Antimicrobial medications are used to treat infections (and sepsis) caused by bacteria, parasites, viruses, and fungi. Antimicrobial resistance (AR)—when germs conquer the drugs that are supposed to kill them and instead keep growing—occurs naturally. However, exposure to antibiotics and other antimicrobial drugs builds resistance mechanisms in germs, speeding up the growth of AR.
Since the COVID-19 pandemic began in 2020, AR has been on the rise. “Bacterial antimicrobial-resistant hospital-onset infections caused by the pathogens listed [below] increased by a combined 20 percent during the COVID-19 pandemic compared to the pre-pandemic period, peaking in 2021,” says the Centers for Disease Control and Prevention (CDC) in the July 2024 report Antimicrobial Resistance Threats in the United States, 2021 – 2022.
The pathogens monitored by the CDC are as follows:
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“In 2022, rates for all but one of these pathogens (MRSA) remained above pre-pandemic levels,” notes the CDC. “In addition, the number of reported clinical cases of C. auris—a type of yeast that can spread in healthcare facilities, is often resistant to antifungal medications, and can cause severe illness—increased nearly five-fold from 2019 to 2022.”
This accelerated growth in AR has serious consequences. “Antimicrobial-resistant infections that require the use of second- and third-line treatments can harm patients by causing serious side effects, such as organ failure, and prolong care and recovery, sometimes for months,” says the CDC. “[And] in some cases, antimicrobial-resistant infections have no treatment options. [Further,] many medical advances are dependent on the ability to fight infections using antibiotics, including joint replacements, organ transplants, cancer therapy, and the treatment of chronic diseases like diabetes, asthma, and rheumatoid arthritis.”
The bottom line is that “at least 2.8 million antimicrobial-resistant infections continue to occur in the U.S. each year, and more than 35,000 people die as a result,” stresses the CDC.
One “core strategy” that the CDC advocates to slow AR is antimicrobial/antibiotic stewardship. Similarly, the Agency for Healthcare Research and Quality (AHRQ) identifies antibiotic stewardship as a “fundamental best practice” that underpins “all four key strategies for MRSA prevention” in the AHRQ Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
In 2015, the CDC created the Core Elements of Antibiotic Stewardship for Nursing Homes to explain the seven components of a successful antibiotic stewardship program (i.e., leadership commitment, accountability, drug expertise, action, tracking, reporting, and education), and by 2022, 83 percent of the roughly 5,000 nursing homes participating in the National Healthcare Safety Network’s (NHSN) Long-term Care Facility Component Annual Facility Survey reported implementation of all seven core elements. And, overall antibiotic use in nursing homes was 5 percent lower in 2021 than in 2019 (possibly due to a decrease in nursing home residents during the pandemic), according to the CDC’s COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022.
So, progress has definitely occurred. Yet, antibiotic stewardship still was described as “embryonic in most nursing homes” only two years ago in the JAMA Network Open physician commentary “Accelerating the Growth of Antibiotic Stewardship in Nursing Homes.”
Taking the following steps can position the infection preventionist (IP), especially a newer IP, to strengthen the nursing home’s antibiotic stewardship program:
Establish a strong foundation of knowledge
With the high level of turnover that continues to plague long-term care, IPs often have a wide range of experiences prior to taking the role, says Steven Schweon, RN, MPH, MSN, CIC, LTC-CIP, CPHQ, FSHEA, FAPIC, an infection preventionist based in Saylorsburg, PA, and a member of the Emerging Infectious Diseases task force at the Association for Professionals in Infection Control and Epidemiology (APIC).
“The IP may have been on the job for two days, two weeks, two months, or two years,” explains Schweon. “To be able to leverage resources to improve the facility’s antibiotic stewardship program, the No. 1 action that the IP can take is to really learn what antibiotic stewardship is.”
An IP who is unfamiliar with antibiotic stewardship or who needs a refresher should take the CDC’s online Nursing Home Infection Preventionist Training, suggests Schweon. “This 24-module course includes two modules that will give the IP fundamental knowledge about what antibiotic stewardship entails: module 14 (Antibiotic Stewardship in Nursing Homes) and module 15 (Infection Prevention and Antibiotic Stewardship Considerations During Care Transitions). I have taken the course myself, and it is excellent.”
While IPs are not required to take the Nursing Home Infection Preventionist Training, the Centers for Medicare & Medicaid Services (CMS) does cite it as the primary example of how IPs may obtain the required baseline “specialized IPC training beyond initial professional training or education” under F-tag 882 (Infection Preventionist Qualifications/Role) in Appendix PP of the State Operations Manual.
Note: The 20-hour CDC course, last updated on Oct. 1, 2023, is accessible via a link here. Learners will have to set up a free account on CDC’s TRAIN website, register, and take the entire course to get continuing-education or certificate-of-completion credit.
Additional resources that can help a new IP get acclimated include the Infection Preventionist Orientation Checklist from Telligen and the Long-Term Care Infection Preventionist’s Survival Guide from Health Quality Innovation Network (HQIN). Finally, APIC offers an Infection Preventionist Career Development and Advancement Guide that covers IP career stages and competencies.
Perform a gap analysis
“As part of their IPCP [infection prevention and control program], facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance,” says CMS under F881 (Antibiotic Stewardship Program) in Appendix PP. “This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms.”
The IP should carefully read F881 to understand the regulatory requirements for an antibiotic stewardship program, says Schweon. “Then, it’s a good idea to do a gap analysis, meaning that you compare (1) what CMS requires for antibiotic stewardship, against (2) the current antibiotic stewardship process that is implemented in the nursing home.”
From a regulatory perspective, the IP needs to know what’s expected in case of survey, points out Schweon. “By doing a gap analysis, you will have an informed perspective on where your facility is compliant and what your regulatory improvement opportunities are with antibiotic stewardship. Taking action to address the improvement opportunities helps to bolster the resident safety program and promote regulatory compliance.”
Note: Failure to have a robust antibiotic stewardship program can feed into other citations. For example, surveyors may cite F756 (Drug Regimen Review, Report Irregular, Act On) if the consultant pharmacist failed to review and report irregularities involving unnecessary antibiotics or F757 (Drug Regimen Is Free From Unnecessary Drugs) if a resident received unnecessary antibiotics.
Do the CDC’s antibiotic stewardship checklist
The F881 guidance in Appendix PP recognizes the CDC’s Core Elements not as a requirement, but as a resource “available to identify core actions to prevent antibiotic resistance within the control of the nursing home.”
The Core Elements come with a Checklist for Core Elements of Antibiotic Stewardship in Nursing Homes that targets specific actions for review in all seven elements, notes Schweon. “Doing this checklist will allow the IP also to compare (1) what the CDC recommends against (2) what the facility currently has in place for antibiotic stewardship.”
Note: The Minnesota Department of Health offers an Antimicrobial Stewardship Gap Analysis Tool in Microsoft Word and Adobe Acrobat (pdf) that also is designed as a companion to the Core Elements. This tool includes more questions and more detailed options for some answers to give nursing homes additional data on their antibiotic stewardship program.
Share improvement opportunities with leadership
Once the IP knows how the facility’s antibiotic stewardship program measures up to regulatory requirements, as well as CDC expectations, the next step is to present those findings, suggests Schweon. “You should talk to your supervisor first, then the Antibiotic Stewardship Committee, and explain where your facility has improvement opportunities. For example, if you have identified improvement opportunities with the laboratory from a CMS or CDC perspective, you might say, ‘We can be doing a better job leveraging the laboratory to help benefit our residents and to augment our antibiotic stewardship program.’”
Participate in performance improvement projects
The surveyor guidance under F868 (QAA Committee) in Appendix PP requires that the IP be an active participant in the Quality Assessment and Assurance (QAA) Committee who reports key data about the facility’s IPCP, including antibiotic use and resistance data, says Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and board member at APIC.
“In addition, the IP needs to participate directly in any performance improvement projects focused on the IPCP, including the antibiotic stewardship program,” says Burdsall. “You’re a part of the interdisciplinary team, and you need to be involved.”
Consider asking questions to be a part of the job
Many nurses who become IPs weren’t previously taught antibiotic stewardship, says Schweon. “So, it’s important for the IP to be proactive about asking questions in order to learn. That not only bolsters your confidence when you deal with, for example, a prescribing clinician, it helps the residents receive better care.”
Key people to talk to include the medical director, the consultant pharmacist, the IP at your local hospital, and laboratory staff, suggests Schweon. “You can build up those relationships by asking questions in a nonthreatening way to bolster your knowledge. For example, when you run into something confusing, you could ask such simple questions as: ‘Can you tell me more about this?’; ‘Can you help me understand what this means?’; ‘What’s the impact of this?”; or ‘What do you think about this?’”
Note: When asking busy professionals for information outside of scheduled interactions and meetings, it may be helpful to ask if they have a preferred communication method (i.e., phone, text, or e-mail) and a preferred day of the week and/or time of day to get questions that don’t involve urgent resident care issues. Find additional suggestions about asking for help here.
Document all IP work
The IP should document everything that they do to support the antibiotic stewardship program, says Schweon. “You want to take credit for all the hard work that you are doing.”
Schweon offers the following examples of work that should be documented:
- The IP attends resident and family council meetings to provide information about antibiotic stewardship.
- The IP educates nursing staff about antibiotic stewardship at a nursing department meeting.
- The IP has a one-on-one meeting with a prescriber. “One example of this conversation that you may need to have is if the urine culture comes back showing Escherichia coli (E. coli) for a resident with a suspected urinary tract infection (UTI), it indicates that their antibiotic needs to be changed, and the prescriber doesn’t want to change their antibiotic even though the current one is ineffective against E. coli,” explains Schweon. “In this scenario, you must have a conversation with the prescriber and ask, ‘Help me understand. Why don’t you want to change this resident’s antibiotic based on the laboratory’s findings?’ That is a conversation that needs to be documented.”
Take advantage of free resources
The Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) provide online tools, webinars, peer groups, and one-on-one technical assistance on a variety of topics, including antibiotic stewardship, notes Schweon. “Contacting your QIN-QIO to see what they can offer to help you improve antibiotic stewardship in your facility is a good start. Every state has one of these organizations available as a resource to providers.”
Note: At press time, QIN-QIO contracts for the five-year 13th statement of work have yet to be awarded. While online resources remain accessible, additional assistance is on hold until after the contract awards. Questions about this process can be submitted to [email protected]. Once the contract awards are made, providers can locate their QIO here.
Another useful resource is the Project Firstline infection prevention and control education from the CDC, says Schweon. “Project Firstline includes a variety of educational tools for frontline workers, including the Fight Antimicrobial Resistance With Infection Control fact sheet.”
The AHRQ and the Minnesota Department of Health have good resources as well, says Schweon. A summary of some key resources from both agencies, as well as other sources, is included below:
| Additional Resources The Minnesota Antimicrobial Stewardship Program Resources for Long-term Care Facilities from the Minnesota Department of Health includes a number of resources, such as a sample antibiotic stewardship policy and a companion guide for using it; action steps and strategies; nursing and clinician attitudes and beliefs surveys; a nursing process evaluation tool for changes in condition; an infection and antibiotic use tracking tool; communication tools, including a template feedback form for prescribing clinicians; clinical decision-making tools, including algorithms for the prevention and management of C. diff infections; infection surveillance resources, including an infection surveillance definition worksheet; and other resources, such as how to understand what asymptomatic bacteriuria is and how to manage it. The Nursing Home Antimicrobial Stewardship Guide from the AHRQ offers four sets of toolkits:
PA-HAI: 2023 PA HAI Summit—Antibiotic Stewardship in Postacute and Long-Term Care Settings—Recorded Session, available via TRAIN, includes a detailed review of how to interpret prescriber practice patterns for urinary tract infection (UTI) cultures. Infection prevention assessment tools, resources and trainings from Telligen. Resources include the Guidebook for Infection Prevention and Control Preparedness. The North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) at the University of North Carolina at Chapel Hill offers educational resources on antibiotic stewardship, including mini-lectures and fact sheets on “Hot Topics” in antibiotic stewardship. Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings from the CDC includes an antibiotic stewardship module. Implementation of an Antibiotic Stewardship Program in Long-term Care Facilities Across the U.S. from the Feb. 28, 2022, JAMA Network Open discusses using a patient safety approach to implement antibiotic stewardship. The CDC TRAIN website (free with registration) has an Antibiotic Stewardship Training Plan targeted to prescribing clinicians and pharmacists that includes a module on antibiotic stewardship in long-term care. The Be Antibiotics Aware campaign from the CDC includes the three-page scenario-based resource Effective Communication With Residents and Families and the one-page educational tool Viruses or Bacteria: What’s Got You Sick? Additional resources targeted to nursing homes are here. |
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