Putting a 'LID' on Antibiotic Use in Long-term Care Settings
By Joseph F. John, JR, MD, MD, FACP, FIDSA, FSHEA, Associate Chief of Staff for Education, Ralph H. Johnson Veterans Administration Medical Center; Professor of Medicine, Medical University of South Carolina, Charleston, is Co-Editor of Infectious Disease Alert.
Dr. John reports no financial relationships in this field of study.
Synopsis: Introduction of a long-term care facility (LTCF) infectious disease (ID) consultation service (LID) led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to LTCF represents a new and effective means to achieve antimicrobial stewardship.
Source: Jump RLP, et al. Putting a "LID" on antibiotic use in long-term care facilities: a novel paradigm in health care delivery. Fed Practitioner 2012;29:10-14.
There are very little data on antibiotic stewardship in LTCF. This work (Jump et al.) came from a Geriatric Research Education and Clinical Center (GRECC) demonstration project at the Cleveland VA Medical Center. The LID was a LTCF Infectious Disease team that provided on site consultations. The risks of residents in the LTCF for hospital infection as well as the risks of antibiotic use selecting out multiresistant microorganisms were part of the LID's ongoing education to house staff in the unit. The project began in July 2009 in the 160-bed LTCF at the facility called the Community Living Center (CLC). The LID team was widely utilized by the CLC as patients transitioned from acute to LTCF and also in well-established patients with suspected infections. Prudent use of antibiotics was a constant theme in the LTCF as emphasized by the LID. With a broad approach to antibiotic stewardship, the most common recommendation by the LID was to reduce or streamline antibiotic use. The authors stress that as the CLC staff became confident in the LIDS recommendations, the staff was much more willing to use "watchful waiting" without starting antibiotics. Oral antimicrobial use was reduced 21% and intravenous antibiotics were reduced by 15%, both highly significant compared to previous non-LID periods. What were the most frequent diagnoses by the LID team? Interestingly, C. difficile infection was #1, at 14.8%, followed by no infection at 14.1% and then UTI at 10.6%. Endocarditis was 6.3% which is a cautionary high rate. The category of Other infections was 11.3%.
Commentary
As the authors explain, here we have a practice model. It had unique features but emphasizes the basis of good antibiotic stewardship. The LID team will not indefinitely reduce antibiotic use, but it highlights the opportunities in unlikely clinical settings like LTCF for strong unions between staff and infectious disease teams. It might be argued that it was a highly specialized geriatric research environment that led to the camaraderie that led to good antibiotic stewardship. At the same time, the availability of the LID consultants, their strong clinical and research backgrounds, and the trust they built over time all contributed to the success of the program.
The authors further emphasize that this type of model could be applied to other clinical centers where the subacute nature of the patients may appear to reduce their infectious risks but in fact are prime targets for teams constructed like LID. Additional data over longer periods of time will be helpful in establishing how persistent, how visible and how interactive teams like LID need to be over extended periods. The VA has an established electronic medical record (EMR) that was not one of the challenges facing the LID. Institutions with developing EMR programs may face that hurdle in coordinating a LID, but the labor will likely be well worth it. The LID also reflects that antibiotic stewardship teams need not necessarily be large to be effective. It is the coordination of the team and the acceptance by the staff that are keys to long term success in control of antibiotic use, even in subacute clinical settings.