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399 Steering the StewardShip: Reducing Antimicrobial Use in a VA Long-Term Care Facility through an On-Site Infectious Disease Consultation Service

Sunday, April 3, 2011
Trinity Ballroom (Hilton Anatole)
Robin L.P. Jump, MD, PhD , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Lucy A. Jury, NP , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Emily P. Peron, PharmD , University of Pittsburgh, Pittsburgh, PA
Amy A. Hirsch, PharmD , Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Danielle M. Olds, RN, PhD , Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Patria Gerardo, MD , Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Curtis J. Donskey, MD , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Robert A. Bonomo, MD , Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH

Steering the StewardShip:  Reducing Antibiotic Use in a VA Long-Term Care Facility through an

On-Site Infectious Disease Consultation Service

Background:   Current estimates indicate that 50-75% of long-term care facility (LTCF) residents receive antibiotics annually, with, 25-75% of these courses considered to be unnecessary.  LTCFs often lack the personnel and diagnostic equipment required to evaluate patients for suspected infection, which may contribute to over-utilization of antibiotics. 

Objective:   Our objective was to determine if an on-site infectious disease (ID) consultation service that rounds weekly at a Veterans Affairs (VA) LTCF would lead to a reduction in antibiotic prescriptions and improved antibiotic stewardship.

Methods:   The antibiotics administered for a six-month period of the year before and after initiation of the on-site ID consultation service (fiscal years 2009 and 2010 respectively) were obtained using barcode medication administration (BCMA) data.  Defined daily doses (DDD) per 1,000 patient days (PD) were calculated using the World Health Organization's definitions. 

Results:   Fluoroquinolones, the most commonly administered antibiotic class, were reduced by 37% from 35.3 to 22.1 DDD/1,000 PD (P<0.01) (Figure).  Use of piperacillin-tazobactam, a broad-spectrum beta-lactam/beta-lactam inhibitor combination (BL/BLI), decreased 74% from 6.9 to 1.8 DDD/1,000 PD  (P<0.01) while use of ampicillin-sulbactam, a less broad-spectrum BL/BLI, increased 104% from 4.6 to 9.3 DDD/1,000 PD (P<0.01).  Amoxicillin-clavulanate and 3rd/4th generation cephalosporin administration remained unchanged.  Intravenous antibiotics increased 42% from 40.6 to 57.8 DDD/1,000 PD (P<0.01) while those agents typically given orally decreased by 27% from 121.1 to 89.0 DDD/1,000 PD (P<0.01).  In total, antibiotic administration decreased by 9% (149.8 to 137.1 DDD/1,000 PD; P<0.01).

Conclusions:   Without specifically targeting fluoroquinolones, the on-site ID consultation service led to a significant reduction in administration of this class of antibiotics at the LTCF.  Furthermore, overall DDD of antibiotics were reduced, particularly for oral agents.  In addition to bringing subspecialist care to the LTCF, these findings suggest that the ID consultation service provides a measure of antibiotic stewardship, with reductions in both broad- and narrow-spectrum agents.  The decrease in fluoroquinolone prescriptions may help lead to less resistance to this class of agents.