Table Of ContentAntimicrobial
Stewardship in Non-
Traditional Settings
A Practical Guide
Shira Doron
Maureen Campion
Editors
123
Antimicrobial Stewardship
in Non- Traditional Settings
Shira Doron • Maureen Campion
Editors
Antimicrobial Stewardship
in Non-Traditional Settings
A Practical Guide
Editors
Shira Doron Maureen Campion
Division of Geographic Medicine Department of Pharmacy
and Infectious Diseases Tufts Medical Center
Tufts Medical Center Boston, MA, USA
Boston, MA, USA
ISBN 978-3-031-21709-8 ISBN 978-3-031-21710-4 (eBook)
https://doi.org/10.1007/978-3-031-21710-4
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
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Introduction
Antimicrobials are critical life-saving tools of modern medicine, but they are also
dangerous. Rapid drug development in the early days of antibiotics meant that even
as resistance was developing, prescribers could almost always count on a new anti-
microbial coming to market that would treat the increasingly resistant pathogens.
But the drug development pipeline is no longer keeping up with the growing resis-
tance trend. As a result, a “post-antibiotic era,” where minor infections could once
again kill and advanced therapies like cancer chemotherapy and organ transplanta-
tion could prove too dangerous, looms large.
Antimicrobial stewardship (AS) is the coordinated effort of measuring and
improving the way antimicrobials are prescribed and used, with the goal of maxi-
mizing benefit and minimizing harms. Those harms include not only the promotion
of antimicrobial resistance but also unnecessary adverse events, side effects, and
costs. Antimicrobial stewardship is critical to preserving our ability to use antimi-
crobials in the future.
In 2014, CDC called on acute care hospitals to implement antimicrobial steward-
ship programs based on the Core Elements of Hospital Antibiotic Stewardship
Programs [1]. In 2015, the Core Elements of Antibiotic Stewardship for Nursing
Homes [2] were released. In 2016, the Core Elements of Outpatient Antibiotic
Stewardship [3] were launched, with the intent to encompass clinics, emergency
departments, dental offices, and urgent care centers. The goal is to continue to
expand stewardship efforts to every corner of health care in which antimicrobials
are in use. However, the implementation of antimicrobial stewardship requires
resources—including time, clinical expertise, and compensation.
The 2007 Infectious Diseases Society of America consensus guidelines recom-
mended that AS programs be established with the dedicated, compensated time of
Infectious Disease specialty trained physicians and pharmacists [4]. However, many
healthcare settings lack the resources necessary to adhere to this recommendation.
Nevertheless, AS can be effectively adapted to environments with limited infectious
diseases resources.
In this book, we provide in-depth reviews on approaches to antimicrobial
stewardship, from the implementation of successful initiatives to the develop-
ment of formal programs, in non-traditional, often resource-limited, settings.
The authors, who are physicians, clinical pharmacists, and veterinarians, are
v
vi Introduction
experts who practice in those settings and have worked therein to improve the
prudent use of antimicrobials. This information will hopefully help health care
professionals to initiate or enhance their antimicrobial stewardship practices.
Acknowledgment: We thank Dr. Kirthana Beaulac for her work on the concep-
tion of this book and early editing.
References
1. CDC Core Elements of Hospital Antibiotic Stewardship Programs. https://www.cdc.gov/
antibiotic- use/core- elements/hospital.html.
2. CDC Core Elements of Antibiotic Stewardship for Nursing Homes. https://www.cdc.gov/
antibiotic- use/core- elements/nursing- homes.html.
3. CDC Core Elements of Outpatient Antibiotic Stewardship. https://www.cdc.gov/antibiotic- use/
core- elements/outpatient.html.
4. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the
Society for Healthcare Epidemiology of America guidelines for developing an institutional
program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77.
Division of Geographic Medicine and Infectious Diseases Shira Doron
Tufts Medical Center
Boston, MA, USA
e-mail: [email protected]
Department of Pharmacy Maureen Campion
Tufts Medical Center
Boston, MA, USA
e-mail: [email protected]
Contents
1 Antimicrobial Stewardship in Long-Term Care Facilities (Nursing
Homes and Rehabilitation Centers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Lucy S. Witt, Sheena Kandiah, and Sujit Suchindran
2 Antimicrobial Stewardship in the Outpatient Setting . . . . . . . . . . . . . . 25
Monika Zmarlicka, Jacinta Chin, and Gabriela Andujar Vazquez
3 Antibiotic Stewardship in the Emergency Department . . . . . . . . . . . . 43
Kellie J. Goodlet, Michael D. Nailor, and Larissa S. May
4 Antimicrobial Stewardship in Critical Access Hospitals . . . . . . . . . . . . 73
Sarah B. Green and David H. Priest
5 Antimicrobial Stewardship in Ambulatory Surgery Centers . . . . . . . . 85
Sophia Macleay Cardwell, Andrew Root, and Andrea Halliday
6 Antimicrobial Stewardship in Canine and Feline
Veterinary Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Claire Fellman and Annie Wayne
7 Antimicrobial Stewardship in Immunocompromised Hosts . . . . . . . . . 123
Tine Vindenes, Hrvoje Melinscak, Kristin Linder, and Majd
Alsoubani
8 Antimicrobial Stewardship in the Intensive Care Unit . . . . . . . . . . . . . 161
Iris H. Chen, David P. Nicolau, and Joseph L. Kuti
9 Antimicrobial Stewardship in Pediatric Patients . . . . . . . . . . . . . . . . . . 185
Jennifer E. Girotto and Nicholas Bennett
10 Antimicrobial Stewardship in Hospital Networks
and Health Care Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
M. Sean Boger and Lisa E. Davidson
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
vii
Antimicrobial Stewardship in Long-Term 1
Care Facilities (Nursing Homes
and Rehabilitation Centers)
Lucy S. Witt, Sheena Kandiah, and Sujit Suchindran
Introduction
Antimicrobial Stewardship Programs and Why Your Facility
Should Have One
Antimicrobial overuse is a well-described problem in long-term care settings such
as nursing homes and sub-acute rehabilitation centers [1–3] and is quickly becom-
ing more recognized in acute rehabilitation centers [4, 5]. An antimicrobial stew-
ardship program (ASP) is an institutional program aimed at optimizing antimicrobial
usage with the goal of improving patients’ health by reducing the number of
healthcare associated infections such as Clostridioides difficile infections (CDI)
and multi-drug resistant organisms (MDRO) along with medication-associated
adverse events. In 2017 the Centers for Medicare and Medicaid Services (CMS),
the federal agency that determines Medicare and Medicaid regulations, required
that all participating long-term care facilities (LTCFs) and rehabilitation centers
establish an ASP that must include “antibiotic use protocols and a system to moni-
tor antibiotic use” [6]. A survey conducted in 2018 showed that a majority of US
nursing homes had at least a “moderately comprehensive” ASP program, an
increase from prior studies [7]. For the purposes of this chapter the term rehabilita-
tion centers will be used to describe both acute and sub-acute rehabilitation facili-
ties. The term long- term care facilities will be used to describe institutions where
residents reside indefinitely.
Numerous studies have described antibiotic overuse and its relationship to
increased CDI, MDROs, and adverse medication effects [2, 3, 8]. Antibiotic overuse
and misuse lead to excess cost to a facility from the costs of the unnecessary
L. S. Witt · S. Kandiah · S. Suchindran (*)
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
e-mail: [email protected]; [email protected]; [email protected]
© The Author(s), under exclusive license to Springer Nature 1
Switzerland AG 2023
S. Doron, M. Campion (eds.), Antimicrobial Stewardship in Non-Traditional
Settings, https://doi.org/10.1007/978-3-031-21710-4_1
2 L. S. Witt et al.
antibiotics themselves, the costs of using expensive antibiotics when less expensive
ones could be substituted, and from treatment of downstream MDROs or medica-
tion side effects as well as increased length of stay in acute care facilities. ASPs
have been shown to alleviate some of this financial burden [9–11]. Furthermore,
residents living in long-term care facilities with inappropriate antibiotic use are at
higher risk for adverse outcomes such as CDI, MDROs, and medication side effects
regardless of whether or not they receive an antibiotic prescription [3]. A majority
of nursing home residents will receive an antimicrobial in the course of a year [1,
12] and 40–75% of these prescriptions may be inappropriate [2] (Fig. 1.1). Residents
of long-term care facilities and sub-acute rehabilitation centers may be frail and
prone to infection making it challenging for providers to balance between caring for
these patients while avoiding antibiotic overuse. Similarly, infections are known to
be a major cause of nursing home resident morbidity and mortality and are the most
common reason for transfer from a nursing home to an acute care hospital [1]. There
is significantly more variability in antimicrobial usage between LTCFs compared to
acute care hospitals making these LTCFs an important target of antimicrobial stew-
ardship interventions [3, 13]. In this chapter we aim to summarize and expand upon
the importance of ASP, describe practical aspects of ASP implementation, and
review existing literature supporting certain interventions. Throughout we will
highlight specific areas of focus that may be applicable in LTCFs and rehabilitation
centers.
Acute Rehabilitation Centers, Sub-Acute Rehabilitation,
and Long- Term Care Facilities
We acknowledge that antimicrobial stewardship strategies may differ depending on
the type of rehabilitation setting. Anticipating each institution’s stewardship needs
requires an understanding of the differences between the settings. Acute rehabilita-
tion facilities care for patients who can be expected to make substantial improve-
ments in functional status over a shorter period of time. They can be a free-standing
Fig. 1.1 Antibiotic use in long-term care facilities. Adapted from CDC Core Elements
1 Antimicrobial Stewardship in Long-Term Care Facilities… 3
hospital or housed within an acute care hospital. Often acute rehabilitation patients
also require ongoing medical treatment in combination with physical, occupational,
or speech therapy. At these facilities, clinical care and leadership of a multidisci-
plinary care team is provided by physicians trained in rehabilitation medicine who
provide daily face-to-face patient assessments. A physician is available at all times
for emergencies. These patients also receive 24-h nursing care and more than three
hours of therapy per day, at least five times weekly. Patients in this setting are usu-
ally discharged to home or community settings after a shorter stay. Research into
ASP in the acute rehabilitation setting is lacking. However, the themes and interven-
tions described in this chapter are likely applicable, with modification, to acute
rehabilitation facilities. Acute rehabilitation facilities housed within acute care hos-
pitals may have more resources given their potential for proximity to specialized
clinical pharmacists, infectious disease physicians, and on-site microbiology
laboratories.
Compared to acute rehabilitation, sub-acute rehabilitation centers target patients
with less intense therapy needs, who often participate in physical therapy for one to
two hours daily. Direct contact with clinicians is less frequent compared to that in
acute rehabilitation facilities. The length of stay is generally longer, and patients
leave these facilities and return to the community or move into LTCFs. LTCF resi-
dents require regular skilled nursing assistance for activities of daily living.
However, these residents do not require the ongoing, intense medical care that takes
place in Long-Term Acute Care Hospitals such as prolonged ventilator weaning.
Given the differences between care settings, we will point out areas that might be
more applicable to rehabilitation centers rather than LTCFs and vice versa.
Existing Guidance
Multiple resources exist which can provide a general framework and aid in imple-
mentation of ASPs in long-term care settings including the Centers for Disease
Control and Prevention’s (CDC) Core Elements of Antibiotic Stewardship for
Nursing Homes and the Agency for Healthcare Research and Quality (AHRQ)’s
published guidance on ASP implementation specific to long-term care settings [12,
14]. Even more focused, the Society for Post-Acute and Long-Term Care Medicine
created a template for policies tailored to LTCFs [15]. Direct links to these resources
are listed at the end of this chapter for independent review. These tools provide use-
ful guidance that can be tailored to a specific institution’s resources and needs.
Infections in Long-Term Care Facilities and Rehabilitation Centers
Infections in LTCFs can be considered in two broad categories: infectious syn-
dromes and problematic pathogens. Interventions that target these syndromes or
infections are likely to be useful and lead to improvement in patient outcomes as
well as possible cost savings [5, 9, 10, 16–18].
The three most commonly reported infectious syndromes in LTCFs are urinary
tract infections (UTIs), skin and soft tissue infections (SSTIs), and respiratory tract
