Emily P. Peron

Effective Antimicrobial Stewardship in a Long-Term Care Facility through an Infectious Disease Consultation Service: Keeping a LID on Antibiotic Use

DESIGN We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF. SETTING A 160-bed VA LTCF. METHODS Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series. RESULTS Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P=.008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and β-lactam/β-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P=.04). CONCLUSIONS Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

Another Setting for Stewardship:: High Rate of Unnecessary Antimicrobial Use in a Veterans Affairs Long-Term Care Facility

BACKGROUND/OBJECTIVE Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). In order to develop effective stewardship interventions, there is a need for data on current patterns of unnecessary antimicrobial prescribing among LTCF residents. The objective of this study was to examine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in our Veterans Affairs (VA) LTCF. DESIGN Retrospective chart review. SETTING Cleveland VA Medical Center LTCF. PARTICIPANTS Randomly selected patients receiving antimicrobial therapy from October 1, 2008 to March 31, 2009. MEASUREMENTS Days of necessary and unnecessary antimicrobial therapy determined using Infectious Diseases Society of America guidelines, syndromes treated with unnecessary antimicrobials, and the frequency of development of Clostridium difficile infection (CDI), colonization or infection with antimicrobial resistant pathogens, and other adverse effects. RESULTS Of 1351 days of therapy prescribed in 100 regimens, 575 days (42.5%) were deemed unnecessary. Of the 575 unnecessary days of therapy, 334 (58%) were for antimicrobial regimens that were entirely unnecessary (n=42). Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n=21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer than recommended treatment duration accounting for 226 (94%) unnecessary days of therapy. Within 30 days of completing the antimicrobial regimens, 5 patients developed CDI, 5 had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse drug events. CONCLUSIONS In our VA LTCF, 43% of all days of antimicrobial therapy were unnecessary. Our findings suggest that antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria.

Antihypertensive Drug Class Use and Differential Risk of Urinary Incontinence in Community-Dwelling Older Women

BACKGROUND Medication use is a potentially reversible cause of urinary incontinence (UI). The objective of this longitudinal cohort study was to evaluate whether self-reported UI in community-dwelling older women is associated with the use of different classes of antihypertensive agents. METHODS The sample consisted of 959 black and white women aged 72-81 years without baseline (Year 1) UI from the Health, Aging, and Body Composition Study. Use of any antihypertensive from 10 drug classes (ie, alpha blockers [central], alpha blockers [peripheral], angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, beta blockers, calcium channel blockers, diuretics [loop], diuretics [potassium-sparing], diuretics [thiazide], and vasodilators) was determined during Year 3 in-person interviews. The number of unique antihypertensive agents used and the standardized daily dosage were also examined. Self-reported UI, operationally defined as leaking urine at least weekly during the previous 12 months, was assessed at Year 4 visits. RESULTS A total of 197 women (20.5%) reported UI at Year 4. Although any antihypertensive use, number of agents used, and standardized daily dosage at Year 3 were not associated with UI at Year 4, use of one particular drug class-peripheral alpha blockers (ie, doxazosin, prazosin, and terazosin)-was associated with fourfold greater odds of UI (adjusted odds ratio = 4.47; 95% confidence interval = 1.79-11.21; p = .0014). Further, in post hoc analyses, these odds nearly doubled in those also taking loop diuretics (adjusted odds ratio = 8.81; 95% confidence interval = 1.78-43.53; p = .0076). CONCLUSION In community-dwelling older women, peripheral alpha blocker use was associated with UI, and the odds nearly doubled when used with loop diuretics.

Challenging Gerontophobia and Ageism Through a Collaborative Intergenerational Art Program

Prejudices against older adults have been shown to reduce effective care delivery and impact long-term health outcomes for older adults. In an effort to combat these prejudices, intergenerational—and often unidirectional—programs focus on challenging ageism. The PALETTE program takes this further to employ collaborative activities as a way to challenge the gerontophobia that often accompanies ageism. Promoting Art for Life Enrichment Through Transgenerational Engagement (PALETTE) is an innovative program for interprofessional undergraduate and graduate students that combines intergenerational arts activities with formal education on aging, ageism, and gerontophobia. Having demonstrated success in changing the attitudes of students, PALETTE serves as a model for an internationally replicable program that has the potential to improve person-centered care while educating future generations of older adults about positive, optimal aging.

Medication Use in Older Adults

Knowledge about the safety and efficacy of individual medications in older adults (i.e., those ≥65 years of age) is often limited due to the frequent exclusion of this population from premarketing clinical trials of new medications. Regardless, multiple medications are commonly prescribed for community-dwelling older adults who may also choose to use over-the-counter medications and dietary supplements. Medications are prescribed at even higher rates in institutional settings, and the types of medications prescribed differ across care settings as well. The use of multiple medications can result in under-, over- or inappropriate prescribing and patient medication nonadherence, which can lead to a decline in patient functional status and an increase in use of health services. Understanding medication use and its effects in older adults who live in different care settings is likely to aid in designing future interventions for the improvement of health care for this population.

Making the Case for Transgenerational Learning: Research

ABSTRACT This article evaluates existing programs designed to bring together groups from different generations, through a literature search on intergenerational learning programs in accordance with the intergroup contact theory. The theory, as described by Allport (1954) and Rothbart and John (1985), asserts that in order to reduce prejudice and achieve the positive effects of intergroup contact, each of the following conditions should be met to some degree: (1) support of established authority or institution; (2) cross-group contact facilitated regularly over time; (3) equal status within the situation; (4) common goals; (5) intergroup cooperation; (6) behavior of minority group members not consistent with their stereotype; and (7) cross-group contact facilitated in a variety of social contexts. It is the authors’ hypothesis that transgenerational engagement in the academic setting is achieved when an activity or program meets all of the aforementioned criteria.

Medication Reviews in Older Adults

Increased scrutiny of medication regimens by healthcare professionals across the continuum of care is to be expected as the worldwide population ages. Similarly, pharmaceutical companies will be expected to develop new drugs that are safe and effective for older adults, including those who are frail, have complex comorbidities, and/or are prescribed multiple medications. Understanding the medication review process from the clinician perspective can help pharmaceutical industry professionals involved in drug development for older adults anticipate potential post-marketing pitfalls.