In the JournalsPerspective

Dedicating staff hours for infection prevention and control improves stewardship in nursing homes

Sarah Kabbani, MD, MSc
Sarah Kabbani

Nursing homes with more staff hours dedicated to infection prevention and control were more likely to fulfill all seven core elements of antibiotic stewardship, according to findings published in Clinical Infectious Diseases.

“In 2016, 42% of U.S. nursing homes reported implementing all of CDC’s Core Elements of Antibiotic Stewardship,” Sarah Kabbani, MD, MSc, medical officer in the Office of Antibiotic Stewardship at the CDC, told Infectious Disease News. “Providing dedicated training and staff hours for infection control and prevention activities may be associated with better implementation of stewardship in nursing homes.”

Nursing homes frequently prescribe antibiotics, increasing the risk for antibiotic-resistant pathogens. In the battle against antimicrobial resistance and overuse, the CDC published the Core Elements of Antibiotic Stewardship for Nursing Homes in 2015 to provide nursing homes with a “framework for stewardship implementation.”

Kabbani and colleagues investigated the uptake of the elements among nursing homes enrolled in a “voluntary surveillance system for tracking health care-associated infections” developed by the CDC. The program is known as the National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) Component, and it began including antibiotic stewardship practices to the annual facility survey in 2014, according to the study.

Participating facilities are required to complete an annual survey, which includes 11 questions regarding antibiotic stewardship practices. For this study, the researchers focused on data collected from the 2016 survey, which was the first to include questions on all seven core elements.

Of the 2,982 surveys submitted, 67% of the nursing homes were for-profit facilities, 61% were part of chain-based or multifacility organizations and the median bed count was 101. Overall, a median of 13 hours a week was dedicated to infection prevention and control (IPC) activities, the researchers reported. However, among facilities implementing all seven core elements, a median of 16 hours a week was dedicated to IPC activities.

According to the study, 42% of participating nursing homes reported implementing all seven core elements, and Kabbani and colleagues highlighted a statistically significant association, based on bivariate analysis, between the implementation of all core elements and for-profit ownership, nursing home chain affiliation and weekly staff hours dedicated to IPC activities.

The researchers also found that 87% of facilities fulfilled the leadership core element, but only 55% had a written statement of support from leadership. Furthermore, 91% of facilities implemented accountability, 77% reported access to drug expertise, 95% reported tracking, 73% enacted education recommendations and about 94% satisfied the action core element.

“The core elements with the lowest implementation were reporting, education, and drug expertise,” Kabbani said.

Kabbani and colleagues discovered a “variability” among certain activities. Although only 43% of facilities reported implementing a follow-up procedure after the start of a new antibiotic, 82% of facilities reported implementing an antibiotic indication documentation policy. Additionally, 51% of facilities used an antibiogram, whereas 73% said they monitored adherence to antibiotic documentation policy.

“To implement antibiotic stewardship effectively, nursing homes need support to report antibiotic use and important outcomes such as Clostridioides difficile infections; provide antibiotic stewardship education to staff, residents and their families; and establish access to individuals with drug expertise,” Kabbani said. “The analysis suggested that nursing homes with a higher amount of weekly staff hours dedicated to [IPC] activities were more likely to fulfill all seven core elements of antibiotic stewardship.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

Sarah Kabbani, MD, MSc
Sarah Kabbani

Nursing homes with more staff hours dedicated to infection prevention and control were more likely to fulfill all seven core elements of antibiotic stewardship, according to findings published in Clinical Infectious Diseases.

“In 2016, 42% of U.S. nursing homes reported implementing all of CDC’s Core Elements of Antibiotic Stewardship,” Sarah Kabbani, MD, MSc, medical officer in the Office of Antibiotic Stewardship at the CDC, told Infectious Disease News. “Providing dedicated training and staff hours for infection control and prevention activities may be associated with better implementation of stewardship in nursing homes.”

Nursing homes frequently prescribe antibiotics, increasing the risk for antibiotic-resistant pathogens. In the battle against antimicrobial resistance and overuse, the CDC published the Core Elements of Antibiotic Stewardship for Nursing Homes in 2015 to provide nursing homes with a “framework for stewardship implementation.”

Kabbani and colleagues investigated the uptake of the elements among nursing homes enrolled in a “voluntary surveillance system for tracking health care-associated infections” developed by the CDC. The program is known as the National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) Component, and it began including antibiotic stewardship practices to the annual facility survey in 2014, according to the study.

Participating facilities are required to complete an annual survey, which includes 11 questions regarding antibiotic stewardship practices. For this study, the researchers focused on data collected from the 2016 survey, which was the first to include questions on all seven core elements.

Of the 2,982 surveys submitted, 67% of the nursing homes were for-profit facilities, 61% were part of chain-based or multifacility organizations and the median bed count was 101. Overall, a median of 13 hours a week was dedicated to infection prevention and control (IPC) activities, the researchers reported. However, among facilities implementing all seven core elements, a median of 16 hours a week was dedicated to IPC activities.

According to the study, 42% of participating nursing homes reported implementing all seven core elements, and Kabbani and colleagues highlighted a statistically significant association, based on bivariate analysis, between the implementation of all core elements and for-profit ownership, nursing home chain affiliation and weekly staff hours dedicated to IPC activities.

The researchers also found that 87% of facilities fulfilled the leadership core element, but only 55% had a written statement of support from leadership. Furthermore, 91% of facilities implemented accountability, 77% reported access to drug expertise, 95% reported tracking, 73% enacted education recommendations and about 94% satisfied the action core element.

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“The core elements with the lowest implementation were reporting, education, and drug expertise,” Kabbani said.

Kabbani and colleagues discovered a “variability” among certain activities. Although only 43% of facilities reported implementing a follow-up procedure after the start of a new antibiotic, 82% of facilities reported implementing an antibiotic indication documentation policy. Additionally, 51% of facilities used an antibiogram, whereas 73% said they monitored adherence to antibiotic documentation policy.

“To implement antibiotic stewardship effectively, nursing homes need support to report antibiotic use and important outcomes such as Clostridioides difficile infections; provide antibiotic stewardship education to staff, residents and their families; and establish access to individuals with drug expertise,” Kabbani said. “The analysis suggested that nursing homes with a higher amount of weekly staff hours dedicated to [IPC] activities were more likely to fulfill all seven core elements of antibiotic stewardship.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

    Perspective

    Nursing homes represent a critical link in the spread of multidrug-resistant organisms and C. difficile among geographically connected health care facilities, and the intensity of antibiotic use facilitates their selection. Transfer of asymptomatic patients harboring these organisms to and from acute-care facilities has likely contributed to and facilitated the establishment of an endemic reservoir of these pathogens. 

    A chronically ill population, high staff turnover and less frequent physician follow-up, coupled with fear of misdiagnosis represent some of the additional challenges of antibiotic stewardship in nursing homes.

    Although adoption of an antibiotic stewardship program is now a CMS requirement for the 15,000 nursing homes in this country, it remains to be seen whether or not the CDC core elements will translate into reduction of unnecessary days of therapy. The article represents a welcome start, but only time will tell.

    • Neil Gaffin, MD
    • Infectious disease specialist,
      Ridgewood Infectious Disease Associates

    Disclosures: Gaffin reports no relevant financial disclosures.