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Combating Antibiotic Resistance: Antimicrobial Stewardship in the Long-Term Acute Care Setting

One of the goals of the 2015 National Action Plan for Combating Antibiotic-Resistant Bacteria is to slow the emergence of resistant bacteria and prevent the spread of resistant infections. The plan’s roadmap includes targeted reductions by 2020 of antibiotic-resistant bacteria recognized as urgent and serious threats by the Centers for Disease Control and Prevention (CDC). In order to meet this goal, the plan calls for the establishment and expansion of antibiotic stewardship programs to ensure judicious use of antibiotics in inpatient, outpatient and long-term care settings.

One of the urgent threats is carbapenem-resistant Enterobacteriaceae (CRE), with a 60% reduction target aimed at infection acquired during hospitalization. The most epidemiologically important CRE, carbapenem-resistant Klebsiella pneumoniae (CRKP), has been increasingly recognized as highly prevalent in the long-term acute care (LTAC) setting. A recent paper published by Mills and colleagues1 cites recent studies identifying 9-fold higher prevalence rates of CRKP colonization in LTAC’s compared to acute care hospitals. The objective of the Mills study was to assess risk factors for colonization or infection with CRKP in LTAC residents. This case-control study performed over a 5-year period at a university-affiliated LTAC on 222 patients, of which 45% had CRKP, identified the following factors associated with a significant risk for CRKP by multivariate analysis:

  • Solid organ or stem cell transplantation
  • Mechanical ventilation
  • Fecal incontinence
  • Exposure in the prior 30 days to meropenem, vancomycin and metronidazole

The authors conclude that patient populations with these clinical conditions may benefit from enhanced surveillance measures to ensure that isolation precautions are promptly initiated. The findings related to prior antibiotic use strongly suggest that “effective and feasible antibiotic stewardship measures are urgently needed in this setting.”

With the Centers for Medicaid and Medicare Services (CMS) proposed rule for the establishment of antimicrobial stewardship programs in long-term care ? to include antibiotic use protocols and monitoring – and recent findings 2 that many LTC facilities are collecting data on prescribing antibiotics and instituting antibiotic approval processes, the challenge of addressing resistance in this setting is well underway.


1 Mills JP, Talati NJ, Alby K, Han JH. The Epidemiology of Carbapenem-Resistant Klebsiella pneumoniae Colonization and Infection Among Long-Term Acute Care Hospital Residents. Infect. Control Hosp. Epidemiol. 2016;37(1):55-60.

2 Yang M, Vleck K, Bellantoni M, Sood G. Telephone Survey of Infection-Control and Antibiotic Stewardship Practices in Long-Term Care Facilities in Maryland. J Am Med Dir Assoc. 2016 Feb 2. pii: S1525-8610(15)00777-X. doi: 10.1016/j.jamda.2015.12.018. [Epub ahead of print] Accessed Feb 15, 2016.

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