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CS Takes Infection Fight to Nursing Homes

Cedars-Sinai is fighting infections in a new way, by battling them in local skilled nursing facilities before they reach the hospital.

The organization is working with eight local nursing homes to ensure patients are getting the appropriate antibiotic at the right time to prevent infections and the spread of drug-resistant bacteria.

"When it comes to infections and bacteria, they don’t know boundaries. They don’t respect the walls of the hospital," said Rekha Murthy, vice president of Medical Affairs and associate chief medical officer, who established the initiative in 2015. "We will not win the war against these serious infections unless we combat them with prevention and control measures across the healthcare continuum."

Cedars-Sinai frequently discharges patients who need extra care to nursing homes. Many of these patients are elderly and often in need of help after a hip replacement, pneumonia or other major illness.

But sometimes these patients are readmitted to the hospital after developing an infection. Cedars-Sinai wants to avoid readmissions by helping the nursing homes correctly diagnose and treat infections for which antibiotics are often improperly prescribed.

Improper use of antibiotics is a national problem for healthcare providers. As many as 70 percent of U.S. nursing home residents get antibiotics each year, and up to 75 percent of those drugs are prescribed incorrectly, according to the Centers for Disease Control and Prevention (CDC). The CDC estimates that more than 2 million illnesses and 23,000 deaths each year are related to antibiotic resistance.

Since implementing the program a year ago in collaboration with the Enhanced Care Program, Cedars-Sinai has seen a 20 percent reduction in the number of days patients are treated with antibiotics at three of the facilities reporting back data. The facilities also have seen a 41 percent reduction in the number of days patients are treated with a fluoroquinolone, a group of antibiotics that can have serious side effects and can promote antibiotic resistance. The program has been rolling out in phases and will eventually capture data from the other nursing homes.

"Antibiotics are the only class of drug that becomes less effective the longer it’s available," said Jonathan Grein, MD, medical director of the Department of Hospital Epidemiology and infection control officer. "These facilities we’re partnering with really want to do the right thing and work in the best interest of the patients. Sometimes they don’t have the resources or expertise to go it on their own."

Cedars-Sinai developed a tool to help staff at nursing homes assess whether a patient has an infection and to spur a conversation with a doctor. The hospital has provided recommendations to each facility about which antibiotics work best on the strain of bacteria most often found in that specific nursing home.

The new tactic has been used initially to identify and properly treat urinary tract infections (UTIs). Elderly nursing home patients often have a high prevalence of UTI-causing bacteria in their urine, even though the patients may not be ill.

In such situations, doctors will sometimes prescribe antibiotics in an effort to be safe, but doing so can put a patient at unnecessary risk of getting Clostridium difficile. The bacterium causes inflammation of the colon, which can lead to other illnesses and even death.

"Stewardship involves routinely looking at the risks versus the benefits of using antibiotics in every patient," said Hali Yang, PharmD, the antimicrobial stewardship pharmacist who helped implement the project.

Cedars-Sinai’s Enhanced Care Program, which already had been working closely with nursing homes, helped make the project possible. The program supports attending physicians at skilled nursing facilities by partnering them with a team of nurse practitioners who frequently visit patients at the facilities.

Soon after Murthy launched the project in 2015, the Centers for Medicare & Medicaid Services and the California Department of Public Health announced new regulations requiring nursing homes to operate their own antimicrobial stewardship programs by 2017. The new regulation is a daunting prospect for many facilities, which often have high staff turnover and usually lack full-time pharmacy and infectious disease specialists who can create and run such a program.

"Without Cedars-Sinai, we’d still be struggling with that," said Eldon Teper, executive director of The Rehabilitation Centre of Beverly Hills, one of the skilled nursing facilities involved in the project. "They’ve been tremendously helpful."