Drug-resistant organisms are common in both long-term care facilities (LTCFs) and acute care hospitals.  It is not uncommon, though, for stakeholders in each setting to blame the other as the principal site for generation and amplification of drug-resistant organisms.  For example, a Los Angeles Times article about a particularly drug-resistant Gram-negative bacteria (Carbapenem-resistant Klebsiella pneumoniae) that was published on March 25, 2011 quotes an infectious diseases expert at Harbor-UCLA Medical Center, Dr. Brad Spellberg, as saying that these organisms were "…brought into the hospital from the nursing home."  Dr. Spellberg added, "There's no evidence that this organism is being spread person-to-person in hospitals." 

Where drug resistance begins and is amplified is unclear because less than optimal infection control measures promote transmission and the widespread inappropriate use of antimicrobials selects for resistant organisms. Control will only be successful if the conditions that favor resistance are addressed in both acute care and long-term care settings. Factors that are modifiable in LTCFs are the improvement of infection control and optimization of antimicrobial use. 

A study published in 1991 demonstrated that 25-75% of systemic antimicrobial use and 60% of topical antimicrobial use in long-term care may be unnecessary or inappropriate (J Am Geriatr Soc 1991;39:963-972).  Use of unnecessary antimicrobials is associated with the development of antimicrobial resistance, drug-related adverse effects and increased healthcare costs.  Given that 3.2 million persons currently reside in US nursing homes and the US population older than 85 is expected to double by 2030, optimizing antimicrobial use in long-term care is imperative in an already overburdened healthcare system. 

Studies have shown that antimicrobial pressure in LTCFs plays a significant role in the development of drug-resistant organisms (J Am Geriatr Soc 2004; Am J Epi 2003).  Antimicrobials are prescribed frequently in LTCFs:  at any one time 8% of residents may be receiving antimicrobials and there is a 50-70% likelihood residents will receive at least one course of systemic antimicrobial therapy during the course of a year (J Am Geriatr Soc 1986;34:703-710).  The bottom line: the choice of giving a single resident an antimicrobial may determine if he/she develops a drug-resistant colonization or infection in the future.   Drug-resistant infections can be particularly detrimental to this already vulnerable patient population.  However, determining whether a resident needs an antimicrobial is also difficult.  Clinical diagnosis of infection in this population is imprecise, there is often limited laboratory and radiological testing and recommendations regarding use of antimicrobials in LTCFs are limited (Infect Dis Clin North Am 1997;11:647-662).

Nonetheless, all healthcare providers should be encouraged to think twice before starting residents on antimicrobial therapy.  A proposed national measure in the acute care setting is the "Antibiotic Time-Out".  This measure would require antimicrobial orders to have a dose, duration (stop date) and indication; clinicians would be required to obtain cultures; and once culture data is reported, prescribing clinicians would need to take a time-out and reassess therapy.  This may be particularly helpful in LTCFs where often the clinician is not on-site to clarify the indication or duration of antimicrobial.  This proposed measure would effectively help inform the entire clinical staff taking care of residents of the treatment plan; additionally, since the prescribing clinicians are often not on-site when cultures are reported, the clinical staff could assist the prescribing clinician in reassessing therapy.  

The Interpretative Guidelines for Long-Term Care Facilities issued by the Center for Medicare and Medicaid Services in September 2009 states that "It is the physician's responsibility to prescribe appropriate antibiotics and to establish the indication for use of specific medications.  As part of the medication regimen review, the consultant pharmacist can assist with oversight by identifying antibiotics prescribed for resistant organisms or for situations with questionable indications and reporting such findings…".  This is strong regulatory language permitting LTCFs to focus their consultant pharmacists on facility-specific antimicrobial use.      

Inappropriate antimicrobial use is common in the acute care setting as well.  In acute care, we have developed programs called "Antimicrobial Stewardship Programs" (ASPs) which utilize strategies to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration.  To our knowledge, there is limited published literature regarding the utility of an ASP in LTCFs.  A recent abstract described assessing and implementing ASPs in three LTCFs with acute-care hospital partners (Calfee, 2011, Society of Hospital Epidemiology of America Annual Meeting).  The findings from this study demonstrate that it is possible to improve antimicrobial prescribing practices in LTCFs which may lead to a reduced risk of drug-resistant organisms in LTCF residents.

It is imperative to improve use of antimicrobials both in acute care settings and LTCFs across California.  Although antimicrobial stewardship has not been well-defined in LTCFs, we should try to implement strategies to reduce the inappropriate use of antimicrobials in long-term care to improve resident outcomes.  A successful ASP in a LTCF could incorporate surveillance already conducted by infection control, improve communications on the indications and duration of antimicrobial therapy, allow an "antibiotic time-out" by the clinical team and provide oversight by the consultant pharmacist.  These strategies will help improve antimicrobial use in LTCFs and therefore the rates of drug-resistant organisms.  If we can optimize the use of antimicrobials and concomitantly improve infection control in LTCFs, then no one will be able to claim that drug-resistant infections originate from long-term care.  Furthermore, we will have markedly improved patient outcomes and therefore patient safety for LTCF residents and consequently for all patients in the healthcare continuum.   

If you have ideas on practical implementation of optimizing antimicrobial use in the long-term care setting, please contact Dr. Kavita K. Trivedi in the Healthcare-Associated Infections Program at the California Department of Public Health.  For additional information on the California Antimicrobial Stewardship Program Initiative, please visit:  http://www.cdph.ca.gov/programs/hai/Pages/AntimicrobialStewardshipProgramInitiative.aspx