- Email: [email protected]
Telephone Survey of Infection-Control and Antibiotic Stewardship Practices in Long-Term Care Facilities in Maryland
JAMDA xxx (2016) 1e4
JAMDA journal homepage: www.jamda.com
Original Study
Telephone Survey of Infection-Control and Antibiotic Stewardship Practices in Long-Term Care Facilities in Maryland Mia Yang MD a, *, Karen Vleck RT (R)(T), MBA, DHA b, Michele Bellantoni MD, CMD a, Geeta Sood MD a a b
Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD Johns Hopkins Bayview Medical Center, Baltimore, MD
a b s t r a c t Keywords: Long-term care telephone survey antibiotic stewardship Maryland
Background: Multidrug-resistant organisms are an emerging and serious threat to the care of patients. Long-term care facilities are considered a reservoir of these organisms partly because of the overprescribing of antibiotics. Antibiotic use is common in long-term care facilities. Antibiotic stewardship programs have been shown to reduce antibiotic consumption in acute-care facilities. The purpose of our study is to investigate existing infection-control practices and antibiotic stewardship programs in longterm care facilities in Maryland. Methods: We telephoned the infection-control personnel in 231 long-term care facilities in Maryland between February 2014 and July 2015 and reached 124 facilities (59%). Results: Among the 124 facilities surveyed, there were 14,371 beds and 337 infection-control personnel with basic infection-control training. Close to 20% of facilities use silver- or antimicrobial-impregnated urinary catheters. Most facilities (97%) track urinary tract infections. Although all report to the health department in the case of an outbreak, only 63 (50.8 %) report directly to the Centers for Disease Control and Prevention. About 80% of facilities isolate patients with Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococci with acute infections only. Eighty percent of facilities have basic guidance on choice of antibiotic, and 27% have a restricted formulary. Only 25% of facilities have an antibiotic approval process. Thirty-five percent of facilities have training for antibiotics prescribing. However, 17% of facilities did not know whether such training existed. Conclusions: Antibiotic stewardship programs in long-term care facilities are still in early development stages, but our results demonstrate that the majority of facilities are collecting data on prescribing antibiotics, and a surprising number have antibiotic approval and antibiotics prescribing training. Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Approximately 1.3 million people live in nursing homes and more than 700,000 live in residential care facilities in the United States.1 About 1.6 to 3.8 million infections occur in long-term care facilities (LTCFs) in the United States per year with an associated annual cost exceeding $1 billion.2 Antibiotic prescribing in LTCFs is common, ranging in annual prevalence from 47% to 79%.3 Up to 25% to 75% of antibiotics prescribed in LTCFs are considered inappropriate.4 Antibiotic stewardship programs and infection- control programs have significantly reduced antibiotic utilization in acute-care settings.5 There is a large disparity between infection-control personnel in
The authors declare no conflicts of interest. * Address correspondence to Mia Yang, MD, Department of Medicine, Johns Hopkins School of Medicine, 5200 Eastern Ave, MFL Center Tower Suite 2200, Baltimore, MD 21224. E-mail address: [email protected] (M. Yang). http://dx.doi.org/10.1016/j.jamda.2015.12.018 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
acute vs LTCFs.6 A 2003 Maryland survey study shows that acute care facilities had 1.2 full-time equivalent (FTE) positions per 200 acute care beds, whereas only 0.3 FTE positions per 200 LTCF beds.6 Ninety percent of acute care infection-control personnel have taken a basic infection- control course, whereas only 3% of long-term care infectioncontrol personnel have taken a basic infection-control course.6 The type of care delivered in acute hospitals vs LTCFs is different as well. Acute hospitals deploy high technology, acute intensive care with the goal of recovery, while LTCFs administer low technology, chronic care that functions as a home for many of the residents.7 Antibiotic prescribing in acute hospitals is not the same as those in LTCFs because of the unique context of long-term care: variations in knowledge and practices among healthcare professionals, complex patient population, and restricted access to physicians and diagnostic tests.8 The practice of antibiotic stewardship in LTCFs is emerging. One effective antibiotic stewardship program involved the development of
2
M. Yang et al. / JAMDA xxx (2016) 1e4
an infectious disease consult team for a LTCF, which was conveniently attached to a large urban Veterans Affairs medical center.9 However, because of financial and geographic limitations, it is not practical to have a consult team in all LTCFs. The purpose of our study is to investigate existing infection-control practices and antibiotic stewardship programs in LTCFs in Maryland. Methods A review of the literature was performed, and a survey was developed focusing on infection-control practices without referencing individual facility rates (Appendix A). All 231 Maryland LTCFs names, number of beds, and phone numbers were obtained from the administrator for the Maryland Medical Director Association. Each facility was contacted by phone, and the infection-control personnel were asked a series of questions after obtaining verbal consent. Each facility was contacted up to 3 times from February 2014 to July 2015. Results Two hundred thirty-one LTCFs in Maryland were identified and contacted. Nine facilities declined participation, 1 facility was closed, 5 had the wrong telephone number, and 7 reported no infection-control personnel. One hundred twenty- four of the remaining 209 facilities (59% response rate) consented to participate. Among the 124 facilities, there were 14,371 beds and 337 infection-control personnel with basic infection-control training. Furthermore, 90.3% of the facilities have a central line protocol, whereas close to 6% do not accept patients with central lines (Table 1). All facilities surveyed have urinary catheter protocols. Close to 20% of facilities use silver- or antimicrobial-impregnated urinary catheters. Ninety-seven percent of facilities track urinary tract infections (UTIs). Although all LTCFs report to the health department in the case of an outbreak, only 51% report directly to Centers for Disease Control and Prevention or National Healthcare Safety Network. Close to 80% of facilities isolate patients with active Clostridium difficile, methicillinresistant Staphylococcus aureus, and vancomycin-resistant Enterococci. About 10% of the facilities indicate that they cannot individually isolate patients (they can only isolate by cohorts) because of the lack of private rooms. In addition, geographic restriction for the residents is impractical. Twelve to 13% of facilities do not isolate or cohort patients with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant Enterococci. Eighty percent of facilities already have antibiotic guides, and 27% have a restricted formulary (Table 2). Antibiotic guidelines varied in complexity and could be as simple as providing sensitivities to organisms with cultures. Twenty-five percent of facilities have an antibiotic approval process, mostly done by the medical director. Antibiotic approval means a list of restricted antibiotics that require approval prior to prescribing, according to the infection-control personnel. It was not confirmed with separate conversations with
facility providers on how antibiotics approval was obtained when the medical director, or the person doing the approval, was unavailable. Of the facilities, 35.5% state that they have training for prescribing antibiotics. Those who provide training for antibiotics prescribing vary; typically by the medical director, then the infection-control personnel, followed by nurse educator, pharmacist, and corporate or a hospitalbased consultant. However, 17% of facilities infection-control personnel did not know whether such training existed. The facility design was also found to be different in LTCFs. Many infection-control personnel reported that there are no private rooms in their facility. Even when there are individual rooms, the facility is a long-term home to the residents, and restriction of movement is not practical or humane. Several infection-control personnel told us that not only do they monitor infection rates, antibiotic use, but also provide feedback to the prescribers. Some infection-control personnel specifically mentioned using the McGreer criteria10 as educational material for antibiotics prescribing. However, the McGreer criteria were not designed, for prescribing antibiotics. Instead, the criteria were designed for tracking and making comparisons among facilities.10 Others mentioned that on a corporate level, there is infection tracking and the ongoing development of antibiotic stewardship programs. Discussion Our study shows that antibiotic stewardship programs in LTCFs in Maryland are still in early development stages. However, our results demonstrate that the majority of facilities are collecting data on antibiotic prescribing. A surprising number have antibiotic approval processes and education on appropriate antibiotic prescribing practices. Maryland requires at least 0.5 FTE positions per facility with education and training in infection surveillance, prevention, and control to be responsible for each facility’s infection-control program.11 As part of the infection-control program required by the state of Maryland, the facility should maintain a record of infection, obtain surveillance data, analyze patterns of infection, and have a communication mechanism in place with the administrator, director of nursing, and the medical director.11 The infection-control personnel should also train employees about infection-control and hygiene but does not explicitly include antibiotic stewardship or antibiotic prescribing.11 Maryland’s regulations for infection-control mirrors that of federal regulations in terms establishing an infection-control program that must investigate, control, and prevent infections as well as maintain a record of infections.11,12 Federal regulations specifically requires that “when the infection-control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.”12 The facility should isolate infected residents only to the degree needed to isolate the infected organism, with the least restrictive method possible.12 This supports the majority of facilities surveyed that isolate only active infections, not colonization or previous infections as per many hospital infection-control policies.
Table 1 Infection-Control Practice
Have CL protocols UC protocol Use impregnated UC Track UTIs Report infections to CDC/NHSN C. diff isolate VRE isolate MRSA isolate
Yes
%
No
%
Do Not Know
Others
112 124 24 120 61 to CDC, 2 to NHSN 95 96 96
90.3 100.0 19.4 96.8 50.8 76.6 77.4 77.4
5 0 95 4 All to health dept for outbreaks 15 16 16
4.0 0.0 76.6 3.2
0 0 5 0 1 0 1 1
7 (5.6%) do not accept CLs NA NA NA NA 14 (11.3%) cohort only 11 (8.9%) cohort only 11 (8.9%) cohort only
12.1 12.9 12.9
(4.03%) (0.81%) (0.81%) (0.81%)
CL, central line; CDC, Centers for Disease Control and Prevention; C diff, Clostridium difficile; MRSA, methicillin-resistant Staphylococcus aureus; NHSN, National Healthcare Safety Network; UC, urinary catheters; VRE, vancomycin-resistant enterococcus.
M. Yang et al. / JAMDA xxx (2016) 1e4
3
Table 2 Antibiotics Stewardship Programs in 231 LTCFs in Maryland Yes
%
No
%
Have Abx guide Have restricted formulary Collect data on abx prescribing Have antibiotics approval
99 34 101 31 (25%)
25 84 23 89
20.2 67.7 18.6 71.8
0 6 0 4
3.2
Have training for antibiotics prescribing
44 (35.5 %)
79.8 27.4 81.5 11 med dir 1- DoN 1- ICP 1- committee 1- med safety officer 7- med dir 5 - ICP 4- nurse educator 3- pharm 2- corporate 2- hospital based 1- QA nurse 1- CME
Do Not Know
%
59
47.6
21
16.9
4.8
Abx, antibiotics; CME, continuing medical education; DoN, Director of Nursing; ICP, infection control personnel; med dir, medical director; pharm, pharmacist; QA, quality assurance.
Multiple studies have shown that the prevalence of residents in LTCFs colonized with multidrug-resistant (MDR) organisms is more than 30%.13e15 Of those who were previously un-colonized, close to 40% acquired at least 1 MDR gram negative organisms in 1 year.15 Antibiotics use is significantly associated with acquisition of MDR organisms.15 Quinolones are often used in LTCFs because of good bioavailability and easy administration, resulting in increasing quinolone-resistant organisms.16 In addition to frequent colonization, limited provider on-site availability in LTCFs may result in more empiric antibiotics prescribed by on-call providers who do not know the patients well.17 Nurses in LTCFs have a central role in assessing and notifying signs of infection. Physicians report that they heavily depend on the nurses’ judgments, especially if provider is not able to evaluate patients in person.8 Family pressure for prescribing antibiotics was a common theme for increasing antibiotics prescribing.8 Antibiotics may also be prescribed when there is a delay in obtaining laboratory and radiologic tests because of the lack of onsite testing.8,16 Obtaining specimens for microbiologic studies are also difficult in LTCFs because of cognitive impairment and incontinence.8,16 Prevalence of bacteriuria is 30% in residents in LTCFs, even in noncatheterized patients16 and is 100% in catheterized residents.18 Thus, it is difficult to determine whether fever or other symptoms of infection are attributable to a UTI.16 In addition to antibiotic prescribing habits, LTCFs are predisposed to cross-contamination. Cross-transmission of MDR organisms between residents and their roommates have been shown to occur frequently despite infection-control precautions.15 This is likely due to the lack of private rooms and the shared dining and activity areas, which are frequently found in these residential care facilities. There are several limitations to our study. Despite multiple phone calls and voicemails, only about 60% of the facilities in Maryland participated in the survey. We do not know how the facilities that could not be reached by phone would have differed from those that participated. It is possible that the nonparticipants had less robust infection- control activities. Calling the main facility phone number depended on the operator to transfer to the appropriate person responsible for infection control. The operator may not know that 1 person serves multiple roles such as quality assurance, director of nursing, and/or infection control and may erroneously report that there is no infection-control person in the facility. Although our survey specifically asked about silver-impregnated urinary catheters, this is limited evidence to suggest a benefit of silver-coated catheters over standard latex catheters at preventing catheter-associated UTIs.19 Infection-control personnel may also not be the best person to report antibiotic stewardship programs because most infectioncontrol personnel are nurses, not prescribers. Perhaps the medical
director would be a better person to survey regarding antibiotics prescribing training and antibiotics approval. A significant limitation of our study is that the survey questions were not detailed enough to determine which facilities have robust infection-control practices from those who have limited antibiotics stewardship programs, especially related to antibiotic guidelines and antibiotics approval programs. In future research, we would specifically ask about the logistics of antibiotics approval process and the quality of antibiotics prescribing training. Overall, there is a growing sense of understanding from LTCFs of the importance of antibiotic stewardship and the development of stewardship programs. The Centers for Disease Control and Prevention recently released guidelines and checklist for antibiotic stewardship for nursing homes.20 It is encouraging that most LTCFs in Maryland already collect data about antibiotics prescribing. In the future, not only do we need to have more support and resources for the infection-control personnel and long-term care leadership, but we also need to involve the front line staff’s observations and expertise into a comprehensive infection-control plan. References 1. Harris-Kojetin L, Sengupta M, Park-Lee E, Valverde R. Long-term care services in the United States: 2013 overview. Vital and Health Statistics. Series 3, Analytical and Epidemiological Studies. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, National Center for Health Statistics; 2013. p. 1e107. 2. Strausbaugh LJ, Joseph CL. The burden of infection in long-term care. Infect Control Hospital Epidemiol 2000;21:674e679. 3. 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.e1e568.e13. 4. Nicolle LE, Bentley DW, Garibaldi R, et al, SHEA long-term-care committee. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 2000;21:537e545. 5. Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. 6. Roup BJ, Roche JC, Pass M. Infection control program disparities between acute and long-term care facilities in Maryland. Am J Infect Control 2006;34: 122e127. 7. Smith PW, Bennett G, Bradley S, et al. SHEA/APIC guideline: Infection prevention and control in the long-term care facility. Am J Infect Control 2008:504e535. 8. Fleming A, Bradley C, Cullinan S, et al. Antibiotic prescribing in long-term care facilities: A meta-synthesis of qualitative research. Drugs Aging 2015;32: 295e303. 9. Jump RL, Olds DM, Seifi N, et al. Effective antimicrobial stewardship in a longterm care facility through an infectious disease consultation service: Keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012;33:1185e1192. 10. Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965e977.
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11. Code of Maryland Regulations (COMAR) 10.07.02.21. Available at: http://dsd. state.md.us/comar/comarhtml/10/10.07.02.21.htm. Accessed December 1, 2015. 12. State Operations Manual. Appendix PP-Guidance to Surveyors for Long Term Care Facilities. F441eF445. Available at: https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed December 1, 2015. 13. Han JH, Maslow J, Han X, et al. Risk factors for the development of gastrointestinal colonization with fluoroquinolone-resistant Escherichia coli in residents of long-term care facilities. J Infect Dis 2014;209:420e425. 14. Lim CJ, Cheng AC, Kennon J, et al. Prevalence of multidrug-resistant organisms and risk factors for carriage in long-term care facilities: A nested case-control study. J Antimicrob Chemother 2014;69:1972e1980. 15. O’Fallon E, Kandel R, Schreiber R, et al. Acquisition of multidrug-resistant gramnegative bacteria: Incidence and risk factors within a long-term care population. Infect Control Hosp Epidemiol 2010;31:1148e1153.
16. Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 1993;14:220e225. 17. Walker S, McGeer A, Simor AE, et al. Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions. CMAJ 2000;163:273e277. 18. Warren JW, Tenney JH, Hoopes JM, et al. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;146:719e723. 19. Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. Available at: http://www.cdc. gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf. Accessed November 25, 2015. 20. The core elements of antibiotic stewardship for nursing homes. US Department of Health and Human Services, CDC. Available at: http://www.cdc.gov/long termcare/index.html. Accessed September 22, 2015.
Appendix A. Survey Questions
If so, what do you report? Bloodstream infections? Ventilator- associated pneumonia? Catheter-associated urinary tract infections (CAUTIs)? Do you isolate patients with C diff? VRE? MRSA? Do you have guidelines for antibiotics use? For example, do you provide sensitivities for organisms? Do you have a restricted antibiotic formulary? For example, is there a list of antibiotics that can or cannot be used in your facility? Do you collect data about antibiotic use? Do you have an antibiotics approval process? For example, is there someone such as the medical director who approves antibiotics? If so, who is responsible for approving antibiotics? Is there training for prescribers on antibiotics use? If so, who is providing the training?
How many beds are in your facility? How many infection-control personnel have basic infection control training (such as offered by Association for Professionals in Infection Control and Epidemiology (APIC))? Do you have a protocol for maintaining central lines? Do you have a protocol for maintaining and changing urinary catheters? Do you use impregnated urinary catheters? Do you have a system for tracking UTIs associated with catheters? Do you report infection rates to the CDC or NHSN (National Healthcare Safety Network)?
JAMDA journal homepage: www.jamda.com
Original Study
Telephone Survey of Infection-Control and Antibiotic Stewardship Practices in Long-Term Care Facilities in Maryland Mia Yang MD a, *, Karen Vleck RT (R)(T), MBA, DHA b, Michele Bellantoni MD, CMD a, Geeta Sood MD a a b
Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD Johns Hopkins Bayview Medical Center, Baltimore, MD
a b s t r a c t Keywords: Long-term care telephone survey antibiotic stewardship Maryland
Background: Multidrug-resistant organisms are an emerging and serious threat to the care of patients. Long-term care facilities are considered a reservoir of these organisms partly because of the overprescribing of antibiotics. Antibiotic use is common in long-term care facilities. Antibiotic stewardship programs have been shown to reduce antibiotic consumption in acute-care facilities. The purpose of our study is to investigate existing infection-control practices and antibiotic stewardship programs in longterm care facilities in Maryland. Methods: We telephoned the infection-control personnel in 231 long-term care facilities in Maryland between February 2014 and July 2015 and reached 124 facilities (59%). Results: Among the 124 facilities surveyed, there were 14,371 beds and 337 infection-control personnel with basic infection-control training. Close to 20% of facilities use silver- or antimicrobial-impregnated urinary catheters. Most facilities (97%) track urinary tract infections. Although all report to the health department in the case of an outbreak, only 63 (50.8 %) report directly to the Centers for Disease Control and Prevention. About 80% of facilities isolate patients with Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococci with acute infections only. Eighty percent of facilities have basic guidance on choice of antibiotic, and 27% have a restricted formulary. Only 25% of facilities have an antibiotic approval process. Thirty-five percent of facilities have training for antibiotics prescribing. However, 17% of facilities did not know whether such training existed. Conclusions: Antibiotic stewardship programs in long-term care facilities are still in early development stages, but our results demonstrate that the majority of facilities are collecting data on prescribing antibiotics, and a surprising number have antibiotic approval and antibiotics prescribing training. Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Approximately 1.3 million people live in nursing homes and more than 700,000 live in residential care facilities in the United States.1 About 1.6 to 3.8 million infections occur in long-term care facilities (LTCFs) in the United States per year with an associated annual cost exceeding $1 billion.2 Antibiotic prescribing in LTCFs is common, ranging in annual prevalence from 47% to 79%.3 Up to 25% to 75% of antibiotics prescribed in LTCFs are considered inappropriate.4 Antibiotic stewardship programs and infection- control programs have significantly reduced antibiotic utilization in acute-care settings.5 There is a large disparity between infection-control personnel in
The authors declare no conflicts of interest. * Address correspondence to Mia Yang, MD, Department of Medicine, Johns Hopkins School of Medicine, 5200 Eastern Ave, MFL Center Tower Suite 2200, Baltimore, MD 21224. E-mail address: [email protected] (M. Yang). http://dx.doi.org/10.1016/j.jamda.2015.12.018 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
acute vs LTCFs.6 A 2003 Maryland survey study shows that acute care facilities had 1.2 full-time equivalent (FTE) positions per 200 acute care beds, whereas only 0.3 FTE positions per 200 LTCF beds.6 Ninety percent of acute care infection-control personnel have taken a basic infection- control course, whereas only 3% of long-term care infectioncontrol personnel have taken a basic infection-control course.6 The type of care delivered in acute hospitals vs LTCFs is different as well. Acute hospitals deploy high technology, acute intensive care with the goal of recovery, while LTCFs administer low technology, chronic care that functions as a home for many of the residents.7 Antibiotic prescribing in acute hospitals is not the same as those in LTCFs because of the unique context of long-term care: variations in knowledge and practices among healthcare professionals, complex patient population, and restricted access to physicians and diagnostic tests.8 The practice of antibiotic stewardship in LTCFs is emerging. One effective antibiotic stewardship program involved the development of
2
M. Yang et al. / JAMDA xxx (2016) 1e4
an infectious disease consult team for a LTCF, which was conveniently attached to a large urban Veterans Affairs medical center.9 However, because of financial and geographic limitations, it is not practical to have a consult team in all LTCFs. The purpose of our study is to investigate existing infection-control practices and antibiotic stewardship programs in LTCFs in Maryland. Methods A review of the literature was performed, and a survey was developed focusing on infection-control practices without referencing individual facility rates (Appendix A). All 231 Maryland LTCFs names, number of beds, and phone numbers were obtained from the administrator for the Maryland Medical Director Association. Each facility was contacted by phone, and the infection-control personnel were asked a series of questions after obtaining verbal consent. Each facility was contacted up to 3 times from February 2014 to July 2015. Results Two hundred thirty-one LTCFs in Maryland were identified and contacted. Nine facilities declined participation, 1 facility was closed, 5 had the wrong telephone number, and 7 reported no infection-control personnel. One hundred twenty- four of the remaining 209 facilities (59% response rate) consented to participate. Among the 124 facilities, there were 14,371 beds and 337 infection-control personnel with basic infection-control training. Furthermore, 90.3% of the facilities have a central line protocol, whereas close to 6% do not accept patients with central lines (Table 1). All facilities surveyed have urinary catheter protocols. Close to 20% of facilities use silver- or antimicrobial-impregnated urinary catheters. Ninety-seven percent of facilities track urinary tract infections (UTIs). Although all LTCFs report to the health department in the case of an outbreak, only 51% report directly to Centers for Disease Control and Prevention or National Healthcare Safety Network. Close to 80% of facilities isolate patients with active Clostridium difficile, methicillinresistant Staphylococcus aureus, and vancomycin-resistant Enterococci. About 10% of the facilities indicate that they cannot individually isolate patients (they can only isolate by cohorts) because of the lack of private rooms. In addition, geographic restriction for the residents is impractical. Twelve to 13% of facilities do not isolate or cohort patients with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant Enterococci. Eighty percent of facilities already have antibiotic guides, and 27% have a restricted formulary (Table 2). Antibiotic guidelines varied in complexity and could be as simple as providing sensitivities to organisms with cultures. Twenty-five percent of facilities have an antibiotic approval process, mostly done by the medical director. Antibiotic approval means a list of restricted antibiotics that require approval prior to prescribing, according to the infection-control personnel. It was not confirmed with separate conversations with
facility providers on how antibiotics approval was obtained when the medical director, or the person doing the approval, was unavailable. Of the facilities, 35.5% state that they have training for prescribing antibiotics. Those who provide training for antibiotics prescribing vary; typically by the medical director, then the infection-control personnel, followed by nurse educator, pharmacist, and corporate or a hospitalbased consultant. However, 17% of facilities infection-control personnel did not know whether such training existed. The facility design was also found to be different in LTCFs. Many infection-control personnel reported that there are no private rooms in their facility. Even when there are individual rooms, the facility is a long-term home to the residents, and restriction of movement is not practical or humane. Several infection-control personnel told us that not only do they monitor infection rates, antibiotic use, but also provide feedback to the prescribers. Some infection-control personnel specifically mentioned using the McGreer criteria10 as educational material for antibiotics prescribing. However, the McGreer criteria were not designed, for prescribing antibiotics. Instead, the criteria were designed for tracking and making comparisons among facilities.10 Others mentioned that on a corporate level, there is infection tracking and the ongoing development of antibiotic stewardship programs. Discussion Our study shows that antibiotic stewardship programs in LTCFs in Maryland are still in early development stages. However, our results demonstrate that the majority of facilities are collecting data on antibiotic prescribing. A surprising number have antibiotic approval processes and education on appropriate antibiotic prescribing practices. Maryland requires at least 0.5 FTE positions per facility with education and training in infection surveillance, prevention, and control to be responsible for each facility’s infection-control program.11 As part of the infection-control program required by the state of Maryland, the facility should maintain a record of infection, obtain surveillance data, analyze patterns of infection, and have a communication mechanism in place with the administrator, director of nursing, and the medical director.11 The infection-control personnel should also train employees about infection-control and hygiene but does not explicitly include antibiotic stewardship or antibiotic prescribing.11 Maryland’s regulations for infection-control mirrors that of federal regulations in terms establishing an infection-control program that must investigate, control, and prevent infections as well as maintain a record of infections.11,12 Federal regulations specifically requires that “when the infection-control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.”12 The facility should isolate infected residents only to the degree needed to isolate the infected organism, with the least restrictive method possible.12 This supports the majority of facilities surveyed that isolate only active infections, not colonization or previous infections as per many hospital infection-control policies.
Table 1 Infection-Control Practice
Have CL protocols UC protocol Use impregnated UC Track UTIs Report infections to CDC/NHSN C. diff isolate VRE isolate MRSA isolate
Yes
%
No
%
Do Not Know
Others
112 124 24 120 61 to CDC, 2 to NHSN 95 96 96
90.3 100.0 19.4 96.8 50.8 76.6 77.4 77.4
5 0 95 4 All to health dept for outbreaks 15 16 16
4.0 0.0 76.6 3.2
0 0 5 0 1 0 1 1
7 (5.6%) do not accept CLs NA NA NA NA 14 (11.3%) cohort only 11 (8.9%) cohort only 11 (8.9%) cohort only
12.1 12.9 12.9
(4.03%) (0.81%) (0.81%) (0.81%)
CL, central line; CDC, Centers for Disease Control and Prevention; C diff, Clostridium difficile; MRSA, methicillin-resistant Staphylococcus aureus; NHSN, National Healthcare Safety Network; UC, urinary catheters; VRE, vancomycin-resistant enterococcus.
M. Yang et al. / JAMDA xxx (2016) 1e4
3
Table 2 Antibiotics Stewardship Programs in 231 LTCFs in Maryland Yes
%
No
%
Have Abx guide Have restricted formulary Collect data on abx prescribing Have antibiotics approval
99 34 101 31 (25%)
25 84 23 89
20.2 67.7 18.6 71.8
0 6 0 4
3.2
Have training for antibiotics prescribing
44 (35.5 %)
79.8 27.4 81.5 11 med dir 1- DoN 1- ICP 1- committee 1- med safety officer 7- med dir 5 - ICP 4- nurse educator 3- pharm 2- corporate 2- hospital based 1- QA nurse 1- CME
Do Not Know
%
59
47.6
21
16.9
4.8
Abx, antibiotics; CME, continuing medical education; DoN, Director of Nursing; ICP, infection control personnel; med dir, medical director; pharm, pharmacist; QA, quality assurance.
Multiple studies have shown that the prevalence of residents in LTCFs colonized with multidrug-resistant (MDR) organisms is more than 30%.13e15 Of those who were previously un-colonized, close to 40% acquired at least 1 MDR gram negative organisms in 1 year.15 Antibiotics use is significantly associated with acquisition of MDR organisms.15 Quinolones are often used in LTCFs because of good bioavailability and easy administration, resulting in increasing quinolone-resistant organisms.16 In addition to frequent colonization, limited provider on-site availability in LTCFs may result in more empiric antibiotics prescribed by on-call providers who do not know the patients well.17 Nurses in LTCFs have a central role in assessing and notifying signs of infection. Physicians report that they heavily depend on the nurses’ judgments, especially if provider is not able to evaluate patients in person.8 Family pressure for prescribing antibiotics was a common theme for increasing antibiotics prescribing.8 Antibiotics may also be prescribed when there is a delay in obtaining laboratory and radiologic tests because of the lack of onsite testing.8,16 Obtaining specimens for microbiologic studies are also difficult in LTCFs because of cognitive impairment and incontinence.8,16 Prevalence of bacteriuria is 30% in residents in LTCFs, even in noncatheterized patients16 and is 100% in catheterized residents.18 Thus, it is difficult to determine whether fever or other symptoms of infection are attributable to a UTI.16 In addition to antibiotic prescribing habits, LTCFs are predisposed to cross-contamination. Cross-transmission of MDR organisms between residents and their roommates have been shown to occur frequently despite infection-control precautions.15 This is likely due to the lack of private rooms and the shared dining and activity areas, which are frequently found in these residential care facilities. There are several limitations to our study. Despite multiple phone calls and voicemails, only about 60% of the facilities in Maryland participated in the survey. We do not know how the facilities that could not be reached by phone would have differed from those that participated. It is possible that the nonparticipants had less robust infection- control activities. Calling the main facility phone number depended on the operator to transfer to the appropriate person responsible for infection control. The operator may not know that 1 person serves multiple roles such as quality assurance, director of nursing, and/or infection control and may erroneously report that there is no infection-control person in the facility. Although our survey specifically asked about silver-impregnated urinary catheters, this is limited evidence to suggest a benefit of silver-coated catheters over standard latex catheters at preventing catheter-associated UTIs.19 Infection-control personnel may also not be the best person to report antibiotic stewardship programs because most infectioncontrol personnel are nurses, not prescribers. Perhaps the medical
director would be a better person to survey regarding antibiotics prescribing training and antibiotics approval. A significant limitation of our study is that the survey questions were not detailed enough to determine which facilities have robust infection-control practices from those who have limited antibiotics stewardship programs, especially related to antibiotic guidelines and antibiotics approval programs. In future research, we would specifically ask about the logistics of antibiotics approval process and the quality of antibiotics prescribing training. Overall, there is a growing sense of understanding from LTCFs of the importance of antibiotic stewardship and the development of stewardship programs. The Centers for Disease Control and Prevention recently released guidelines and checklist for antibiotic stewardship for nursing homes.20 It is encouraging that most LTCFs in Maryland already collect data about antibiotics prescribing. In the future, not only do we need to have more support and resources for the infection-control personnel and long-term care leadership, but we also need to involve the front line staff’s observations and expertise into a comprehensive infection-control plan. References 1. Harris-Kojetin L, Sengupta M, Park-Lee E, Valverde R. Long-term care services in the United States: 2013 overview. Vital and Health Statistics. Series 3, Analytical and Epidemiological Studies. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, National Center for Health Statistics; 2013. p. 1e107. 2. Strausbaugh LJ, Joseph CL. The burden of infection in long-term care. Infect Control Hospital Epidemiol 2000;21:674e679. 3. 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.e1e568.e13. 4. Nicolle LE, Bentley DW, Garibaldi R, et al, SHEA long-term-care committee. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 2000;21:537e545. 5. Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. 6. Roup BJ, Roche JC, Pass M. Infection control program disparities between acute and long-term care facilities in Maryland. Am J Infect Control 2006;34: 122e127. 7. Smith PW, Bennett G, Bradley S, et al. SHEA/APIC guideline: Infection prevention and control in the long-term care facility. Am J Infect Control 2008:504e535. 8. Fleming A, Bradley C, Cullinan S, et al. Antibiotic prescribing in long-term care facilities: A meta-synthesis of qualitative research. Drugs Aging 2015;32: 295e303. 9. Jump RL, Olds DM, Seifi N, et al. Effective antimicrobial stewardship in a longterm care facility through an infectious disease consultation service: Keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012;33:1185e1192. 10. Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965e977.
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11. Code of Maryland Regulations (COMAR) 10.07.02.21. Available at: http://dsd. state.md.us/comar/comarhtml/10/10.07.02.21.htm. Accessed December 1, 2015. 12. State Operations Manual. Appendix PP-Guidance to Surveyors for Long Term Care Facilities. F441eF445. Available at: https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed December 1, 2015. 13. Han JH, Maslow J, Han X, et al. Risk factors for the development of gastrointestinal colonization with fluoroquinolone-resistant Escherichia coli in residents of long-term care facilities. J Infect Dis 2014;209:420e425. 14. Lim CJ, Cheng AC, Kennon J, et al. Prevalence of multidrug-resistant organisms and risk factors for carriage in long-term care facilities: A nested case-control study. J Antimicrob Chemother 2014;69:1972e1980. 15. O’Fallon E, Kandel R, Schreiber R, et al. Acquisition of multidrug-resistant gramnegative bacteria: Incidence and risk factors within a long-term care population. Infect Control Hosp Epidemiol 2010;31:1148e1153.
16. Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 1993;14:220e225. 17. Walker S, McGeer A, Simor AE, et al. Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions. CMAJ 2000;163:273e277. 18. Warren JW, Tenney JH, Hoopes JM, et al. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;146:719e723. 19. Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. Available at: http://www.cdc. gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf. Accessed November 25, 2015. 20. The core elements of antibiotic stewardship for nursing homes. US Department of Health and Human Services, CDC. Available at: http://www.cdc.gov/long termcare/index.html. Accessed September 22, 2015.
Appendix A. Survey Questions
If so, what do you report? Bloodstream infections? Ventilator- associated pneumonia? Catheter-associated urinary tract infections (CAUTIs)? Do you isolate patients with C diff? VRE? MRSA? Do you have guidelines for antibiotics use? For example, do you provide sensitivities for organisms? Do you have a restricted antibiotic formulary? For example, is there a list of antibiotics that can or cannot be used in your facility? Do you collect data about antibiotic use? Do you have an antibiotics approval process? For example, is there someone such as the medical director who approves antibiotics? If so, who is responsible for approving antibiotics? Is there training for prescribers on antibiotics use? If so, who is providing the training?
How many beds are in your facility? How many infection-control personnel have basic infection control training (such as offered by Association for Professionals in Infection Control and Epidemiology (APIC))? Do you have a protocol for maintaining central lines? Do you have a protocol for maintaining and changing urinary catheters? Do you use impregnated urinary catheters? Do you have a system for tracking UTIs associated with catheters? Do you report infection rates to the CDC or NHSN (National Healthcare Safety Network)?