Antimicrobial Stewardship in Long Term Care Facilities: Lessons Learned

Background: Studies suggest 25-75% of antibiotics (abx) are inappropriate in long term care facilities (LTCF). Antimicrobial Stewardship Programs (ASP) are limited in LTCF but can be successful. One study demonstrated a decrease in abx usage by 30% post intervention (intv) and significant decrease in Clostridium difficile (C. diiff) colitis cases. Outcome measures are difficult to track as there are no centralized monitoring systems.

Methods: This is a retrospective cohort analysis, comparing pre/post intv May-Nov 2014/2015 data in 5 LTCF where Kaiser Permanente geriatricians round. We reviewed charts and discussed pts with geriatricians once/week. ID consultation was available 24/7.

Primary endpoints: 1. Decrease in antimicrobial days of therapy (DOT), measured by abx days avoided and associated cost savings. 2. De-escalation of antimicrobial therapy, measured by # days of broad-spectrum abx avoided. Abx were ranked 1-4, 1=most narrow-spectrum, 4=broadest spectrum.  Secondary endpoint: evaluate C. diff infections and rehospitalization rate at 30 days post-ASP intv.

Results:

Total # pts in study: 188

# cases: instances any pt was discussed: 231

# interventions: each abx discussed (some cases had >1 intv): 294

# diagnoses: diagnosis of each intv (some pts had >1 dx): 245

	Male	Female
# pts:	80 (42.55%)	108 (57.45%)
Ages	20-95	31-95
Mean age	74.2	76.6

 

Dx	# dx	%
UTI	78	32%
Resp inf	71	29%
Skin/soft tissue	35	14%
C diff	19	8%
Bone/joint	17	7%
Bacteremia	13	5%
GI	8	3%
Other	4	2%

Intv changes were made in 167/231 (72%) cases.

Fig 1: Types of interventions.

Abx changes occurred among 50/294 (17%) intvs.

Fig 2: Rankings before/after interventions.

Total DOT and cost savings:

Days of Therapy (DOT)	Total Amount	Cost
DOT Saved	1028	$28,458
DOT Extended	609	$13,754
Net	419	$14,704

Fig 3: Top sampling of abx saved.

Among 231 cases, 7 developed C. diff within 30 days post-intv; of these, 3 had a hx C diff. Comparing 2014 and 2015 June-Nov  C diff rates (# cases/1000 pt days):

2014	2015	P value
28.05	18.61	(χ2=3.49, p<.06)

Of 231 cases, 57/231 (24.7%) were readmitted to the hospital within 30 days of intv.

Conclusion: ASP in LTCF decreased DOT and cost. While C. diff rates were not significantly decreased, we identified future data collection priorities for LTCFs including hospital readmission and prior abx usage.