antibiotic stewardship in nursing homes -...

ANTIBIOTIC STEWARDSHIPIN NURSING HOMES

Philip Sloane, MD, MPHCecil G. Sheps Center for Health Services Research and

University of North Carolina at Chapel Hill

Outline of Presentation1. What is Antibiotic Stewardship and Why Is It

Important for Nursing Homes?2. CMS Mandate for Nursing Homes to Implement

Antibiotic Stewardship3. Key Quality Improvement Targets in Nursing Home

Infection Management4. Developing an Antibiotic Stewardship Program in

Your Nursing Home

What is Antibiotic Stewardship? and

Why Is It Important for Nursing Homes?

Antibiotic Stewardship Is

A set of commitments and activities designed to: - optimize the treatment of infections

and - reduce the adverse events associated with antibiotic overuse

In Operational Terms, Antibiotic Stewardship Is.

A system of informatics, data collection, personnel, policies and procedures designed to assure that patients get: the right drug at the right time for the right duration

Why Antibiotic Stewardship Is Important for Society Overall

and Specifically for Nursing Homes

Worldwide Crisis of Antibiotic Resistance Multi-drug resistance increasingly common Over 20,000 deaths annually in U.S.A. from multi-

drug resistant infections Projected 317,000 deaths per year by 2050

http://www.bbc.com/future/story/20170328-12-questions-we-need-to-prioritise-in-2017

http://www.bbc.com/future/story/20170328-12-questions-we-need-to-prioritise-in-2017

Whats Causing the Crisis?2. Resistant Strains

Spread Rapidly16

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1983-87 1988-92 1993-97 1998-2002 2003-07 2008-12

1. Fewer New Antibiotics Being Developed

3. Antibiotics Are Overused

Chart1

300

900

3321

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542321

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MRSA

VRE

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MRSAVREFQRP

1980300

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16

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Total # New Antibacterial Agents

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Total # New Antibacterial Agents

1983-8716

1988-9214

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1998-20027

2003-075

2008-121

May 26, 2016 at 5:03 PM

The superbug that doctors have been dreading just reached the U.S.

By Lena H. Sun and Brady Dennis CRE, a family of bacteria pictured, is considered one of the deadliest superbugs because it causes infections that are often resistant to most antibiotics. (Centers for Disease Control and Prevention/Reuters)

For the first time, researchers have found a person in the United States carrying bacteria resistant to antibiotics of last resort, an alarming development that the top U.S. public health official says could mean "the end of the road" for antibiotics.

The antibiotic-resistant strain was found last month in the urine of a 49-year-old Pennsylvania woman. Defense Department researchers determined that she carried a strain of E. coli resistant to the antibiotic colistin, according to a study published Thursday in Antimicrobial Agents and Chemotherapy, a publication of the American Society for Microbiology. The authors wrote that the discovery "heralds the emergence of a truly pan-drug resistant bacteria." Colistin is the antibiotic of last resort for particularly dangerous types of superbugs, including a family of bacteria known as CRE, which health officials have dubbed "nightmare bacteria." In some instances, these superbugs kill up to 50 percent of patients who become infected. The Centers for Disease Control and Prevention has called CRE among the country's most urgent public health threats.

Why the Focus on Nursing HomesAntibiotic usage tends to be quite highNHs with the highest prescribing rates tend

to also have the highest clostridium difficile infection ratesResidents LIVE there (as opposed to

hospital)

Antibiotic Prescribing Rates across 31 North Carolina Nursing Homes

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median

The Average: Nursing Home Resident 4.6 antibiotic prescriptions per year 1 prescription every 80 days On antibiotics 10% of the time

Resistant Bacteria Now Commonly Colonize Nursing Home Residents

VRE

CR-GNR

MRSA

20 40 60 80

% of Nursing Home Residents with Positive Culture

Bact

eria

l col

onie

s pre

sent

J Clin Micro 50(5); 1698-1703, 2012.

63%

72%

18%

- results of skin, airway, skin and wound cultures in 82 residents -

Reasons Antibiotics Are Prescribed

PresumedUrinary

Infection

Respiratory Infection

PresumedSkin and Soft

Tissue Infection

Other Infection

The most common other infection is C. difficile

CMS Mandate for Nursing Homes

to Implement Antibiotic Stewardship

42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489Reform of Requirements for Long-Term Care Facilities

Implementation Timetable: Antibiotic Stewardship 11/28/2017 Infection Preventionist (IP) 11/28/2019IP on Quality Assessment and Assurance Committee 11/28/2019

We are requiring facilities to develop an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program and designate at least one infection Preventionist (IP). That program should include antibiotic use protocols and a system to monitor antibiotic use.

Prescribing antibiotics just in case was accepted in the past, but now antibiotics should be given after

careful, evidence-based consideration of risks and necessity.

Yes, This is a policy change

This session will provide guidance on key elements of antibiotic stewardship for your nursing home

F Tags that Surveyors Can Cite to Enforce Antibiotic Stewardship

Federal Tag 441: Infection Control Federal Tag 329: Unnecessary DrugsFederal Tag 332/333: Medication ErrorsFederal Tag 428: Drug Regimen Review

Can Antibiotic Usebe Safely Reduced?

Education and QI Works: Results from Randomized Trial

- Antibiotic Prescriptions Per 100 Resident-Days

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Intervention Group All IndicationsComparison Group All Indications

Follow-Up ==>

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Average = 2.19 prescriptions per year

Average for 31 North Carolina Nursing Homes

Antibiotic Prescribing Rates in 28 Minnesota Nursing Homes

Key Areas for Improvement in Nursing Home

Antibiotic Use

Decision-Making Can Be Complicated

I learned in nursing school back in 1968

Supervisor

Nurse Provider

FamilyEvery time mother [Does X]

she needs antibiotics

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&ved=0ahUKEwjjmKvhvYzLAhVKSSYKHTMKDdcQjRwIBw&url=https://openclipart.org/detail/399/phone-icon&psig=AFQjCNHlYMNUKcOICIsm2cWSmvH1osAbeQ&ust=1456268679003980http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwih45Kcv4zLAhXM7yYKHQTDCXYQjRwIBw&url=http://www.dreamstime.com/photos-images/man-watching-football-tv.html&psig=AFQjCNHT3UzdEQVkB-cTMH8nyqsZ8xjyog&ust=1456268982207914http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi0zbmXwozLAhUM7SYKHd4JA0wQjRwIBw&url=http://allnurses.com/nursing-study-tips/3-tips-for-1009589.html&bvm=bv.114733917,d.eWE&psig=AFQjCNF-dST1DJB0_JIl3FRfMqT69HvfDg&ust=1456269744774770

Case #1

Mrs. Jenkins, a 79 year old with stroke, incontinence

Wet incontinence pad has odor No complaints Normal vital signs

What would you do and why?

Is This Evidence-Based Practice?

What Causes Changes in Urine Color or Odor?

DietMedicationsDehydrationBacteria in urine

If person is not sick, its asymptomatic bacteriuria

Is Cloudy or Smelly Urine a Reason To Give Antibiotics?

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Yes No Geriatr Nurs. 2005 Jul-Aug;26(4):245-51.

Nurses

Geriatricians

Perc

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What should you do for Mrs. Jenkins?

Should you get a urine culture just in case?

Ordering a Urine Culture: A Gateway to Overprescribing?

- results of 254 randomly sampled cultures from 31 nursing homes -

Antibiotic Prescribing Decision when the Culture was Ordered

Prescribing Decision when the Result was Reported

Antibiotic - 75 cases (30)% -

No antibiotic- 179 cases (70%) -

CultureResult

Neg = 21

Pos = 54

Neg = 68

Pos = 111

17 (25%) were prescribed antibiotic 99 (89%) were prescribed antibiotic

2 (10%) stopped and 19 (90%) continued or changed antibiotic

0 (0%) stopped and 54 (100%) continued or changed antibiotic

Bottom Line: 189 (74%) received a course of antibiotics, although 86% had a temperature less than 99oF, 74% lacked documentation of any urinary tract-specific signs or symptoms, and only 18% met the modified McGeer criteria for urinary tract infection. Why?

Received Full Antibiotic

Course

17

99

19

54

What Happened? Positive cultures were overtreated Negative cultures were ignored Most common reason cultures were ordered was mental

status change, which is rarely due to urine infectionInterestingly..The two sepsis cases that arose during 7 days post-culture in these 254 patients were from non-urinary sources and had negative urine cultures

Mrs. White 84 year old with arthritis

and moderate dementia Uncooperative with dressing Irritable Eats half of breakfast Says shes tired

Case #2: Two Different People

Ms. Blue 34 year old nurse Divorced, alone this weekend You were going to have lunch

with her, but she cancels Low energy; not hungry Doesnt want to get dressed Doesnt want to deal with

people

Case #2: Two Different People

Ms. White 84 year old with arthritis

and moderate dementia Uncooperative with dressing Irritable Eats half of breakfast Says shes tired

Ms. Blue 34 year old Divorced, alone this weekend Low energy ; not hungry Doesnt want to deal with

people Doesnt want to get dressed

Both Have Similar Nonspecific Symptoms *

* Nonspecific Symptoms dont relate to any particular body part or body system

What You Might Say to Your Friend Ms. Blue

Coming down with a virus? Too much to drink last night? Didnt sleep well? Pain? Stress? Depression?

What the Nursing Supervisor SaysAbout Ms. White

36

Probably the urine. Needs an antibiotic.

Turning to antibiotics as a knee jerk reaction.

Jumping to conclusions In nursing homes --- One

of the biggest causes of unnecessary antibiotic use

In medical decision-making the most common reason for medical errors

What else could be causing Ms. Whites fatigue, irritability, and poor appetite?

The Big Seven: Common Reasons for Nonspecific Symptoms

Dehydration Medication side effect Coming down with a virus Didnt sleep well Pain Constipation Stress / anxiety / depression

Active Interventions for Non-Specific Symptoms

Assess hydration status (and encourage fluids) Review current medications Look for signs of a respiratory or GI virus Think about sleep problems Ask about pain / discomfort Ask about constipation Look for sources of stress, anxiety or depressionMonitor symptoms and vital signs (especially

temperature)Use nursing interventions where appropriate

Should we get a urine culture just in case

Case 3: Mr. Leonard

76 year old non-smoker 5 days of illness Began with nasal

congestion, sore throat Soon cough became main

symptom, worse at night Small amount of sputum Decreased appetite, more

tired but up and about

More about Mr. Leonard

41

Temperature: 99.4FBlood Pressure: 130/75Respiratory rate: 18Pulse: 75Pulse ox: 97%Mental status: BaselineLung exam: Scattered wheezes

1. What is the most likely diagnosis?2. What treatment(s) are indicated?

What is Mr. Leonards Diagnosis?

Upper Respiratory Infection

Nasal congestion

Sore throat

Sneezing

Acute Bronchitis

Cough

Low grade fever

Normal other vital signs/non-focal lung exam (often with expiratory wheezes)

What can be done for acute bronchitis?

Reassure patient and/or familyMonitor vital signs and worsening signs or

symptomsEncourage fluids and restAcetaminophen or NSAIDS for fever/painNasal saline spray/humidified air for congestionCough medicine or inhaled bronchodilator

TO DO:

Most cases of bronchitis are VIRAL and wont improve with antibiotic treatment.

What About Antibiotics?

J Am Geriatr Soc. 2011 Jun;59(6):1093-8

65% of acute bronchitis cases in nursing homes did not follow evidence-based

antibiotic treatment guidelines

2d most common reason for inappropriate antibiotic use in NHs

http://www.ncbi.nlm.nih.gov/pubmed/21539527

Common Reasons for Antibiotic Treatment of ViralRespiratory Infections

1. Belief that antibiotics can help2. Just in case pneumonia develops3. Meeting patient/family

expectations

Do Antibiotics Improve Cold and Bronchitis Symptoms?

Antibiotics: DO NOT shorten recovery time or

improve symptoms DO increase adverse effects

Cochrane Database Syst Rev. 2014 Mar 1, 245.Lancet Infect Dis. 2013 Feb;13(2):123-9

Am Jour of Respir and Crit Care Med. 186, 8 (2012); 716-723

Antibiotics for respiratory symptoms in moderate to severe COPD may be the

exception, depending on the clinical situation.

http://www.ncbi.nlm.nih.gov/pubmed/24585130http://www.ncbi.nlm.nih.gov/pubmed/23265995

Do Antibiotics for Viral Infections Prevent Pneumonia?

Antibiotics do reduce pneumonia risk slightly 40 courses are needed to prevent 1 case of pneumonia.

If pneumonia develops, antibiotic resistance more likely

BMJ. 2007 Nov 10;335(7627):982

Nursing home residents with viral respiratory illness must be carefully monitored for signs or symptoms of

pneumonia.

But the Family Expects an Antibiotic

Studies show:Patient/family expectations for antibiotics are

overestimatedSatisfaction is not severely impacted when

antibiotics not given Communication and education are key

BMJ. 1998 Sep 5;317(7159):637-42.Cochrane Database Syst Rev. 2013 Apr 30:4.J Gen Intern Med. 2014 Nov 6

Nursing staff have the opportunity to educate and reassure

http://www.ncbi.nlm.nih.gov/pubmed/?term=Butler+CC,+Rollnick+S,+Pill+R,+Maggs-Rapport+F,+and+Stott+N:+Understanding+the+culture+of+prescribing:+qualitative+study+of+general+practitioners'+and+patients'+perceptions+of+antibiotics+for+sore+throats.+BMJ+1998;+317:+pp.+637-642http://www.ncbi.nlm.nih.gov/pubmed/23633320http://www.ncbi.nlm.nih.gov/pubmed/25373834

How To Talk To Patients And Families About Viral Respiratory Illness

Inform that resident is ill and staff is helping them by providing symptom relief and monitoring

Advise on illness course Colds: up to 1.5 weeks Bronchitis: up to 3 weeks

Respond to concerns

Reassure that antibiotics not needed explain risks explain that you will monitor

BMJ. 2008;337:a437

What Could You Tell Mr. Leonards Concerned Family?

Advise on illness course:

Respond to concerns about symptoms:

His cough might last several more days to several weeks, and it may take him a while to feel better.

Were going to help him feel more comfortable so his body can fight this virus. Hell need plenty of fluids and rest. Also, well give medicine for his

fever and cough, and keep an eye on him.

If the Family Asks Specifically About Antibiotics

Mr. Leonards chest cold is caused by a virus, and antibiotics wont help viruses. Giving him antibiotics when they arent needed can cause side effects and

make it so that antibiotics wont work when he really needs them. We will monitor him closely for any

change in condition that might indicate a need for antibiotics.

A 82 year old man Had an insect bite on his

left leg Has been treating with

Triple Antibiotic cream MD saw the leg (see

photo), prescribed Bactrim. After several days the patch was no better, prescribed Augmentin

Main symptom is itching

Case 4: Red Patch on the Leg

Bilateral lower extremity edema and redness

Resident reports burning sensation

Afebrile Nursing home nurse

phones on-call MD with request for antibiotic

Case #5: Weekend Phone Message

Source: Pawar et al, ICDHE 2012; 33:1107-12

Over Half of C Diff Infections in NHs Occur within a Month Post-Hospital Discharge

Emergency Departments and Hospitals: Big Risk, Hard to Control

Reducing Antibiotic Overuse Works:Impact of fluoroquinolone restriction on

rates of C. difficile infection in a Community Hospital

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Infect Control Hosp Epidemiol. 2009 Mar;30(3):264-72.

Chart3

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1.49777

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rate

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121.56693

131.66991

141.77967

151.89663

162.02129

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181.49777

191.44764

201.39918

211.35234

221.30707

231.26332

241.22103

251.18015

261.14065

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Timerate

Jan0.77796

Feb0.82909

Mar0.88358

Apr0.94165

May1.00354

Jun1.0695

Jul1.13979

Aug1.2147

Sep1.29454

Oct1.37962

Nov1.47029

Dec1.56693

Jan1.66991

Feb1.77967

Mar1.89663

Apr2.02129

May2.15413

Jun1.49777

Jul1.44764

Aug1.39918

Sep1.35234

Oct1.30707

Nov1.26332

Dec1.22103

Jan1.18015

Feb1.14065

Mar1.10246

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Options Available to Reduce C Diff Post Hospitalization

1. Try to Reduce Antibiotic Burden Re-evaluate need for antibiotics in the first place Re-evaluate duration of antibiotic treatment Re-evaluate choice of antibiotic

2. Probiotics Cochrane review (2013): moderate quality

evidence suggests that probiotics are both safe and effective for preventing Clostridium difficile-associated diarrhea

Source: Goldenberg, et al. Cochrane Database Syst Rev. 2013 May 31;5:CD006095.

Antibiotic PrescribedEmpirically

(% of the time)

Percent Resistant (% of isolates)Escherichia

Coli(44%)

Proteus(13%)

Klebsiellapneumoniae

(13%)

Ciprofloxacin (26%) 57% 69% 11%TMP-SMX (16%) 42% 45% 14%Nitrofurantoin (12%) 4% 98% 23%Ceftriaxone (11%) 17% 7% 11%Levofloxacin (7%) 58% 63% 8%

Empirically Chosen Antibiotics for UTI are Often Ineffective (except at promoting resistance)

- Data from 75 prescriptions and 1,580 positive cultures in 31 NHs -

Recommended Duration of Antibiotic Therapy (non-hospitalized patients)

Type of infection Sanford Guide, 2015ID

SocietyDavidWeber

Actual NH Practice

Simple UTI (cystitis) 3 days

1 3 days1 3 days

COPD exacerbation 3-10 days

2 -- 3-5 days

Pneumonia without sepsis

Until afebrile for 3d >5 days

4 >5 days

Cellulitis (lower extremity) 10 days

3 5 days 5-7 days

1 TMP-SMX 3 days; Nitrofurantoin 5-days; 2 Varies with drug, No therapy required in most cases; 3 Not diabetic; 4 Minimum 5 days (should be afebrile 48-72 hours); non-ambulatory treat as HCAP; assess using score for severity

Recommended Duration of Antibiotic Therapy (non-hospitalized patients)

Type of infection Sanford Guide, 2015ID

SocietyDavidWeber

Actual NH Practice

Simple UTI (cystitis) 3 days

1 3 days1 3 days 7.5 days

COPD exacerbation 3-10 days

2 -- 3-5 days7.8 daysPneumonia

without sepsisUntil afebrile

for 3d >5 days 4 >5 days

Cellulitis (lower extremity) 10 days

3 5 days 5-7 days 9.6 days

1 TMP-SMX 3 days; Nitrofurantoin 5-days; 2 Varies with drug, No therapy required in most cases; 3 Not diabetic; 4 Minimum 5 days (should be afebrile 48-72 hours); non-ambulatory treat as HCAP; assess using score for severity

Summary: Situations Leading to Antibiotic Overuse1. Urine appearance and odor2. Urine test results 3. Nonspecific symptoms4. Cough5. Wounds6. Red and swollen legs7. Emergency departments and hospitals8. Empirical antibiotic choice9. Antibiotic treatment too long

Antibiotic Stewardship

Works.sometimes

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Antibiotic Use Jan-Apr 2015, by NHUSING DATA TO MOTIVATE OR REINFORCE CHANGE

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Change in Antibiotic Use 15-16, by NH

How to Develop an Antibiotic

Stewardship Program in Your Nursing Home

#1: Commit Leadership / Create Team

Agree to incorporate antibiotic stewardship into facility Quality Assurance and Performance Improvement goals, monitoring, and reporting

Identify an infection preventionist (a.k.a. infection control nurse or infection specialist) and provide time

Set up an antibiotic stewardship leadership team Communicate expectations to medical and nursing staff

Create an Antibiotic Stewardship Teamand Make them Accountable

Medical Director

Infection Preventionist

Consultant Pharmacist

Director of Nursing

Laboratory ID Consultant

#2: Gather and Report Data

Antibiotic prescriptions / 1,000 resident-days Percent of time on antibiotics C difficile infection rate Urine cultures: multidrug resistance rate Rate of hospitalization for sepsis

Rate of fever among persons who had antibiotics initiated in the nursing home, by infection site

Proportion of prescriptions that are high C diff risk antibiotics, by infection site

Urine cultures per 1,000 resident-days

Core Outcomes

Selected Process

Measures

Infection Tracking Excel Spreadsheets UNC Antibiotic

Stewardship Start-Up Package

Antibiotic Prescribing Portion of Infection Tracking Spreadsheets UNC Antibiotic

Stewardship Start-Up Package

Infection Tracking Excel Spreadsheets UNC Antibiotic Stewardship Start-

Up Package

#3: Educate Everyone Involved in Decision-Making

Nurses Providers

Supervisors Residents and Family

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwih45Kcv4zLAhXM7yYKHQTDCXYQjRwIBw&url=http://www.dreamstime.com/photos-images/man-watching-football-tv.html&psig=AFQjCNHT3UzdEQVkB-cTMH8nyqsZ8xjyog&ust=1456268982207914http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi0zbmXwozLAhUM7SYKHd4JA0wQjRwIBw&url=http://allnurses.com/nursing-study-tips/3-tips-for-1009589.html&bvm=bv.114733917,d.eWE&psig=AFQjCNF-dST1DJB0_JIl3FRfMqT69HvfDg&ust=1456269744774770

#4: Set Goals and Establish Policies Timetable for implementing programData reporting

Education

Quality improvement reports

? Involvement in collaborative

Initial targets

Establishing Policies and Procedures

Some say to do this first However, reviewing data and setting facility priorities may be

better to do first Best policies and procedures are endorsed by facility staff

and updated regularly AMDA will soon publish a report with sample policies and

procedures for antibiotic stewardship

Evidence-Based Strategies That Work Communication guidelines for nursing staff around suspected infections SBAR; protocols(e.g, asking for photos of skin problems)

Publicizing antibiotic use statistics (QAPI) Antibiotic initiation protocols Antibiotic duration guidelines Antibiotic time-out Protocol for ordering of urine cultures Protocol for management of urine culture results- CRITICAL ROLE OF LEADERSHIP CANNOT BE OVEREMPHASIZED -

Resources

Implementation Manual

A step-by-step guide explaining how to incorporate our materials into a program that will improve outcomes

UNC Antibiotic Stewardship Start-

Up Package

Training for Nursing Staff

One-hour in-service DVD

Pocket cards with key guidelines


Up Package

Posters to Provide Periodic Reminders to StaffUNC Antibiotic Stewardship Start-

Up Package

Training for Medical Staff

CD-ROM of case discussions by university experts

Pocket cards with key guidelines


Up Package

Educational Materials for Residents / Families

Brochure entitled Why Not Antibiotics

Website has 5-minute video


Up Package

Training DVD for Emergency Department Staff

Multidisciplinary case discussions from UNC faculty on emergency department management of nursing home residents


Up Package

https://nursinghomeinfections.unc.edu/

ANTIBIOTIC STEWARDSHIPIN NURSING HOMESOutline of PresentationWhat is Antibiotic Stewardship? and Why Is It Important for Nursing Homes? Antibiotic Stewardship IsIn Operational Terms, Antibiotic Stewardship Is.Why Antibiotic Stewardship Is Important for Society Overall and Specifically for Nursing HomesWorldwide Crisis of Antibiotic ResistanceSlide Number 8Whats Causing the Crisis?Slide Number 10Slide Number 11Slide Number 12Antibiotic Prescribing Rates across 31 North Carolina Nursing HomesResistant Bacteria Now Commonly Colonize Nursing Home ResidentsSlide Number 15CMS Mandate for Nursing Homes to Implement Antibiotic StewardshipSlide Number 17Yes, This is a policy changeSlide Number 19Can Antibiotic Usebe Safely Reduced?Education and QI Works: Results from Randomized Trial- Antibiotic Prescriptions Per 100 Resident-DaysSlide Number 22Key Areas for Improvement in Nursing Home Antibiotic UseDecision-Making Can Be ComplicatedCase #1Slide Number 26What Causes Changes in Urine Color or Odor?Is Cloudy or Smelly Urine a Reason To Give Antibiotics?What should you do for Mrs. Jenkins?Ordering a Urine Culture: A Gateway to Overprescribing?- results of 254 randomly sampled cultures from 31 nursing homes - What Happened?Mrs. WhiteMs. BlueMs. WhiteWhat You Might Say to Your Friend Ms. BlueWhat the Nursing Supervisor Says About Ms. WhiteJumping to conclusionsThe Big Seven: Common Reasons for Nonspecific SymptomsActive Interventions for Non-Specific SymptomsCase 3: Mr. LeonardMore about Mr. LeonardWhat is Mr. Leonards Diagnosis?What can be done for acute bronchitis?What About Antibiotics?Slide Number 45Do Antibiotics Improve Cold and Bronchitis Symptoms?Do Antibiotics for Viral Infections Prevent Pneumonia?But the Family Expects an AntibioticHow To Talk To Patients And Families About Viral Respiratory IllnessWhat Could You Tell Mr. Leonards Concerned Family?If the Family Asks Specifically About AntibioticsSlide Number 52Slide Number 53Slide Number 54Reducing Antibiotic Overuse Works:Impact of fluoroquinolone restriction on rates of C. difficile infection in a Community HospitalOptions Available to Reduce C Diff Post HospitalizationSlide Number 57Recommended Duration of Antibiotic Therapy (non-hospitalized patients)Recommended Duration of Antibiotic Therapy (non-hospitalized patients)Summary: Situations Leading to Antibiotic OveruseAntibiotic Stewardship Works.sometimesUsing Data to Motivate or Reinforce ChangeChange in Antibiotic Use 15-16, by NHHow to Develop an Antibiotic Stewardship Program in Your Nursing Home#1: Commit Leadership / Create TeamCreate an Antibiotic Stewardship Teamand Make them Accountable#2: Gather and Report DataSlide Number 68Slide Number 69Slide Number 70Slide Number 71Slide Number 72Slide Number 73Slide Number 74#3: Educate Everyone Involved in Decision-Making#4: Set Goals and Establish PoliciesEstablishing Policies and ProceduresEvidence-Based Strategies That WorkResourcesSlide Number 80Slide Number 81Slide Number 82Slide Number 83Slide Number 84Slide Number 85Slide Number 86

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