Antibiotic Stewardship Works, CMS Pushes to Implement

Marcia Frellick

October 11, 2015

SAN DIEGO, California — As more evidence rolled in on the benefit of antibiotic stewardship programs — this time in pediatrics — experts here at IDWeek 2015 discussed a proposal by the Centers for Medicare and Medicaid Services (CMS) that would require long-term-care homes to adopt such programs.

"The landscape of care has changed. Service delivery has changed. The population of people who reside in nursing homes has changed. So we thought it necessary and timely to revise the rules of engagement," said Shari Ling, MD, deputy chief medical officer of the CMS.

Dr Ling explained the proposed changes in the regulations for nursing homes and reminded meeting attendees that the deadline for submitting comments on the proposed rule is October 14. (Comments can be added at www.regulations.gov by following the "submit a comment" instruction.)

"This will be applicable to 15,000 nursing homes or long-term-care facilities and the 1.5 million residents who call these facilities their home," said Dr Ling.

The proposed changes, which would update infection prevention and control programs from 1991, include requiring each long-term-care home to have an antibiotic stewardship program that has antibiotic use protocols, policies to monitor antibiotic use, and a system for recording incidents when the rules or protocols are violated.

The proposal also calls for an infection prevention and control officer or person, "and that person has to be involved in the quality improvement efforts of that facility," Dr Ling said.

A Lack of Resources

Dale W. Bratzler, DO, MPH, chief quality officer and professor of medicine at Oklahoma University, in Oklahoma City, is concerned that the proposal of having infectious disease specialists at each site will demand resources that just aren't there.

"The rules suggest that nursing homes have to have the availability of infection-preventionist-trained individuals, essentially ID doctors, and in our state, we don't have enough certified infection preventionists to cover all the hospitals in the state, never mind that there are three times as many nursing homes as there are hospitals," he told Medscape Medical News.

"I think it's a huge problem for rural states, but I suspect it's true in every state. You'd have to have broad consulting agreements that there will be enough individuals to do this," he said.

He suggests that the CMS narrow the directives to a few big things that they want every nursing home to do, rather than instituting broad stewardship policies.

Stewardship in a Pediatric Population

Researchers reported more than a threefold drop in rates of Clostridium difficile infection at University of California, Davis, Children's Hospital after it started an antibiotic stewardship program.

Benefits of antibiotic stewardship programs have been well documented in adult populations, but there are not as many data on programs in pediatric populations, according to Natasha Nakra, MD, and Jean Wiedeman, MD, PhD, from the Department of Pediatrics at UC Davis.

The program, implemented in 2011, has two main components: the prospective auditing of charts to determine whether antimicrobial prescribing was appropriate; and a requirement that prescribers get authorization from an infectious disease specialist before ordering broad-spectrum or expensive antibiotics.

The number of cases per 10,000 patient-days went from 9.2 in the period from 2008 to 2010 to 2.8 by the end of 2014, Dr Nakra and Dr Wiedeman reported. Costs from using fewer antibiotics also dropped, saving $56,000 a year.

Dr Nakra, Dr Wiedeman, and Dr Ling have disclosed no relevant financial relationships.

IDWeek 2015. Abstract 1468. Presented at a press conference on October 9, 2015.

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