Time Out! A Close Look at Antibiotic Use in Post-acute and Long-term Care

Neil Gaffin, MD

Disclosures

October 02, 2018

We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard…
—John F. Kennedy; Rice University; September 12, 1962

Antibiotic Therapy in Long-term Care

As an infectious disease specialist, I was recently involved in the care of an elderly, frail gentleman who developed fulminant Clostridium difficile colitis after a prolonged hospitalization stemming from cardiac disease. Despite aggressive treatment, he died from the infection. Sadly, he was the father of one of my colleagues.

This unfortunate event is the reason why I devote time every day to antibiotic stewardship. It's yet another reminder why it's critical to prescribe these drugs only when absolutely necessary, and if so, to prescribe for the shortest effective duration.[1]

Among healthcare-associated infections, C difficile stands out because of its association with broad-spectrum antibiotic use.[2] It is potentially lethal among the frail elderly, and highly transmissible owing to the tenacity of its spores.[3] Antibiotic stewardship programs can significantly reduce the incidence of infection and colonization not only for C difficile but also other multidrug-resistant bacteria.[4]

Involvement in "front-line" stewardship for the past 5 years in both acute and long-term care facilities has afforded me the opportunity to review and scrutinize thousands of patient charts. Questioning whether a bacterial infection is present and then recommending either to discontinue therapy or to define the narrowest-spectrum therapy for the shortest duration possible is by no means an easy task.

The vast majority of antibiotic use in nursing facilities is unnecessary.[5] Common reasons for antibiotic initiation are respiratory and urinary tract infections. Typically, a 5- to 7-day course of an antibiotic (eg, a fluoroquinolone) is prescribed over the phone in reaction to a nursing call regarding a chest radiograph or urine culture report. The diagnosis and need for continuation are usually never reconsidered thereafter, and the resident completes the course.

Cough associated with an abnormal chest radiography report or worsening confusion due to dehydration that gets attributed to a urinary tract infection (asymptomatic bacteriuria) are common scenarios.[6] Unfortunately, this situation has contributed to a reduction in antibiotic effectiveness and has facilitated the establishment of a chronically ill population that harbors multidrug-resistant organisms and C difficile.[7]Frequent transfers between acute care and even other nursing facilities enhances interinstitutional spread of these pathogens.[8]

As of November 28, 2017, the Centers for Medicare & Medicaid Services require all nursing facilities to have antibiotic stewardship programs in place.[9,10]It is unclear, however, whether this alone will be enough to achieve the desired goal of reducing unnecessary prescriptions.

Below are actual cases seen recently during antibiotic stewardship rounds at skilled nursing facilities that are typical of those that one might encounter.

A Woman With Hypoxemia

A 97-year-old nursing home resident with multiple medical problems, including congestive heart failure, chronic atrial fibrillation, and asthma developed a transient episode of sneezing and coughing. Room air oxygenation was noted to be 88%, and nasal oxygen was administered. She was otherwise comfortable and remained so thereafter. The covering MD was immediately notified of the change in her condition. A stat portable chest x-ray was read as a "mid right lung infiltrate" (Figure 1). No previous film was available for comparison. Her white blood cell (WBC) count was 6700 cells/µL. A 5-day course of levofloxacin was prescribed.

Figure 1. Chest x-ray revealing "mid right lung infiltrate." Courtesy of Neil Gaffin, MD.

During stewardship rounds the next day, the nurse states that the patient is asymptomatic but still on low-flow oxygen via nasal cannula. You also review the chest x-ray. You reach out to her attending physician to discuss the case. What should you recommend?

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