A Survey of Antimicrobial Stewardship Practices in Nebraska Long Term Care Facilities

Background: Resistant pathogens are becoming an increasing problem in long term care facilities (LTCF) and antibiotic stewardship is one tool available to combat this. There is very little information on the use of antibiotic stewardship practices or programs (ASP) in LTCF.

Objective: To assess antibiotic stewardship practices in Nebraska LTCF. 

Methods: A survey was developed and submitted to all 220 LTCF in Nebraska using the Nebraska Infection Control Network.  The survey was provided electronically via Zoomerang to the directors of nursing of each facility with instruction to have the responsible party complete the survey.  The majority of questions were yes/no or multiple choice, although some allowed for open-ended responses.

Results: Response rate was 17% (37/220). Formal ASP were reported in 22 (59%) facilities.  Multiple health-care workers were involved in 36% of programs with ICPs (68%), nurses (32%), medical directors (27%), and pharmacists (23%) having responsibility for the ASP. Methicillin-resistant S. aureus rates were tracked in 97% of LTCF while Clostridium difficile infection (87%), vancomycin-resistant Enterococci (73%), and multidrug-resistant gram negatives (49%) were also monitored.  An antibiogram was available in 28 (75%) facilities.  Antibiotic use was monitored in 89% of facilities, costs in 81%, and individual prescriber use in 11%.  Almost all facilities were contacted by the laboratory when a resistant organism was found, usually by fax.  Formularies were uncommon (19%) as was preapproval of antibiotics (11%).  Thirty facilities assessed antibiotic appropriateness, but only 10 restricted antibiotic use or used antibiotic protocols.  Specific pathogens or practices were only targeted in 5 LTCF.  Education about appropriate use was provided at 21 facilities, but was directed at prescribers in only 3. Only 51% of respondents believed antibiotics were overused in their facilities, but 82% felt an ASP would be helpful.  Barriers to the development of an ASP were described by 26 facilities and classified into 4 categories: communication issues (N=2), systems issues (N=2), patient/family expectations (N=4), and physician practice/compliance issues (N=15).

Conclusions: Antibiotic stewardship programs were more common than expected in LTCF. Formulary control and antibiotic restrictions are uncommon, but antibiotics use is nearly universally monitored. While most facilities reported they reviewed antibiotics for appropriateness there were not many programs specifically targeting areas of overuse. Education about appropriate antibiotic use was not directed at prescribers. Physician prescribing behavior and family expectations are viewed as major barriers to ASP implementation.