Antibiotic Awareness in Long Term Care Facilities – Insight from Dr. Ravina Kullar

Briefly describe your work involving antimicrobial stewardship and antibiotic awareness. I wear many hats when it comes to stewardship.

The company I am a part of stands behind promoting consistency of treatment and optimal patient outcomes through conducting evidence-based medicine research. Additionally, a passion of mine is to educate the public on the consequences of antimicrobial resistance through TED talks and by serving as an ID consultant on the educational TV show "The Doctors". I believe that the latter is very important; the public rarely reads scientific literature and it is essential for pharmacists to get the message out to patients in an effective manner that resonates with them as well as clinicians. I am also very proud of the work I do in leading implementing antimicrobial stewardship (AS) initiatives in long-term care facilities (LTCFs).

What stewardship initiative or antibiotic awareness effort specific to LTCF are you most proud of that you have participated in or lead?

Leading AS initiatives in LTCFs has been quite rewarding because this is relatively an unchartered territory where elderly patients are being negatively impacted by antibiotic overuse.  I have collaborated with Cedars Sinai Medical Center in Los Angeles, CA to help implement AS in neighboring LTCFs. It was a team effort with assistance from the ID Fellow, Los Angeles Department of Public Health, and the ASP physicians and pharmacist. I frequently visit these facilities to educate nurses on AS principles and help demonstrate to them that they can be AS champions and help lead the fight in antibiotic resistance. I have also helped implement antibiotic “time-outs” at several other LTCFs throughout southern California and am working with the Los Angeles Department of Public Health to develop a toolbox for implementing AS in LTCFs. Pharmacists working collaboratively with nursing colleagues and helping provide education to optimize antibiotic use is key to successful LTCF stewardship.

Have you measured the impact of this initiative; if so, what has the impact been?

Seeing improvement in antibiotic usage in LTCFs takes time—double or even triple the time it takes to see improvement in the inpatient setting due primarily to the high turnover rate of nurses. Patience is key in implementing AS initiatives in this setting in addition to starting with one quality improvement (QI) initiative at a time. That said, our Cedar Sinai team focused on optimizing management of suspected urinary tract infections (UTIs) first as after results from a baseline survey revealed that ~ 70% of patients were being treated for asymptomatic bacteriuria, partly due to inappropriate urine culture ordering.  We 1) provided education to the facilities and worked with the microbiology labs to assure “urinalysis with reflex to urine culture and sensitivity, if indicated” rather than the standard order for “urine culture and sensitivity”; 2) created LTCF-specific antibiotic recommendations for UTIs based on facility specific antibiograms; 3) created SBAR forms; 4) continually educated nurses on the initiative. Implementation of the program was associated with a 14% reduction in monthly antimicrobial days of therapy (DOT), including a 39% reduction in fluoroquinolone (FQ) DOT. Reduction in FQs is low-hanging fruit for LTCF stewardship, as many facilities have a high resistance to FQs and FQ use is associated with many adverse drug events, particularly in the elderly population.

What actions do pharmacists take at your institution to optimize antibiotic use in LTCF?

Pharmacists empower others by serving as educators and patient-care resources. Pharmacists also build bridges between members of the care team, as well as advocate for collaboration to effectively optimize ASPs.

What is your primary goal for the next year to continue to improve antibiotic use in LTCF?

Continue educating others (clinicians and non-clinicians) on how to be a part of the solution of slowing the spread of antimicrobial resistance and advocating for them to join in AS efforts.

What is one pearl you have for non-ID trained pharmacists to help them be antibiotic stewards?

Everyone can be a leader in being an antibiotic steward. Take ownership! Educate yourself, be curious, and reach out to others if you have questions. Collaborate and learn from other clinicians including pharmacists, nurses, physicians, microbiologists, IT, IPs, etc. Each one of these members play a part in AS activities. Further, you cannot effectively succeed in leading AS by hiding behind a computer. You must get out there on the floor and develop trust with other clinicians.

Ravina Kullar, PharmD, MPH, FIDSA

Vice-President, Doctor Evidence, LLC.

Adjunct Faculty, UCLA David Geffen School of Medicine