Pharmacist-led Antibiotic Stewardship Program at a Nursing Home
1st Place Winner - 2017 CALTCM Poster Session 
by Mariam Khachatryan, Pharm.D.
PGY-1 Pharmacy Resident

Urinary Tract Infections (UTIs) are among the most commonly treated infections in long-term care, accounting for 30-40% of all infections treated. It is important to note also, that about 50% of women and up to 40% of men have asymptomatic bacteriuria. Although challenging, it is crucial to differentiate between symptomatic UTIs and asymptomatic bacteriuria because while symptomatic UTI requires treatment with antibiotics, asymptomatic bacteriuria does not. The overuse of antibiotics in nursing homes not only increases side effects and costs, but also increases resistance to the antibiotics. As of January 2017, SB 361 has required that all nursing facilities implement an antibiotic stewardship program (ASP). Los Angeles Jewish Home for the Aging (LAJHA), the facility at which this research was conducted, has implemented ASP as of September 2016 and with the current program in place, pharmacists are able to review and make recommendations regarding the choice of antibiotic, the dose or possible discontinuation based on IDA criteria, the facility antibiogram, patient allergies, as well as culture and sensitivity results.

Although current research has shown the benefits of an ASP in different settings, LAJHA is unique with an on-site pharmacy and a pharmacist who is able to make recommendations daily. This study is a retrospective cohort divided into two phases: A baseline Pre-ASP phase from September 2015 to February 2016 and the Post-ASP phase from September 2016 to February 2017 when ASP was implemented. Of all orders with an indication of UTI, 44% and 68% of orders in the pre-ASP and post-ASP group respectively did not meet McGeer Criteria and should not have been treated with antibiotics. The study focused on this group of patients with asymptomatic bacteriuria and found that the ASP was effective in reducing the number of days of antibiotic use from 8 to 6 days on average. Results also suggested that physicians were more likely to change the antibiotic to a more appropriate choice but were not as likely to discontinue. Contrary to what we would expect, we also saw a decline (although not a statistically significant decline) in the appropriate choice of antibiotics in the post-ASP group.

We then carried out further analysis and found that there was actually an increase in the number of people that were admitted to LAJHA on an antibiotic that was started outside of the facility. This could partially explain that decline in appropriate choice of antibiotic. Exploratory outcomes analyzed the pharmacist interventions and results concluded that 50% of all recommendations were accepted, and of those, only 18% were for discontinuation. Most accepted recommendations were for a change in the antibiotic or a change in the dose. Of the recommendations that were not accepted on the other hand, 62% were for discontinuation of the antibiotic.

The results of this study reveal the impact of the pharmacist on empiric antibiotic prescribing at a skilled nursing facility and the successful reduction of inappropriate use of antibiotics in elderly. It is evident that physicians and pharmacists need to work together towards decreasing resistance to antibiotics by reducing inappropriate use. Also, with regular periodic in-services to nurses and prescribing staff, even more improvement can be expected with the ASP in place.