Antimicrobial Stewardship in Long-Term Care Facilities: Approaches to Creating an Antibiogram when Few Bacterial Isolates Are Cultured Annually

Antibiogram development for Australian residential aged care facilities

OBJECTIVE

Knowledge of local antibiotic resistance data, provided by antibiograms (a cumulative summary of in vitro-antimicrobial-susceptibility-test results), can aid prescribing of appropriate empirical antibiotics. This study aimed to explore the feasibility of antibiogram development for residential aged care facilities (RACFs).

DESIGN

Retrospective observational study of culture and sensitivity data.

SETTING

Nine RACFs in Queensland, Australia.

METHOD

Available antimicrobial susceptibility results were collected retrospectively for all residents of recruited RACFs from January 1, 2020, to December 31, 2022. Data were managed and analyzed with WHONET software®, and antibiograms were developed in accordance with the CLSI-M39 guidelines. Antibiogram data beyond the standard 12-months and pooling of data from geographically similar RACFs were explored as options to improve feasibility and validity of the antibiograms.

RESULTS

The most prevalent bacteria in the RACFs were Escherichia coli and Staphylococcus aureus. Due to the low number of positive cultures (less than 30) for individual RACFs, an annual antibiogram was not feasible. Extending the time-period to three years improved feasibility of antibiograms for E.coli in seven RACFs and S.aureus in five RACFs. Combining the data from closely located RACFs allowed for sufficient urinary and skin swab isolates to produce annual pooled antibiograms for all three years.

CONCLUSION

Use of extended time period antibiograms can provide RACF specific urinary and skin/soft tissue resistance data without the necessity of private pathology provider input. However, pooled syndromic antibiograms can be made available on an annual basis, which may be the preferred option.

Exploring stakeholders' perspectives on antibiogram use, development, and implementation in residential aged care settings

BACKGROUND

Knowledge of local antibiotic resistance data provided by antibiograms (cumulative-antimicrobial-susceptibility-tests) can assist prescribers to make appropriate empirical antibiotic choices.

OBJECTIVE

This study explored the perceptions and knowledge of key stakeholders about the role of antibiograms in residential aged care facilities (RACF), and to understand barriers and enablers of antibiogram development and implementation in this setting.

METHOD

Semi-structured interviews were conducted with aged-care health professionals ('end-users') and antibiogram content experts. This study was conducted in Queensland, Australia in 2023. Using qualitative techniques, framework thematic analysis was used to identify themes, which were mapped to the 'Integrated Promoting Action on Research Implementation in Health Services' framework constructs.

RESULTS

Twenty interviews were conducted comprising of five 'content-experts' and fifteen 'end-users'. Five themes were identified which indicated lack of knowledge about how to use antibiograms, and its availability. Potential insufficient data was the primary issue identified by content experts with regards to feasibility of annual antibiograms. Pragmatic solutions were offered, such as pooling pathology data from facilities in the same geographical location, extending antibiogram data to two-or three-yearly, or utilising local hospital antibiograms. Presenting antibiogram data in a mode and format suiting preferences of individual users would encourage uptake and improve usability. Antimicrobial stewardship (AMS) champions and pharmacists were highlighted as drivers of educating and promoting antibiogram use.

CONCLUSION

Clinicians recognised the potential role of antibiograms in improving empirical antibiotic prescribing choices. Establishing their baseline knowledge provides an essential starting point for the education needs of this group. This study provides practical recommendations regarding the presentation of antibiograms to ensure appropriate use and uptake as an AMS tool in RACFs. Pragmatic solutions suggested to overcome challenges of antibiogram development for RACFs should be applied and evaluated to determine feasibility of RACF-specific antibiograms.

Antimicrobial resistance patterns and empiric antibiotic selections for patients admitted from post-acute care facilities

PURPOSE

To characterize the susceptibilities of positive bacterial cultures and the appropriateness of empiric antimicrobial regimens for patients admitted from post-acute care facilities (PACFs).

METHODS

This was a retrospective quality improvement study. The study included patients admitted from a PACF to one of 2 tertiary care teaching hospitals within the University of Pennsylvania Health System, located in Philadelphia, PA, from August 2020 to December 2021. Patients were included if they had at least one positive culture within 72 hours of admission.

RESULTS

A total of 167 patients and 230 isolates from the study period were evaluated. The majority of positive cultures were from a urinary source (114 of 230, 49.6%). Nineteen patients (11.4%) had a history of multidrug-resistant organisms. The most common empiric antibiotics used were vancomycin (61.7%) and cefepime (59.3%). Sixty-one patients (36.5%) received inappropriate empiric therapy based on the culture results. When comparing our hospitals' general antibiogram to that of only PACF patients, Escherichia coli and Klebsiella pneumoniae had at least a 20% difference in susceptibility to levofloxacin, ceftriaxone, and cefepime. Extended-spectrum β-lactamase resistance was also higher in the PACF cohort (odds ratio, 2.09; 95% confidence interval, 1.4-3.1).

CONCLUSION

Clinically significant differences in antimicrobial susceptibility were found among patients admitted from PACFs compared to our health system's general antibiogram. The increased resistance rates identified in this study support the need for hospitals to evaluate this at-risk patient population, which may drive changes to empiric antibiotic prescribing practices.

Providing value to patients and providers via a pediatric statewide antibiogram in South Carolina

Objective

Antimicrobial stewardship has special challenges in particular populations and facilities, including pediatrics. We sought to augment the information available to antimicrobial stewardship programs (ASPs) by created a cumulative statewide antibiogram for neonatal and pediatric populations.

Methods

In the Antimicrobial Stewardship Collaborative of South Carolina (ASC-SC), we created statewide antibiograms, including a separate antibiogram accounting for the pediatric and neonatal intensive care unit (NICU) populations. We collated data from the 4 pediatric and 3 NICU facilities in the state to provide a cumulative statewide antibiogram.

Results

Methicillin-susceptible Staphylococcus aureus was more prevalent than methicillin-resistant Staphylococcus aureus. Pseudomonas aeruginosa, Citrobacter koserii, and Acinetobacter baumannii were isolated in only 1 NICU.

Conclusions

These antibiograms should improve empiric prescribing in both the inpatient and outpatient setting, providing data in some areas that historically do not have pediatric antibiogram to inform prescribing. The antibiogram alone is not sufficient independently to improve prescribing but is one important aspect of stewardship in the pediatric population of South Carolina.

Enhancing the empiric antibiotic selection by introducing an antibiogram toolkit in a tertiary care hospital in Southern India - A prospective study

WHAT IS KNOWN AND OBJECTIVE

Antibiograms gives an overview of the cumulative susceptibility of formal antibiotics to bacterial isolates, which reflects the portion of each bacterium susceptible to a given antibiotic formulation by using antimicrobial susceptibility testing. The objective of this study is to gather and analyse data from drug utilization evaluation (DUE) studies and antimicrobial susceptibility tests in order to create an antibiogram toolkit that will help clinicians to select appropriate antimicrobial agents for initial empirical antibiotic therapy at point of care settings and avoid irrational use of antibiotics.

METHODS

A prospective interventional study was conducted at tertiary care hospital, biological samples of infectious patients were collected from various wards as per Clinical & Laboratory Standards Institute CLSI M39-A4 guidelines. Antimicrobial susceptibility results were analysed using WHONET software. Antibiotic stewardship committee was formed and involved in monitoring the usage of antibiotics, measuring outcomes, collecting feedback and finding the scope for improving the application of antibiogram toolkit in the hospital. Antibiotic usage tracking method was followed to know the level of adherence to the prescribing guidelines by the health care professionals.

RESULTS AND DISCUSSION

A total of 157 samples were obtained from various wards of the hospital. In that, Escherichia coli, Staphylococcus aureus and Klebsiella Pneumoniae were isolated in significant numbers. Antibacterial susceptibility results were collected, an initial antibiogram was developed for 18 antibacterial agents with respect to 3 gram-positive (+) and 1 gram-negative (-) organisms. 90% of prescribers mentioned that the antibiogram was useful, and 76% of them adhered to the guidelines. 26% were not adhered due to the patient-related factors.

WHAT IS NEW AND CONCLUSION

In our study, we have used qualitative and quantitative evaluation of drug utilization (DUE) reports to understand the existing prescribing pattern of antibiotics and setting target organisms and antibacterials to develop the hospital antibiogram. Combining DUE studies and antibiogram development was helpful in implementing effective antibiotic policies for the hospital. Further, this study pattern will be continued on a yearly basis and focused on developing cumulative antibiograms to understand the changes in resistance pattern of antimicrobials and utilization of antibiotics in the hospital.

Visualization of cross-resistance between antimicrobial agents by asymmetric multidimensional scaling

What is known and objective

In our previous studies, we developed a cross‐resistance rate (CRR) correlation diagram (CRR diagram) that visually captures the magnitude of CRRs between antimicrobials using scatter plots. We used asymmetric multidimensional scaling (MDS) to transform cross‐resistance similarities between antimicrobials into a 2‐dimensional map and attempted to visually express them. We also explored the antibiograms of Pseudomonas aeruginosa before and after the transfer to newly built hospitals, and we determined by the CRR diagram that the CRRs among β‐lactam antimicrobials other than carbapenems decreased substantially with the facility transfer. The present study tests whether the analysis of CRRs by asymmetric MDS can be used as new visual information that is easy for healthcare professionals to understand.

Method

We tested the impact of changes in the nosocomial environment due to institutional transfers on CRRs among antimicrobials in asymmetric MDS, as well as contrasted the asymmetric MDS map and CRR diagram.

Results and Discussion

In the asymmetric MDS map, antimicrobial groups with the same mechanism of action were displayed close together, and antimicrobial groups with different mechanisms of action were displayed separately. The asymmetric MDS map drawn solely for antimicrobials belonging to the group with the same mechanism of action showed similarities to the CRR diagram. Also, the distance of each antimicrobial to other antimicrobials shown in the asymmetric MDS map was negatively correlated with the CRRs for them against that antimicrobial.

What is new and conclusion

The asymmetric MDS map expresses the dissimilarity as distances between agents, and there are no meanings or units on the ordinate and abscissa axes of the output map. In contrast, the CRR diagram expresses the antimicrobials' resistance status as values, such as resistance rate and CRR. By analysing the CRRs in the asymmetric MDS, it is feasible to visually recognize cross‐resistance similarities between antimicrobial groups as distances. The use of the asymmetric MDS combined with the CRR diagram allows us to visually understand the resistance and cross‐resistance status of each antimicrobial agent as a 2‐dimensional map, as well as to understand the trends and characteristics of the data by means of quantitative values.

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Recommendations for Improving Antimicrobial Stewardship in Long-Term Care Settings Through Collaboration

Antimicrobial stewardship is a collaborative venture and antimicrobial stewardship in long-term care (LTC) settings is no exception. There are many barriers to implementing effective antimicrobial stewardship programs in LTC settings, including constrained financial resources, limited access to physicians and pharmacists with antimicrobial stewardship training, minimal on-site infectious syndrome diagnostics and laboratory expertise, and high rates of staff turnover. This article suggests that collaboration at the level of health care facilities and systems, with public health departments, with laboratory partners, and among personnel, including nursing staff, prescribers, and pharmacists, can lead to effective antimicrobial stewardship programs in LTC settings.

Monitoring antimicrobial cross-resistance with cross-resistance rate correlation diagrams: Changes in antibiotic susceptibility of Pseudomonas aeruginosa due to hospital relocation

WHAT IS KNOWN AND OBJECTIVE

Though most medical institutions calculate antimicrobial susceptibility and resistance rates of microbes isolated at their own facility as part of their efforts to promote the proper use of antibiotics, very few, if any, regularly monitor cross-resistance rates between antimicrobial agents. The authors have devised a tool in the form of a cross-resistance rate correlation diagram (CRR diagram) that allows easy identification of increases or decreases in, or changes in the pattern of, antimicrobial cross-resistance. The objective was to perform an analysis by CRR diagrams of the effect of relocation to a newly built facility on antimicrobial resistance and cross-resistance rates at a medical facility.

METHODS

The Sakai City Medical Center relocated in July 2015 to a newly built facility located in a different primary medical care zone 3.5 km away. Based on the drug susceptibility test data compiled at the Sakai City Medical Center, resistance and cross-resistance rates of Pseudomonas aeruginosa before and after the relocation of the hospital facility were calculated, and the rates were assessed using CRR diagrams.

RESULTS AND DISCUSSION

It was possible to confirm the effect of hospital relocation on antibiotic susceptibility of P aeruginosa in terms of changes in resistance and cross-resistance rates. The effect of the facility's relocation on cross-resistance rates was particularly notable with respect to β-lactam antibiotics: cross-resistance rates among β-lactams decreased substantially, represented as a large wedge-shaped change towards the origin on the CRR diagram. Rates of cross-resistance between classes of antibiotics with a different mechanism of antibiotic action changed little.

WHAT IS NEW AND CONCLUSION

Including cross-resistance rates in the routine monitoring of resistance and susceptibility rates practiced by a medical institution can provide a comprehensive insight into the dynamics of bacterial flora in the facility. CRR diagrams, which allow visualization of the status and changes in cross-resistance, not only provide a new perspective for clinicians, but they also contribute to the proper use of antibiotics and serve as a tool in the education of healthcare professionals and students about antibiotic resistance.

Antibiograms Cannot Be Used Interchangeably Between Acute Care Medical Centers and Affiliated Nursing Homes

OBJECTIVE

To determine whether antibiograms for Veterans Affairs (VA) nursing homes (NHs), termed Community Living Centers, are similar to those from their affiliated acute care medical centers.

DESIGN

Descriptive study.

SETTING AND PARTICIPANTS

We compared the 2017 antibiograms for VA NHs to their affiliated VA medical centers (VAMCs). Antibiograms included antibiotic susceptibility rates for commonly observed bacteria in this setting (Staphylococcus aureus, Enterococcus spp, Escherichia coli, Klebsiella spp, Proteus mirabilis, and Pseudomonas aeruginosa).

METHODS

Antibiograms were considered to be in complete agreement when the overall susceptibility rate between the NH and affiliated VAMC was either at or above 80% or below 80% across all bacteria and antibiotics. Average percentage of bacteria-antibiotic comparisons in disagreement per facility pair, and number of facilities with agreement for specific bacteria-antibiotic comparisons were also assessed. The chi-square test was used to compare disagreement between NH-VAMC facilities based on geographic proximity of the NH to the VAMC, culture source, and bed size.

RESULTS

A total of 119 NH-VAMC affiliate pairs were included in this analysis, with 71% (84/119) on the same campus and 29% (35/119) on geographically distinct campuses. None of the NH-VAMC pairs demonstrated complete agreement (all bacteria vs all antibiotics) between their antibiograms. On average, 20% of the bacteria-antibiotic comparisons from the antibiogram disagreed clinically per NH-VAMC pair, and almost twice as often the nursing home had lower susceptibility (higher resistance) than the acute care facility. Some bacteria-antibiotic comparisons agreed in all facilities (eg, E coli-imipenem; S aureus-linezolid; S aureus-vancomycin), while others showed greater disagreement (eg, Klebsiella spp-cefazolin; Klebsiella spp-ampicillin-sulbactam; P aeruginosa-ciprofloxacin). Rates of clinical disagreement were similar by geographic proximity of the NH to the VAMC, culture source, and bed size.

CONCLUSIONS AND IMPLICATIONS

Overall, this study showed a moderate lack of agreement between VA NH antibiograms and their affiliate VAMC antibiograms. Our data suggest that antibiograms of acute care facilities are often not accurate approximations of the nursing home resistance patterns and therefore should be used with caution (if at all) in guiding empiric antibiotic therapy.

Decisional Guidance Tool for Antibiotic Prescribing in the Skilled Nursing Facility

OBJECTIVES

To derive weighted-incidence syndromic combination antibiograms (WISCAs) in the skilled nursing facility (SNF). To compare burden of resistance between SNFs in a region and those with and without protocols designed to reduce inappropriate antibiotic use.

DESIGN

Retrospective analysis of microbial data from a regional laboratory.

SETTING

We analyzed 2484 isolates collected at a regional laboratory from a large mixed urban and suburban area from January 1, 2015, to December 31, 2015.

PARTICIPANTS

A total of 28 regional SNFs (rSNFs) and 7 in-network SNFs (iSNFs).

MEASUREMENTS

WISCAs were derived combining Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, and reports restricted to fluoroquinolones, cefazolin, amoxicillin clavulanate, and trimethoprim/sulfamethoxazole.

RESULTS

Pooling the target isolates into WISCAs resulted in an average of 28 of 37 achieving a number greater than 30 with an average of 50 isolates (range = 11-113; >97% urinary). Significant differences were found in antibiotic susceptibility between grouped rSNF data and iSNF data of 75% vs 65% (2.76-11.77; P = .002). The susceptibilities were higher in iSNFs with active antibiotic reduction protocols compared with iSNFs without protocols and rSNFs (effect size = .79 vs .67 and .65, respectively) (I² = 93.33; P < .01). Susceptibilities to cefazolin (95% vs 76%; P < .001) and fluoroquinolones (72% vs 64%; P = .048) were significantly higher in iSNFs with active urinary tract infection protocols as compared with iSNFs without antibiotic reduction protocols.

CONCLUSION

These results suggest that WISCAs can be developed in most SNFs, and their results can serve as indicators of successful antibiotic stewardship programs. J Am Geriatr Soc 68:55-61, 2019.