Antimicrobial stewardship in nursing homes

1. 21-03-19
1
Andreas Voss, MD, PhD
CWZ and Radboud umc, Nijmegen, The Netherlands

2. 21-03-19
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Morrill al. ICHE 2016;37:979 (Rhode-Island, USA)
¤ FTE for infection control: 74%
¤ Formal AMS programs: 28%
¤ Budget support for AMS: 15%
¤ FTE for AMS: 26%
Morrill al. ICHE 2016;37:979 (Rhode-Island, USA)

3. 21-03-19
3
While the Dutch have AMS programs running in their hospitals for years
AMS in the nursing home setting is (more or less) unknown (in the NL)
¤ Andrea Eikelenboom (CWZ, ZZG)
¤ Mike Verkaaik (ZZG)
¤ Mariëlle van Loosbroek (ZZG)
¤ Evelien Lutke Schipholt (CWZ)
¤ Marjorie Nelissen (IVM)
¤ Stephanie Natsch (Radboudumc)
¤ Andreas Voss (CWZ, Radboudumc)

4. 21-03-19
4
adopt
adapt or
Can we copy & paste hospital AMS
guidelines to the nursing homes?
No way that
C&P works !
Can we copy & paste hospital AMS
guidelines to the nursing homes?

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5
adapt
Adapt it is, but
what needs to
be done?
Can we copy & paste hospital AMS
guidelines to the nursing homes?
Need for a different set-up

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¤ Structure
² presence of microbiology & pharmacy, ID/MMB consultant
¤ Implementation of AMS team
² antibiotic formulary present but nothing else
¤ Surveillance
² limited prevalence or use data
¤ Training/Education
² no training for nurses, little for elderly-care MDs
Hospital Elderly Care
HAI, AB-use, AMR

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6,7%
5,8%
7,3%
7,0%
5,5% 5,5% 5,6%
6,4%
3,3% 3,2% 3,1%
3,8%
2,2% 2,3% 2,5% 2,6%
0,0%
1,0%
2,0%
3,0%
4,0%
5,0%
6,0%
7,0%
8,0%
2007 2008 2009 2010 2011 2012 2013 2014
Rx for HAIs
No HAIS
First step into AMS

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Intrinsic or extrinsic motivation
Van den Dool et al. ICHE 2016;37:761

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¤ Nursing homes are sufficiently connected to the hospital network to
drive national epidemics
¤ Emerging pathogens can, in the absence of control measures, sustain
or initiate nationwide outbreaks
à To protect overall healthcare network good infection control and
AMS in nursing homes desirable
Van den Dool et al. ICHE 2016;37:761
Intrinsic or extrinsic motivation

10. 21-03-19
10
Zhiqiu et al. Infect Control Hosp Epidemiol 2015;36:759 (Rochester, USA)
NHs tend to follow voluntary infection
control guidelines only if doing so does not
require substantial financial investment in
new/dedicated staff or infrastructure
What does
this mean
for AMS?

11. 21-03-19
11
¤ Project group and planning
¤ Built and implement new AB-use list (if needed)
¤ Focus group to better understand HCWs, patients and family
members
¤ Implement new rules for MD’s and nurses
¤ Create AMS-team: MD, pharmacists, CM/ID
¤ Create (standardized) score-list for AB-use
¤ How should AMS-team work in nursing home?
¤ Training and education
Treatment
Cystitis women
Cystitis risk-group.
UTI + tissue invasion
(women)

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According to
formularium
Correct dosing
Correct interval
Correct application
(iv/po)
Correct length
Hebben wij vernieuwd
Keuze is reeds zeer beperkt, cipro, ceftriaxone
Beperking is niet nodig, niet vrijwillig i.m.
Vanuit KF systeem, indicatie start AB opgenomen
Lokale wordt aan gewerkt
Project Nijmegen
Support by administration, medical staff and budget
Basic requirements for an AMS program
Implement local AB formularium
Determine reserve antibiotics for the local
situation
Determine responisibility to monitor AB-use
Get IT support
Get national and local resistance data
We did that
Choice was already very limited
(ciprofloxacin, cefriaxone)
AMS team
By pharmacy software, include start AB
Available

13. 21-03-19
13
SO, KF, AM, DIP
In afspraak met de andere SO’s
Gedaan, komt volgens voor iedereen
Gedaan, komt volgens voor iedereen
Veel tijd voor de SO
Nog niet duidelijk uitgewerkt
Project NijmegenOrganizing an AMS program
Implement an A-team
Foster coopertion and acceptance
Create an implementation plan
Create structure of the program/action plan
Evaluate time requirements
Med specialist, farmacist, ICP, clin micro
Cooperation with other MDs of fascility
Done and given to MDs and team leaders
Done and given to MDs and team leaders
Done (MD about 1 hour per unit per day)
Elderly Care MD
¤ Indications
² noted and correct
¤ Questions to colleagues
¤ Full review
² using check-list (flow)
¤ Feed-back colleagues
Pharmacist
¤ Daily use-data
¤ Automatic stop?
¤ Interactions
CM/ID
¤ Second reviewer
¤ Indications
¤ Dx advise
¤ Rx consult
A-team review (twice a week)
Feedback (non-automated) Consult (by phone)Alert (via farmacy)

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Haalbaarheid voor geheel VPH?
t.z.v. geen categorieën identificeert
Geen kritische voorschriften (cipro, ceftriaxon)
Project Nijmegen
Implementable?
Monitoring of special patient groups in
your hospital
Critical-reserve-antibiotics
Monitoring
Implementable in whole nursing home?
We did not create special “patient” groups
No critical-/reserve-antibiotics
• moet geheel anders – veel van de
punten niet van toepasing
• direct feedback door SO aan collega’s
o indicatie vermelden
o lengte therapie
o correct dosis
o correct eerste keus
o correct interval
• Onderzoek UWI – altijd kweken, hoe
vaak is het raak
Project NijmegenImprove AB-use
Continue to improve prescribing
Feedback and improvements
reserve-AB
Optimize surgical prophylaxis
S. aureus BSI Rx via ID-service
Streamline AB-use
Optimize dosing of AB
Bundle interventions
o Needs to be totally different in NH
o Direct feedback by MD to colleagues
• Include indication, length of Rx,
correct dosing, correct first choice,
correct interval
o Research question with regard to UTI
• Do immediate culture to get better
inside in resistance

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¤ No information for nurses, patients and family
members
AMS training for nurses and patients:
Is that really needed?
ANTIBIOTICS

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Olans et al. CID 206;62:84
Nurses are antibiotic first responders, central communicators,
coordinators of care, as well as 24-hour monitors of patient status,
safety, and response to antibiotic therapy.
¤ Nurses are the cause of antibiotic-use if
they take a dip-test without prior
consultation of the MD
¤ Became part of the score list à no dip-
slide test by nurses without consultation

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ANTIBIOTICS
¤ MD easy describes antibiotics when pushed by family
à educate patients’ family members
¤ While being “on-duty” = taking care of elderly patients they
don’t know well, MDs faster start antibiotics
² no dip-slide tests
² try to postpone to working hours
² PM orders/additional information while passing on duty

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¤ Nursing home is NOT a hospital
²no switch, “no” reserve-AB, limited # antibiotics, structure/logistics
¤ Dedicated MD is a must!!!
¤ Face-to-face meetings (A-team) important during start-up
¤ What to do with ciprofloxacin use
¤ Impact of “culture with first Rx”
¤ How to implement in whole NH
¤ NH was better than expected
² improvement possible, but mostly they used 1st choice AB, correct dose,
interval and length or Rx, plus included, indication for AB
¤ Most frequent mistake
² during being on-duty, due to pressure of nurses or family
¤ Ways to improve
² education of nurses and family (e-learning)
² Rules to use urine-sticks and Uricult
² Try to delay treatment and less empiric treatment

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Van Buul al. J Am Med Dir Assoc 2015;16:229 (NL)
Overall 25%
inappropriate
UTI 32%
Thank you! Any questions?

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https://www.slideshare.net/iPrevent