Stacie Urbanick, MSN, RN:
Stories of Antibiotic Use and Resistance

I am the Director of Nursing in a long-term care facility. Because our residents have multiple co-morbidities, this makes it sometimes challenging to determine what the reason might be behind new clinical symptom changes within our residents. Prior to the antibiotic stewardship initiative, it used to be that providers would be updated, and antibiotic treatments would be initiated, sometimes without all clinical symptoms met. Now, we take a deeper dive into antibiotic use, and attempt to rule out all possible factors to clinical changes prior to starting antibiotics. Studies show that antibiotic use places individuals at higher risk for adverse effects, which could have negative impacts to residents in the facility.

The greatest challenge we face is the educational component – this is true for both family members of residents, residents, and sometimes the medical providers. For example, when a resident does not meet criteria for antibiotic use, we report this back to the prescribing provider to inquire if they would like to discontinue treatment based on absent symptoms, however, we find that some providers like to continue treatment.

Having worked in LTC (long-term care) for 15 years, it seems as though there is high prevalence of Clostridium difficile infections (CDI) and superbugs [antibiotic-resistant bacteria that are resistant to essentially all available antibiotics] than before. I do believe this is due to the overprescribing antibiotics and as a result, CDI and emergence of superbugs is becoming more common. I can recall very rarely seeing residents in precautions [infection control measures taken to prevent the spread of illnesses] for cases of CDI, MRSA (methicillin-resistant Staphylococcus aureus), or VRE (vancomycin-resistant Enterococci). It now seems as though there are always a couple residents at a given time in precautions, either because they have an active antibiotic-resistant bacterial infection, or have a history of one.

One area that antibiotic use has affected my work is within cases of residents with recurrent CDIs. For these residents, we have major challenges with fully clearing CDIs due to limited antibiotic options. Another challenge we face is how we prevent them from reoccurrence once the history is there. We are challenged with the ethical dilemma of knowing a resident does not meet criteria for antibiotics, yet antibiotic treatment is continued per provider preference. This seems to be an issue across most long-term care facilities, and we are uncertain we know what the true rationale is for this. Antibiotic use is truly a gray area.

My personal worry is the more often we use antibiotics, the smarter the superbugs are going to become, and soon we will run out of antibiotic options. If we do not make sure we are using antibiotics appropriately and accurately treating clinical reasons that may otherwise be causing acute changes we are seeing in illnesses, the more prevalent superbugs will become. I think we need to be especially careful with the vulnerable population (elderly and pediatrics). I have two small children under the age of 3 – what does the future look like for them as they grow older regarding the availability of effective antibiotics?

I would like to see more education to the community and providers for proper infection prevention practices so we can decrease the need for antibiotics. If we make this a focus, I think we would see a decline in illnesses, and therefore decrease the amount of antibiotic use all together. If we could practice hand hygiene more fluently in the community, restaurants, grocery stores, etc., we perhaps would not see illnesses we currently do. In long-term care, most of our residents do not develop the flu or a GI (gastrointestinal) bug on their own – it is likely being contracted from somewhere else, such as a visitor or volunteer coming in to the facility.