From the CDC’s “What You Need to Know About Antibiotics in Nursing Homes”:
Antibiotic stewardship refers to a set of commitments and actions designed to make sure patients receive the right dose, of the right antibiotic, for the right amount of time; and only when truly necessary. Improving antibiotic use will ensure these life-saving medications are effective and available when we need them.
A “whole team” approach is needed to reduce the inappropriate prescribing of antibiotics in nursing homes. Everyone on the team has a part to play and a contribution to make to effective Antibiotic Stewardship.
We need physician leadership to set the tone and the standard. We need administrative commitment: invest resources to improve outcomes that drain to the bottom line. We need ongoing staff education with access to outside experts such as consulting pharmacists. We need introductory and ongoing family and patient education. We need to put our data collection and interpretation to work for us: what it means and how to use it to improve outcomes. As physicians, to succeed in our leadership role in Antibiotic Stewardship in nursing homes, we must always ask ourselves and correctly answer the following questions:
Are antibiotics indicated for this patient’s problem?
Prescribing of unnecessary antibiotics not only leads to antibiotic resistance and extra expense, there is the serious risk of infections caused by the antibiotics, especially C. difficile. Monilial infections caused by antibiotics are also more likely in the debilitated nursing home population.
Which antibiotic is appropriate for a given infection? Is a culture or X-ray indicated?
When the nurses call a physician regarding a possible infection in a nursing home setting, they will more often than not request an antibiotic. It is up to the physician to maintain his or her leadership role in the care of the patient and order appropriate tests or determine whether the patient needs to be seen by the doctor prior to ordering antibiotics.
Is the patient allergic to any antibiotics?
This is most critical to patient safety. If the nursing home staff does not volunteer this information, the physician must specifically query the staff regarding allergies. And if the allergy history has not been documented in the chart, it must be obtained from the patient or family prior to prescribing.
Is there a risk of a serious drug interaction between the antibiotic being prescribed and any of the medications the patient is already taking?
Most nursing home patients are taking multiple medications. It is vital that the physician and/or pharmacist determine whether there is a risk of cardiac arrhythmia or other serious adverse effects due to a drug interaction with the antibiotic being prescribed.
Is the Infection Control Protocol at the nursing home implemented as outlined to prevent spread of infection in the facility and thereby avoid prescribing of antibiotics for additional patients?
If the physician’s patient has an infection or the physician becomes aware that another patient in the facility has a potentially communicable infection, he or she must consult with the nurses to confirm the appropriate protocol has been established and it is being adhered to.
Nursing home staff at every level can support the patient, family, and physician by considering the following questions:
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What are we looking at?
Assess the physical, behavioral, and environmental status of the patient. -
What does it mean?
Evaluate findings. -
What do we have to do about it?
Plan of care/approach. -
Who do we have to get to help?
Family/consultant/community resources. -
How do we have to account for it?
Documentation, especially transition of care within the facility.
Working together, under physician leadership with administrative support, and ensuring effective communication and documentation among all team members, we can improve antibiotic use in nursing homes.
Further guidance from the CDC is available via its website and Core Elements for Antibiotic Stewardship in Nursing homes.