In the long-term care (LTC) setting, 70% of residents receive at least one course of antibiotics each year and up to 75% of this use is reported to be inappropriate or unnecessary. The harms of antibiotic misuse in frail older LTC residents are significant, including Clostridium difficile infection, adverse drug events and drug interactions, and colonization and/or infection with resistant bacteria. This crisis has prompted the President of the United States to formally recognize antibiotic misuse and resistance as a global public health crisis and a key national security threat. In response, the Centers for Disease Control (CDC) recently outlined Core Elements to improve antibiotic use in long-term care facilities (LTCFs) and mandate that at least one Core Element be implemented immediately. While these Core Elements are timely, they are based on data extrapolated from acute care hospitals, an environment that differs substantially from LTC. Effective and financially resourceful antibiotic stewardship interventions to improve patient safety in LTCFs remain unknown and absent, particularly within the VA. As such, there is a critical need for the development of tailored antibiotic stewardship interventions to improve the care of the 50,000+ Veterans who reside in VA LTCFs (known as community living centers or CLCs) annually. Treatment of suspected urinary tract infection (UTI) is the largest contributor to antibiotic use in LTCFs. Much of this use is unnecessary and/or inappropriate. My recent work showed that over 50% of initial antibiotic selection for suspected UTI was inappropriate at two VA CLCs. There is a vast amount of literature targeting providers and nurses evaluating interventions designed to improve the appropriate diagnosis of UTI. However, focused on diagnosis, these studies have failed to correct inappropriate treatment selection when antibiotics are truly indicated. This is extremely concerning as true UTIs are the most common cause of hospitalization in LTC residents and the number one cause of bacteremia. Clinical pharmacists are drug therapy experts and are ideally suited to correct inappropriate UTI antibiotic therapy. Therefore, I hypothesize that an educational program targeting CLC pharmacists will lead to improved antibiotic use for UTIs. My long-term goal is to improve the quality of care of residents nationally through reduction of inappropriate antibiotic use. Accordingly, the work proposed, creates, implements, and tests a feasible ?real world? model for antibiotic stewardship in VA CLCs. This model places the pharmacist in a prominent antibiotic stewardship role by taking advantage of a pharmacist?s expertise in guiding appropriate antibiotic use, while using the pharmacist as a consistent presence for many CLCs. This model was specifically designed with the ability to disseminate this work to VA CLCs nationally. To improve the utility of this model, interventions will be based off facility-specific antibiotic use rates and antibiograms. The objectives of this proposal are to pilot test the implementation and effectiveness of our antibiotic stewardship intervention through three specific aims:
Aim 1. To describe antibiotic use and inappropriate antibiotic use for suspected culture positive UTI among VA CLCs nationally and identify independent predictors of inappropriate antibiotic use.
Aim 2. To develop an educational intervention targeting CLC pharmacists to reduce inappropriate treatment of UTIs and pilot test the intervention in two CLCs.
Aim 3. To evaluate the effectiveness of the educational intervention on UTI related antibiotic use (primary outcome), and the frequency of inappropriate antibiotic use, and absence of de-escalation by day 4. The proposed research is significant, because it is expected to result in an intervention that can be disseminated broadly to effectively improve antibiotic use, and ultimately improve resident safety through reduction of antibiotic resistant infections in CLCs nationally.

Public Health Relevance

Studies suggest that up to 75% of the antibiotics used in long-term care facilities are incorrectly prescribed, a finding that likely contributes to the rapid growth in antibiotic resistant bacteria in this setting. Despite advances in VA acute care hospitals, antibiotic stewardship, defined as any activity that optimizes antibiotic use or stops unnecessary use, is largely absent in VA long-term care facilities (CLCs). This proposal seeks to develop and implement an educational intervention targeting CLC pharmacists to improve antibiotic use for urinary tract infections, thus having a positive impact on the public health through improving the care and safety of our Veterans residing in CLCs and our nation?s population at large.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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HSR&D Career Development Award (CDA0)
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Providence VA Medical Center
United States
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