Antimicrobial Stewardship in Long-Term Care Facilities: A Call to Action

Predatory bacteria are nontoxic to the rabbit ocular surface

Given the increasing emergence of antimicrobial resistant microbes and the near absent development of new antibiotic classes, innovative new therapeutic approaches to address this global problem are necessary. The use of predatory bacteria, bacteria that prey upon other bacteria, is gaining interest as an "out of the box" therapeutic treatment for multidrug resistant pathogenic bacterial infections. Before a new antimicrobial agent is used to treat infections, it must be tested for safety. The goal of this study was to test the tolerability of bacteria on the ocular surface using in vitro and in vivo models. Predatory bacteria Bdellovibrio bacteriovorus and Micavibrio aeruginosavorus were found to be non-toxic to human corneal stromal keratocytes in vitro; however, they did induce production of the proinflammatory chemokine IL-8 but not IL-1β. Predatory bacteria did not induce inflammation on the ocular surface of rabbit eyes, with and without corneal epithelial abrasions. Unlike a standard of care antibiotic vancomycin, predatory bacteria did not inhibit corneal epithelial wound healing or increase clinical inflammatory signs in vivo. Together these data support the safety of predatory bacteria on the ocular surface, but future studies are warranted regarding the use predatory bacteria in deeper tissues of the eye.

Prevalence and impact of Clostridium difficile infection in elderly residents of long-term care facilities, 2011: A nationwide study

The elderly population is particularly vulnerable to Clostridium difficile infection (CDI), but the epidemiology of CDI in long-term care facilities (LTCFs) is unknown.We performed a retrospective cohort study and used US 2011 LTCF resident data from the Minimum Data Set 3.0 linked to Medicare claims. We extracted CDI cases based on International Classification of Diseases-9 coding, and compared residents with the diagnosis of CDI to those who did not have a CDI diagnosis during their LTCF stay. We estimated CDI prevalence rates and calculated 3-month mortality rates.The study population consisted of 2,190,613 admissions (median age 82 years; interquartile range 76-88; female to male ratio 2:1; >80% whites), 45,500 of whom had a CDI diagnosis. The nationwide CDI prevalence rate was 1.85 per 100 LTCF admissions (95% confidence interval [CI] 1.83-1.87). The CDI rate was lower in the South (1.54%; 95% CI 1.51-1.57) and higher in the Northeast (2.29%; 95% CI 2.25-2.33). Older age, white race, presence of a feeding tube, unhealed pressure ulcers, end-stage renal disease, cirrhosis, bowel incontinence, prior tracheostomy, chemotherapy, and chronic obstructive pulmonary disease were independently related to "high risk" for CDI. Residents with a CDI diagnosis were more likely to be admitted to an acute care hospital (40% vs 31%, P < 0.001) and less likely to be discharged to the community (46% vs 54%, P < 0.001) than those not reported with CDI during stay. Importantly, CDI was associated with higher mortality (24.7% vs 18.1%, P = 0.001).CDI is common among the elderly residents of LTCFs and is associated with significant increase in 3-month mortality. The prevalence is higher in the Northeast and risk stratification can be used in CDI prevention policies.

Antimicrobial Stewardship in Long-Term Care: Metrics and Risk Adjustment

An antimicrobial stewardship program (ASP) has been recommended for long-term care facilities because of the increasing problem of antibiotic resistance in this setting to improve prescribing and decrease adverse events. Recommendations have been made for the components of such a program, but there is little evidence to support any specific methodology at the present time. The recommendations make minimal reference to metrics, an essential component of any ASP, to monitor the results of interventions. This article focuses on the role of antibiotic use metrics as part of an ASP for long-term care. Studies specifically focused on development of antibiotic use metrics for long-term care are reviewed. It is stressed that these metrics should be considered as an integral part of an ASP in long-term care. In order to develop benchmarks for antibiotic use for long-term care, there must be appropriate risk adjustment for interfacility comparisons and quality improvement. Studies that have focused on resident functional status as a risk factor for infection and antibiotic use are reviewed. Recommendations for the potentially most useful and feasible metrics for long-term care are provided along with recommendations for future research.

Antimicrobial Stewardship in Rhode Island Long-Term Care Facilities: Current Standings and Future Opportunities

Our survey of antimicrobial stewardship practices among Rhode Island long-term care facilities demonstrated opportunities to develop formal programs. Results suggest infection preventionists are largely responsible for ensuring appropriate antibiotic use in long-term care facilities and there is a need for increased interdisciplinary access to individuals with antimicrobial stewardship expertise. Infect Control Hosp Epidemiol 2016;37:979-982.