Chris Crnich, MD

Author – Chris Crnich, MD
Assistant Professor of Medicine in the Division of Infectious Diseases at the University of Wisconsin School of Medicine and Public Health and is the Hospital Epidemiologist at the William S. Middleton VA Hospital.

A significant proportion of antibiotic use in nursing homes is inappropriate. Inappropriate antibiotic use unnecessarily places residents at risk for adverse drug events and is the major driver of antibiotic resistance in nursing homes.

A traditional approach to the problem of inappropriate antibiotic use in nursing homes centers on educating the provider making prescribing decisions. The thinking goes, that if we can get providers to better understand the adverse consequences of antibiotics and increase their knowledge about antibiotic choice and dosing, the problem of inappropriate antibiotic use in nursing homes will go away. Unfortunately, it is not that simple.

Prescribing in nursing homes is unique in that most decisions to initiate antibiotics are made over the phone without the benefit of a clinical exam performed by the prescribing provider. Coupled with the clinical uncertainty created by the atypical presentation of acute illness in the frail elderly and limited access to diagnostic test results creates a perfect environment for overuse of antibiotics. When viewed through this prism, the likelihood of inappropriate antibiotic use is not simply determined by the provider but by the particulars of the resident’s presentation, accessibility to diagnostic tests, features of the nursing home staff primarily responsible for the clinical exam, as well as the quality of communication between providers and facility staff.
Recognizing that inappropriate antibiotic use is an outcome determined more by the nursing home system rather than an individual provider’s decisions and behaviors is an important step towards addressing this problem. With this in mind, future efforts to improve antibiotic use in nursing homes must begin to focus on strategies that: 1) standardize nursing assessments of the resident with suspected infection; 2) enhance the accessibility of clinical information and diagnostic test results, and 3) improve the quality of communication between providers involved in the antibiotic start process.

Implementing these types of interventions in the nursing home environment will not be without challenge but as Albert Einstein once said, “Insanity is doing the same thing over and over again and expecting different results”. Ignoring the important role of the system on antibiotic use will lead to more of the same. We can and must do better.

Ramanan Laxminarayan, PhD

Author – Ramanan Laxminarayan, Ph.D.,
director of Extending the Cure (ETC)

Our ability to conquer microbial diseases with antibiotics goes back only 70 years. Yet, the inevitable and rapid development of resistance to these miracle drugs may soon usher in an era where common infections are once again deadly or very costly to treat. 

Since its inception in 2007, Extending the Cure (ETC) has worked to inform stakeholders of the magnitude of this unfolding crisis and to offer broad-based economic solutions based on the idea that antibiotic effectiveness should be managed as a shared societal resource, much like forests or fisheries.

 As a capstone to our efforts, ETC and the CDC have brought together representatives from leading research, medical, and trade organizations to express our mutual commitment to extend the useful life of antibiotics. At the start this year’s Get Smart about Antibiotics Week, my colleague and close collaborator, Arjun Srinivasan, and I will unveil a consensus statement on antibiotic resistance from 22 national health organizations at a joint telebriefing on November 13.