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1 EDUCATIONAL SERIES: Navigating Infection Control and Antimicrobial Stewardship in Long-Term Care Webinar #2: Introduction to Antimicrobial Stewardship in Long Term Care: What is Antimicrobial Stewardship and Why is it Important? New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In Number: (888) Access Code:

2 Kirthana Beaulac, PharmD, BCPS Pharmacist Head, Antimicrobial Stewardship Program and Infectious Disease Pharmacist Tufts Medical Center Shira Doron, MD Associate Professor of Medicine Tufts University School of Medicine Antimicrobial Steward and Associate Hospital Epidemiologist Tufts Medical Center

3 Introduction to Antimicrobial Stewardship in Long Term Care: What is Antimicrobial Stewardship and Why is it Important? Shira Doron, MD and Kirthana Beaulac, PharmD

4 4 Learning Objectives Define the concept of antimicrobial stewardship Describe the need and rationale for antimicrobial stewardship in long term care Interpret the CMS requirements for antimicrobial stewardship in long term care Prepare for implementation of antimicrobial stewardship in your facility

5 Polling Question How confident are you that the antimicrobial stewardship policy and practices in your facility are adequate to reduce unnecessary antibiotic use? A. I am completely confident that the antimicrobial stewardship policy and practices in my facility are adequate B. I am somewhat confident that the antimicrobial stewardship policy and practices in my facility are adequate C. I have no confidence that the antimicrobial stewardship policy and practices in my facility are adequate

6 The problem

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8 Meanwhile the population keeps aging

9 And the bugs are becoming harder to treat

10 Bad Bugs No Drugs Ventola CL. PT. 2015; 40(4):

11 The drug development pipeline for antibacterials 11

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18 Antimicrobial Therapy Appropriate initial antibiotic while improving patient outcomes and healthcare Unnecessary Antibiotics, adverse patient outcomes and increased cost A Balancing Act

19 Antibiotics are a risk factor for acquisition of multidrug-resistant bacteria Table 3. Factors Associated with Acquisition of Multridrug-Resistant Gram-Negative Bacteria among Case Patients and Control Patients Matched According to Duration of Follow-up OFallon E; Kandel R; Schreiber R; DAgata EM. Infection Control & Hospital Epidemiology. 31(11): , 2010 Nov. DOI: / Copyright University of Chicago Press.

20 Antibiotics MDRO colonization MDRO infection Hospital admission Discharge to Long Term Care Transmission of MDROs to and from the resident across care settings

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23 Opportunities for Improvement 20-50% of antibiotic prescriptions in acute care are considered inappropriate or unnecessary 50% of outpatient antibiotic prescriptions are considered inappropriate or unnecessary 50-75% of antibiotic prescriptions in long-term care are considered inappropriate or unnecessary

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25 Long Term Care Infection Prevention and Antimicrobial Stewardship Requirements

26 Long Term Care Infection Prevention and Antimicrobial Stewardship Requirements

27 Mega Rule Minimum Requirements Develop Protocols Both antibiotic use protocols and stewardship program protocols Be reviewed annually Be incorporated into the infection control program Develop a system for monitoring antibiotic use When a resident is new, when they re transferred from a hospital or other facility, or during monthly review Be incorporated in the infection control program Provide feedback to prescribers about appropriateness or compliance with facility protocols Assessment, monitoring, and communication of antibiotic use shall occur by a pharmacist, at least monthly

28 Stewardship in long term care Source:

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33 Common long-term care scenarios in which antibiotics can be avoided Placement of urinary catheters for management of incontinence Urine culture as part of routine workup of non-specific symptoms Obtaining a wound culture in the absence of cellulitis, abscess or necrosis Performing a C. diff test in a patient whom symptoms have resolved and therapy completed (test of cure)

34 Common long-term care scenarios in which antibiotics are not needed 35 Positive urine culture in the absence of symptoms (cloudy or smelly urine should not be considered symptoms) Upper respiratory infection (common cold with or without fever, bronchitis, sinusitis not meeting clinical criteria for antibiotics) Abnormal chest x-ray without signs/symptoms of respiratory infection Diarrhea with a negative C. diff toxin assay Predictable mental status fluctuations in a patient with dementia

35 Interactive break What are some of the challenges associated with implementing stewardship in long term care?

36 Discussion Question How confident are you that the antimicrobial stewardship policy and practices in your facility are adequate to reduce unnecessary antibiotic use? A. I am completely confident that the antimicrobial stewardship policy and practices in my facility are adequate B. I am somewhat confident that the antimicrobial stewardship policy and practices in my facility are adequate C. I have no confidence that the antimicrobial stewardship policy and practices in my facility are adequate

37 MARK YOUR CALENDARS! Mar 13 th WEBINAR: Antimicrobial Stewardship: Strategies for Implementation Apr 3 rd May 8 th Jun 12 th Jul 10 th Aug 14 th Sep 11 th WEBINAR: Infection Control: Prevention WEBINAR: Approach to the Patient with Suspected UTI WEBINAR: Infection Control: Management (Case Scenarios) WEBINAR: Antibiotic Selection, De-Escalation, and Duration WEBINAR: How to Get an A on Your Report Card: Prevention and Management of C. difficile and Other Healthcare Associated Infections WEBINAR: Measure Your Success: Monitoring and Tracking Data 38

38 The Learning Center Captures valuable data such as: Pre and post tests Knowledge checks Surveys Learners course specific reports: Test responses Activity completions Feedback Number of Attempts Access at Learning4Quality.org Questions, comments, or concerns,

39 Connect with the New England QIN-QIO on Social Media! 40

40 QIN-QIO State Leads Connecticut Florence Johnson Maine Danielle Watford Massachusetts Sarah Dereniuk-Dudley New Hampshire Pam Heckman Rhode Island Nelia Odom Vermont Gail Harbour This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSMAIS

41 For Massachusetts Facilities Facility recognition for program completion Binder resources will be ed Submission of monthly antibiotic starts on the first day of each month (submit for prior month) at this link: Contact for any questions: Melissa Cumming MDPH AR Coordinator