Establishment of Antimicrobial Stewardship Programs in Long-Term Care Facilities

Background: The risk of colonization and infection with multidrug-resistant organisms (MDRO) among long-term care facility (LTCF) residents is well documented.  Prevalent use and misuse of antibiotics within LTCF compound other factors that predispose this population to acquisition of and infection with MDRO. Despite these facts, introduction of antimicrobial stewardship programs (ASP) in LTCF has not been described.  This may be due to perceived lack of financial or personnel resources or to unwillingness to initiate a new program that is not currently mandated.

Objective: (1) To establish ASP in LTCF using existing personnel through collaboration with acute care hospital (ACH) partners and access to external expertise and (2) to develop and pilot tools for ASP development and implementation in LTCF.

Methods: Three LTCF and their ACH partners were selected for participation in the project.  Project sponsors provided participants with access to infectious disease and pharmacy consultants, technical support, and a “tool kit” of materials to assist with program development and monitoring.  Participants created an ASP team, assessed baseline practices, identified 1-2 areas for intervention, set goals, and implemented strategies to reach the goals.  A kick-off meeting, monthly conference calls, and site visits were conducted to further assist participants.

Results: After assessing current practices, all LTCF participants identified inappropriate treatment of asymptomatic bacteriuria as an area for intervention. By the end of the 8-month project, 2 LTCF reported qualitative improvement in prescribing practices. Factors that appeared to contribute to successful ASP implementation were a motivated team, support from facility administration and medical leadership, collaboration with the ACH partner, and ability to provide antimicrobial use and resistance data to prescribing clinicians and facility leadership.  Participants reported that the availability of the tool kit, a forum for discussing best practices and implementation challenges with other participants, and focusing initial activities on a limited number of specific problem areas were helpful in building the momentum needed for program development. At the end of the project, most participants felt that their ASP was sustainable and capable of further expansion.

Conclusions: With access to basic tools (e.g., data collection forms, surveys, educational materials), expert advice, and a forum to discuss barriers and best practices with other facilities, LTCF developed and implemented ASP within a short time period using existing personnel and resources.  These findings demonstrate that it is possible to improve antibiotic prescribing practices in LTCF which may lead to a reduced risk of MDRO and other complications of antimicrobial therapy in LTCF residents. Larger scale initiatives to assist LTCF with implementation of ASP should be considered.