Welcome and Overview
In order to fully understand the relationships between infections, antibiotics, antibiotic resistance, and antibiotic stewardship, a primer on antibiotics provides a helpful foundation. This session will discuss what antibiotics are and how they work, basic terminology, potential risks and side effects of antibiotic use, and general considerations that guide use and prescribing. The session concludes with an introduction to why it is important to use antibiotics judiciously.
This session is one of a series of six sessions for nursing homes to support implementation of principles and practices of antibiotic stewarship and prevention and management of C. difficile infections.
- Describe the process of how antibiotics work in the body.
- Discuss the risks and benefits of antibiotic use.
- Differentiate common terms related to antibiotics.
- Identify or list common considerations related to choosing an antibiotic.
- Discuss why it is important to use antibiotics judiciously.
How can you use this session?
This session focuses on the role of antibiotics in fighting bacterial infections in the nursing home setting. The material is intended to be useful for guiding individual practice and as an educational resource for staff involved in the care of nursing home residents. Nursing home leaders can review the content in this session and decide which components would be helpful to staff in their facility. The components can be shared and discussed during staff education sessions, or they can be accessed by staff online at any time.
Depending on which components you choose to review and/or share and discuss with staff, this session may take 30-90 minutes.
Here is an outline of what is in this session. You can click on the hyperlinks to go directly to a section or scroll down below the outline to see all section content.
Watch recorded webinar Exploring Antibiotics
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Antibiotics are drugs that either kill bacteria or stop bacteria from reproducing. They help get infection under control so the body’s immune system, natural defenses, can finish the job of healing.
Topics covered in this webinar:
- Bacteria characteristics
- Describing antibiotics
- How antibiotics work with the immune system
- How antibiotics work
- How antibiotics are used
- Tools to help choose antibiotics
- Classes of antibiotics
- Infection control practitioners
Antibiotics are great in many ways – they are one of the biggest breakthroughs in healthcare and have saved countless lives. Diseases that used to be considered fatal are now assumed treatable.
Penicillin, the first commercialized antibiotic, was discovered in 1928 by Alexander Fleming. While it wasn’t distributed among the general public until 1945, it was widely used in World War II for surgical and wound infections among the Allied Forces. It was hailed as a “miracle drug” and a future free of infectious diseases was considered. It is very interesting to note that when Fleming won the Nobel Prize for his discovery, he warned of bacteria becoming resistant to penicillin in his acceptance speech (CDC).
Although, antibiotics are powerful tools in preventing and curing illness, it is helpful to be aware of potential side effects:
- Allergic (hypersensitivity) reactions – these can range from skin rash to severe anaphylactic reactions that are life-threatening;
- Gastrointestinal effects such as abdominal pain, diarrhea, anorexia, nausea, and vomiting;
- Liver and kidney toxicity;
- Ototoxicity (hearing loss); and
- Neurologic effects – headache, dizziness, or more severe effects such as neuropathy.
Antibiotics may increase the overall cost of care by leading to emergency room visits for treatment of allergic reactions as well as the development of severe diarrheal disease (e.g., pseudomembranous colitis caused by C. difficile) that require treatment. These conditions cannot only be costly but result in increased morbidity and mortality.
Nursing home administrators can:
- Commit to improving appropriate antibiotic use and create a culture that supports antibiotic stewardship.
- Identify physician, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities in the facility.
- Include antibiotic stewardship responsibilities in job descriptions of medical director/nurse leads/pharmacists.
- Work collaboratively with medical director and attending physicians using these strategies:
- Ensure that policies are in place for clinicians to receive and review microbiology reports and antibiogram to detect trends in antibiotic resistance.
- Develop and implement policies that encourage best practices for antibiotic prescribing, including establishment of minimum criteria for prescribing antibiotics and review of antibiotic appropriateness and resistance patterns.
- Develop facility specific treatment recommendations. Use standing orders or care pathways to guide care when changes in condition are noted (e.g., urinary tract symptoms or upper respiratory symptoms or skin and soft tissue infections). This will help staff determine what signs and symptoms suggest bacterial infection and the potential need for antibiotics. See optional resources at end of this session for support in developing facility specific treatment recommendations.
- Provide tools and resources to assist staff in the assessment of changes in resident condition so they are able to present a clear and accurate picture to the prescribers. For example, encourage use of communication tools, such as SBAR (situation, background, assessment, and recommendation), to help facilitate effective staff and prescriber verbal interactions. Access the SBAR tool in the session TeamSTEPPS® in LTC: Communication Strategies to Promote Quality and Safety.
- Develop and implement clear policies and practices to ensure that residents are not started on antibiotics unless they are needed.
- Work with clinicians to develop and implement nursing protocols for monitoring residents’ status for an evolving condition if there is no specific indication for antibiotics.
- Discuss efforts to address antibiotic overuse and misuse with providers so they understand what information is being tracked and so they do not make the assumption staff are “asking for an antibiotic” when instead the goal is to determine the most appropriate next step in management.
- Build an interdisciplinary team culture that welcomes questioning of antibiotic orders that are not supported by the resident’s clinical symptoms, lab testing, imaging, or culture results.
What specifically can be done by nursing home clinicians to ensure antibiotics are used appropriately?
Nursing home clinicians can:
- Avoid use of antibiotics to treat viral illnesses such as colds, influenza, and viral gastroenteritis.
- Remember that treatment with antibiotics is only appropriate when the practitioner determines, on the basis of an evaluation, that the most likely cause of the resident’s symptoms is a bacterial infection.
- Obtain microbiology cultures prior to starting antibiotics when possible so antibiotics can be adjusted or stopped when appropriate.
- Use antibiotics only for as long as needed to treat infections, minimize the risk of relapse, or control active risk to others. Antibiotics are generally not indicated to treat colonization.
- Follow facility specific treatment recommendations. Use standing orders or care pathways to guide care when changes in condition are noted.
- Develop and implement nursing protocols for monitoring residents’ status for an evolving condition if there is no specific indication for antibiotics.
- Use tools and resources to assess changes in resident condition in order to present a clear and accurate picture to the prescribers. For example, use communication tools, such as SBAR (situation, background, assessment, and recommendation), to help facilitate effective staff and prescriber verbal interactions.
- Question antibiotic orders that are not supported by the resident’s clinical symptoms, lab testing, imaging, or culture results.
- Engage residents and their family members in addressing the need to improve antibiotic use.
- Review the facility’s microbiology reports and antibiogram to detect trends in antibiotic resistance.
These are actions that support compliance with new infection control and antibiotic stewardship components in the regulation on Reform of LTC Requirements.
Track which antibiotics are being used, for which conditions, and for what duration. Also track if a culture was obtained and any change in treatment made based on culture results.
Use an antibiogram developed for your organization. This allows the facility to determine patterns of antibiotic sensitivity or resistance that have developed over time within the facility. By referring to an antibiogram, physicians and other prescribers can avoid using antibiotics where resistance has developed.
About Antibiograms (Antimicrobial Susceptibilities of Selected Pathogens) - one-page description and examples of antibiograms from the Minnesota Department of Health
Concise Antibiogram Toolkit - toolkit from AHRQ
Here is an audit tool to help you assess antibiotic prescribing in your organization: Word
NOTE: This tool is also provided in the session Antibiotic Stewardship.
Here are more resources from the Minnesota Department of Health to help track antibiotic usage:
NOTE: These tools are also provided in the session Clostridium difficile Part Two: Strategies to Prevent, Track, and Monitor C. difficile.
Discussion questions: Discuss the following questions with your team.
- In healthcare, ‘doing something’ can feel better than watching and waiting or managing a person’s symptoms. Do you feel this can contribute to antibiotic overuse or misuse?
- Are there other factors that encourage the use of antibiotics before it is clear whether an antibiotic is indicated?
Engage the resident and family in talking about antibiotics. See the CDC fact sheet titled Core Elements for Antibiotic Stewardship in Nursing Homes: What You Need to Know About Antibiotics in a Nursing Home.
Antibiotics are remarkably effective against bacteria. However, emergence of bacterial resistance to antibiotics, a naturally occurring phenomenon, can be made worse by misuse of antibiotics. Antibiotic resistance is the ability of a bacteria to change so that antibiotics can’t kill it or stop it from reproducing.
Here is a graphic from the CDC that shows a timeline of key antibiotic resistance events, comparing the timeline of when the antibiotic was introduced and when antibiotic resistance was developed (click on the graphic to download and print it):
It is important for us to slow the pace of antibiotic resistance. The pace of development of antibiotic resistance is now faster than the development of new drugs. Since 1980, the rate of development and approval of new antibiotics has steadily declined. We can no longer assume new drugs will be coming out that will be effective against resistant bacteria now present in our communities. In fact, we have situations now where we do not have antibiotics to treat common bacterial infections in hospitals – the bacteria are resistant to all our current antibiotics.
True/False: Discuss if these statements are true or false and why.
Antibiotics work for all types of infections. See answer…
It is always best to start an antibiotic if you are not certain if there is a bacterial infection because the risk of harm from the antibiotic is so low. See answer…
It is best to stick with antibiotics you know have worked before. See answer…
- Antibiotics work with the immune system to fight bacteria.
- Antibiotics are not effective against and should not be used to treat viruses.
- Antibiotics are not harmless drugs; they have side effects and can cause harm.
- Understanding the risks and benefits of antibiotic use for each individual is critical.
- Factors contributing to antibiotic resistance include excess, inappropriate use of antibiotics, and incorrect use of broad spectrum agents.
- It is important to use antibiotics judiciously to lessen the emergence of bacterial resistance to antibiotics.
- There are many specific actions that nursing home administrators and clinicians can take to ensure antibiotics are used appropriately.
This resource was developed by ABIM Foundation as part of the Choosing Wisely®;Campaign, with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.
This CDC video (4:05) features a patient perspective on how you can help prevent the spread of resistant bacteria, protect your patients, and preserve antibiotics.
This video is presented by Lisa Avery, PharmD, BCPS and was recorded at the February 2016 ASCP-New York Conference (1:09:34).
- Discuss spectrum of activity of antimicrobials commonly prescribed to geriatric patients.
- Review antimicrobial adverse reactions and drug interactions that occur in the geriatric population.
- Determine appropriate antimicrobial dosing recommendations for geriatric patients.
Facility Specific Treatment Recommendations:
- Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, SHEA/CDC Position Paper
- Minimum Criteria for Initiation of Antibiotics in Long-Term Care Residents - Pocket Reference Card