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Vicentini C, Libero G, Cugudda E, Gardois P, Zotti CM, Bert F. Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review. J Antimicrob Chemother 2024; 79:1748-1761. [PMID: 38870077 PMCID: PMC11290887 DOI: 10.1093/jac/dkae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs. OBJECTIVES We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies. METHODS A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach. RESULTS The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills. CONCLUSIONS Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.
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Affiliation(s)
- Costanza Vicentini
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Giulia Libero
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Eleonora Cugudda
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Paolo Gardois
- Department of Public Health Sciences and Pediatrics, Medical Library ‘Ferdinando Rossi’, University of Turin, Torino, Italy
| | - Carla Maria Zotti
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Fabrizio Bert
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
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Belan M, Agrinier N, Gonthier D, Boivin JM, Charmillon A, Chopard V, Dif C, Hansmann V, Pereira O, Thilly N, Pulcini C. Antibiotic stewardship in French nursing homes: a 2019 regional survey. JAC Antimicrob Resist 2021; 3:dlab105. [PMID: 34647021 PMCID: PMC8499689 DOI: 10.1093/jacamr/dlab105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/28/2021] [Indexed: 11/18/2022] Open
Abstract
Background Antibiotic resistance is a growing issue in nursing homes (NHs). Antibiotic
stewardship (ABS) programmes can reduce antibiotic use in NHs, but few
studies have assessed to what extent they are implemented in NHs. Objectives To describe ABS current practices and describe the opinion of NH stakeholders
regarding ABS and opportunities for improvement in one French region. Methods We invited by e-mail the medical and nurse coordinators of all NHs of the
Grand Est region, France, to participate in our survey in 2019. The online
questionnaire included 35 questions covering four topics: NH
characteristics, current ABS practices, attitudes towards ABS and opinions
on strategies to promote ABS. A score evaluating implementation of core ABS
elements was calculated using the current ABS practice responses. Results Out of 417 NHs, 75 (18%) participated in our survey. The three most
implemented ABS activities were antibiotic consumption monitoring
(65%), antibiotic plan documentation (56%) and antibiotic
prescription guide distribution (54%). Audit and feedback, training
sessions or identification of a local ABS leader ranged from 13% to
29%. Participants positively perceived ABS and most suggestions to
improve ABS programmes in NH, with maximal interest in training, audit and
feedback interventions. The median score for implementation of core ABS
elements was 3.3 (IQR = 2.3–5.4; theoretical
range 0–11), and the score distribution was not associated with any
NH characteristic. Conclusions While there is still room for improvement, NHs had a positive attitude
towards ABS strategies. Some regional and national initiatives to promote
ABS in NHs exist and should be actively promoted.
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Affiliation(s)
- Martin Belan
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, F-54000, Nancy, France
| | - Nelly Agrinier
- Université de Lorraine, APEMAC, F-54000, Nancy, France.,CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, F-54000, Nancy, France
| | | | - Jean-Marc Boivin
- Université de Lorraine, APEMAC, F-54000, Nancy, France.,CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, F-54000, Nancy, France
| | - Alexandre Charmillon
- CHRU-Nancy, Infectious Diseases Department, in Charge of Mobile Infectiologie Team, F-54000, Nancy, France.,Grand Est Antibiotic Stewardship Network Coordinator, AntibioEst, F-54000, Nancy, France
| | - Virginie Chopard
- Observatoire du Médicament, des Dispositifs médicaux et de l'Innovation Thérapeutique Grand Est, F-54000, Nancy, France
| | - Claudine Dif
- Direction Régionale du Service Médicale Grand Est, F-67000, Strasbourg, France
| | | | - Ouarda Pereira
- Direction Régionale du Service Médicale Grand Est, F-67000, Strasbourg, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, F-54000, Nancy, France.,Methodology-Promotion-Investigation Department, Université de Lorraine, CHRU-Nancy, F-54000, Nancy, France
| | - Céline Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, F-54000, Nancy, France.,Université de Lorraine, APEMAC, F-54000, Nancy, France
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Fu CJ, Mantell E, Stone PW, Agarwal M. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey. Am J Infect Control 2020; 48:13-18. [PMID: 31447117 PMCID: PMC6935405 DOI: 10.1016/j.ajic.2019.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.
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Affiliation(s)
| | | | | | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY.
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4
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Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.
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Palms DL, Kabbani S, Bell JM, Anttila A, Hicks LA, Stone ND. Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes Enrolled in the National Healthcare Safety Network. Clin Infect Dis 2019; 69:1235-1238. [DOI: 10.1093/cid/ciz102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/13/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
In 2016, 42% of nursing homes enrolled in the National Healthcare Safety Network reported meeting all 7 of the Centers for Disease Control and Prevention’s Core Elements of Antibiotic Stewardship. Bivariate analyses suggested that implementation of all core elements differed by ownership type and amount of infection prevention staff hours.
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Affiliation(s)
- Danielle L Palms
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jeneita M Bell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Angela Anttila
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nimalie D Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Stone PW, Herzig CTA, Agarwal M, Pogorzelska-Maziarz M, Dick AW. Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018778636. [PMID: 29806527 PMCID: PMC5974557 DOI: 10.1177/0046958018778636] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P < .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P < .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs.
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Affiliation(s)
| | | | - Mansi Agarwal
- 1 Columbia University School of Nursing, New York, NY, USA
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Tolg MSA, Dosa DM, Jump RLP, Liappis AP, LaPlante KL. Antimicrobial Stewardship in Long-Term Care Facilities: Approaches to Creating an Antibiogram when Few Bacterial Isolates Are Cultured Annually. J Am Med Dir Assoc 2018; 19:744-747. [PMID: 29934089 DOI: 10.1016/j.jamda.2018.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/09/2018] [Indexed: 12/18/2022]
Abstract
Antibiograms are important clinical tools to report and track antibiotic susceptibility and help guide empiric antimicrobial therapy. Antibiograms support compliance with antimicrobial stewardship (AMS) requirements from the Centers for Medicare and Medicaid Services and are in line with recommendations from the Centers for Disease Control and Prevention Core Elements of AMS for nursing homes/long-term care facilities (LTCFs). Unlike most acute-care settings, LTCFs are challenged in creating antibiograms because of the low number of bacterial isolates collected annually. Determining the best methodology for creating clinically useful antibiograms for LTCFs needs to be explored. Possible approaches include (1) extending the isolate data beyond 1 year, (2) combining isolate data from the same geographic region, (3) using a nearby acute-care facility's antibiogram as a proxy, or (4) collapsing isolate data. This article discusses the benefits and limitations of each approach.
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Affiliation(s)
- Maria-Stephanie A Tolg
- Veterans Affairs Medical Center, Infectious Diseases Research Program, Providence, RI; Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, RI
| | - David M Dosa
- Veterans Affairs Medical Center, Infectious Diseases Research Program, Providence, RI; Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) and the Specialty Care Center of Innovation at the Louis Stokes Cleveland, Department of Veterans Affairs Medical Center, Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Angelike P Liappis
- Section of Infectious Diseases, Washington DC Veterans Affairs Medical Center, Washington DC
| | - Kerry L LaPlante
- Veterans Affairs Medical Center, Infectious Diseases Research Program, Providence, RI; Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, RI; Warren Alpert Medical School of Brown University, Providence, RI.
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McElligott M, Welham G, Pop-Vicas A, Taylor L, Crnich CJ. Antibiotic Stewardship in Nursing Facilities. Infect Dis Clin North Am 2018; 31:619-638. [PMID: 29079152 DOI: 10.1016/j.idc.2017.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Misuse and overuse of antibiotic therapy is a frequent cause of resident harm in nursing facilities. As a result, newly released policy and regulatory initiatives will require antibiotic stewardship programs (ASPs) in nursing facilities. Although implementing ASPs can be challenging, improving the quality of antibiotic prescribing is achievable in this setting. The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.
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Affiliation(s)
- Miranda McElligott
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Grace Welham
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Aurora Pop-Vicas
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Lyndsay Taylor
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Christopher J Crnich
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA; William S. Middleton Veterans Affairs Hospital, Madison, WI, USA.
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