Infections are all-too-common in nursing homes. And all-too-often facilities treat these conditions with large doses of antibiotics. Now the Obama Administration has announced a major initiative aimed at dramatically reducing the use of these drugs. And the effort has the potential to fundamentally change the way nursing homes operate—and the way residents receive care.
Today, antibiotic use is routine in nursing facilities. The Centers for Disease Control estimates that two-thirds of all residents will be given at least one course of antibiotics this year, and that 25 percent to 75 percent of those prescriptions will be inappropriate. But as a result of the heavy use of antibiotics, 27,000 nursing home residents will suffer from a drug-resistant infection. And many will die.
The problem goes far beyond nursing homes. Overuse of antibiotics (in food as well as in medicines) has created a deadly increase in antibiotic resistant bacteria such as Clostridium difficile (c. dif.) and methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that each year, 2 million Americans will get sick and 23,000 will die from antibiotic resistant infections. These conditions add $20 billion to the nation’s annual health care bill. If you want to know more about the dangers of MRSA, read the book Superbug by Maryn McKenna.
The White House initiative is aimed at sharply reducing antibiotic use in nursing homes and elsewhere. One way facilities can do that is by changing the way the drugs themselves are prescribed. For example, facilities can establish tougher guidelines for when antibiotics should be given (not, for example, if a culture shows some bacteria but not a full-blown infection or because a patient “doesn’t seem herself”).
But the real long-run benefit will come if the initiative encourages nursing homes to rethink care by reducing the root causes of antibiotic use—the infections themselves. In nursing homes, 250,000 residents get an infection each year, mostly respiratory infections such as pneumonia, urinary tract infections (UTIs), or skin infections such as bedsores.
These conditions can largely be prevented. For example, by far the best way to reduce urinary tract infections is to decrease the use of catheters. Less time on a catheter means less risk of infection. It is pretty much that simple.
Similarly, bedsores can be prevented by keeping residents dry.
But aren’t these ideas contradictory? How can a facility reduce catheter use and keep residents dry?
It isn’t hard. At the best facilities, aides get to know the residents and learn to anticipate when they will need to relieve themselves. That way, they can help get them to the toilet before they wet themselves or, at the very least, change their adult diapers in a timely way.
For the facility, that means fewer changes of bed linens, less need to clean the patient, and less catheter use. For the resident, it means she can preserve her dignity, will have fewer UTIs, will get fewer antibiotics, and will be less likely to get a serious hard-to-treat bacterial infection such as c. dif. And it means fewer emergency department visits or hospitalizations, which are both dangerous for frail elders and enormously expensive.
It may not work for every resident but it does for most. Indeed, the CDC has encouraged facilities to reduce catheter use since 2009.
The White House initiative, which applies to hospitals and physicians as well, leaves it to the facilities to figure out how to reduce their antibiotic use. It does not, at least so far, mandate specific reductions.
However, it created a national task force to recommend ways to cut antibiotic use in both agriculture and medicine. And it will require nursing homes and hospitals to put in place “antibiotic stewardship programs” within three years. Those that do not will suffer the business equivalent of the death penalty: They will no longer get paid by Medicare or Medicaid.
What is an antibiotic stewardship program? It can include better monitoring and reporting of antibiotic use, improved staff education, and requires institutions to put a single individual in charge of its antibiotic initiatives.
These days, of course, the nation is obsessing over Ebola. While Ebola is deadly, the chances of getting it in the U.S. are vanishingly small. Older Americans are far more likely to get sick or die from other, more common infections, or from the consequences of the antibiotics we routinely use to treat them. The White House initiative is an important step in breaking that cycle.
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