term care facilities. Orv. Hetil., 2014, 155(23), 911–917.

Evaluating the integration of palliative care in national health systems: an indicator rating process with EAPC task force members to measure advanced palliative care development

BMC Palliative Care ◽

10.1186/s12904-021-00728-z ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Natalia Arias-Casais ◽

Eduardo Garralda ◽

Miguel Antonio Sánchez-Cárdenas ◽

John Y. Rhee ◽

Carlos Centeno

Keyword(s):

Primary Care ◽

Palliative Care ◽

Long Term Care ◽

Task Force ◽

National Level ◽

Structured Interviews ◽

Term Care ◽

Care Facilities ◽

Rating Process

Abstract Background Palliative care (PC) development cannot only be assessed from a specialized provision perspective. Recently, PC integration into other health systems has been identified as a component of specialized development. Yet, there is a lack of indicators to assess PC integration for pediatrics, long-term care facilities, primary care, volunteering and cardiology. Aim To identify and design indicators capable of exploring national-level integration of PC into the areas mentioned above. Methods A process composed of a desk literature review, consultation and semi-structured interviews with EAPC task force members and a rating process was performed to create a list of indicators for the assessment of PC integration into pediatrics, long-term care facilities, primary care, cardiology, and volunteering. The new indicators were mapped onto the four domains of the WHO Public Health Strategy. Results The literature review identified experts with whom 11 semi-structured interviews were conducted. A total of 34 new indicators were identified for national-level monitoring of palliative care integration. Ten were for pediatrics, five for primary care, six for long-term care facilities, seven for volunteering, and six for cardiology. All indicators mapped onto the WHO domains of policy and education while only pediatrics had an indicator that mapped onto the domain of services. No indicators mapped onto the domain of use of medicines. Conclusion Meaningful contributions are being made in Europe towards the integration of PC into the explored fields. These efforts should be assessed in future regional mapping studies using indicators to deliver a more complete picture of PC development.

Reducing Morbidity and Mortality Rates from COVID-19, Influenza and Pneumococcal Illness in Nursing Homes and Long-Term Care Facilities by Vaccination and Comprehensive Infection Control Interventions

Geriatrics ◽

10.3390/geriatrics6020048 ◽

2021 ◽

Vol 6 (2) ◽

pp. 48

Author(s):

Roger E. Thomas

Keyword(s):

Nursing Homes ◽

Infection Control ◽

Strong Evidence ◽

Disease Transmission ◽

Long Term Care ◽

Term Care ◽

Care Facilities ◽

Meta Analyses ◽

The COVID-19 pandemic identifies the problems of preventing respiratory illnesses in seniors, especially frail multimorbidity seniors in nursing homes and Long-Term Care Facilities (LCTFs). Medline and Embase were searched for nursing homes, long-term care facilities, respiratory tract infections, disease transmission, infection control, mortality, systematic reviews and meta-analyses. For seniors, there is strong evidence to vaccinate against influenza, SARS-CoV-2 and pneumococcal disease, and evidence is awaited for effectiveness against COVID-19 variants and when to revaccinate. There is strong evidence to promptly introduce comprehensive infection control interventions in LCFTs: no admissions from inpatient wards with COVID-19 patients; quarantine and monitor new admissions in single-patient rooms; screen residents, staff and visitors daily for temperature and symptoms; and staff work in only one home. Depending on the vaccination situation and the current risk situation, visiting restrictions and meals in the residents’ own rooms may be necessary, and reduce crowding with individual patient rooms. Regional LTCF administrators should closely monitor and provide staff and PPE resources. The CDC COVID-19 tool measures 33 infection control indicators. Hand washing, social distancing, PPE (gowns, gloves, masks, eye protection), enhanced cleaning of rooms and high-touch surfaces need comprehensive implementation while awaiting more studies at low risk of bias. Individual ventilation with HEPA filters for all patient and common rooms and hallways is needed.