Best Practices: How nursing homes can reduce antibiotic use

When a MRSA outbreak affecting at least 22 patients and employees at the Park Manor Nursing Home was confirmed in the summer of 2006, facility medical director Dr. Joe Boero didn't know where to begin.

The infection control team at the Park Falls, Wis., facility suspected the high rate of drug-resistant bacteria in the facility was linked to physicians prescribing antibiotics “to anything that moved,” Boero recalled. Nursing director Paula Koch had just returned from a conference on antibiotic overuse and drug-resistant bacteria. But the team had no proof this was linked to Park Manor's methicillin-resistant Staphylococcus aureus outbreak. “You have to get me some data,” Boero told the team.

So they developed a spreadsheet on antibiotic use. “Anything they could think of, they started counting,” Boero said. The spreadsheet listed the type of antibiotic given to each patient for specific symptoms and length of use. Each physician, antibiotic and type of bacteria was given a color for easy tracking.

“They essentially made an invisible problem more visible,” said Dr. Chris Crnich, an associate professor in the infectious diseases division at the University of Wisconsin, who advised and evaluated the program. Collaboration, charting and leadership support were critical to the project's success, he added.

The team found that staff at the 108-bed facility had prescribed a total of 503 antibiotics in 2006, which averaged 11.7 prescriptions per 1,000 patient days. That led the nursing home to launch an antibiotic resistance-reduction program.

All physicians were educated about antibiotic overuse through a letter campaign at the end of 2006. In 2009, Boero began contacting doctors who showed up as outliers. He faced some pushback.

In September, the Centers for Disease Control and Prevention issued recommendations to fight superbugs in nursing homes. It said that up to 75% of antibiotics prescribed in long-term-care facilities are given unnecessarily. In recent years, public health leaders have urged use of antibiotic stewardship programs to combat overuse in healthcare settings.

The push arises from the growing number of bacteria resistant to multiple antibiotic therapies. In 2014, President Barack Obama described the problem as a threat to national security; in January, he proposed $993 million in funding for 2016 to tackle the issue.

A study in the Journal of Infection Control and Hospital Epidemiology in May linked antibiotic overuse to diagnostic challenges. It's a problem in correctly treating urinary tract infections, one of the key drivers of antibiotic use in long-term-care facilities, said Dr. David Gifford, senior vice president at the American Health Care Association, which represents nursing homes.

When a urinary tract infection is suspected, nursing home residents are tested. About half of elderly people have excess bacteria, but that's not always indicative of an infection, Gifford said. It still results in more frequent antibiotic prescribing, he added. “You could have every facility in the country implement prevention methods, but if we don't change how we test, we will not see much change,” he said.

In 2014, Park Manor started applying criteria that limited when nurses could request tests for urinary and respiratory tract infections. While a total of 291 UTI tests were ordered in 2006, only 85 were ordered last year. “When the tests go down, antibiotic use goes down,” Boero said.

The efforts paid off: In 2014, Park Manor logged 212 total antibiotic prescriptions, for an average 6.04 per 1,000 patient days. That was more than a 40% reduction in the antibiotic prescription rate since the program started in 2006.

There's a push for similar antibiotic stewardship efforts across the country. The CDC, Society for Healthcare Epidemiology of America and American Geriatrics Society have released tools to help long-term-care facilities track healthcare-associated infections and drive down antibiotic overuse rates.

In July, the CMS proposed requiring 15,000 long-term-care facilities serving Medicare and Medicaid patients to each hire an infection prevention and control officer and institute an antibiotic stewardship program.

But Crnich cautioned against “simply reducing antibiotics at all costs and undertreating infections.”

Gifford noted that there are powerful factors working against reducing antibiotic use, such as medical liability concerns, patients and families demanding antibiotic treatment, and federal readmission penalties related to potentially preventable bladder infections.

“Facilities are trying to improve, but you've also got all these forces,” he said. “It's kind of like swimming upstream.”