Toolkit 1. Working With Your Lab To Improve Antibiotic Prescribing

Overview of the Toolkit

How can a lab help improve antibiotic prescribing at your nursing home?

Laboratories can use culture results from the nursing home to create a specialized annual report called an antibiogram. The antibiogram report shows the organisms present in specimens from nursing home residents who are suspected of having an infection along with the percent susceptibility of each organism to various antibiotics. Referring to an antibiogram report helps prescribing clinicians make better, empirically-based decisions by avoiding antibiotics with high rates of resistance found in the nursing home. Because antibiograms provide information on local susceptibility patterns, they may help to improve the selection of antibiotics to treat infections from organisms with high resistance rates.

What Is the Working with Your Lab to Improve Antibiotic Prescribing Toolkit?

The toolkit guides nursing homes in working with a lab to obtain an antibiogram. Five tools are included in the toolkit:

• Background: Purpose and Use of the Antibiogram (tool 1) (PDF | Word)
• Step by step guide to working with a lab to obtain an antibiogram (tool 2) (PDF | Word)
• Sample letter of agreement with a lab (tool 3) (PDF | Word)
• Antibiogram formats and instructions (tool 4) (PDF | Word)
• Sample policy letter to communicate with clinicians or staff (tool 5) (PDF | Word)
• Distribution planning guide to help plan how the antibiogram report will be distributed to prescribing clinicians (tool 6) (PDF | Word)

How is the Toolkit implemented?

Implementing the toolkit involves six steps:

1. The medical director should lead the implementation of this toolkit. The medical director should work with the nursing home's lab to create an antibiogram, distribute it appropriately, make sure that it is updated each year, and teach other staff how to use it. The medical director should also work with the infection control team, staff and leadership at the nursing home, and the home’s consulting pharmacist to figure out the best way to fit the antibiogram into the work flow for residents with suspected infections or the transfer of patients to hospitals or other care facilities. Leadership by the medical director helps drive successful implementation by building support among nursing home staff and prescribing clinicians. Tool 1 provides background information that may be useful to the medical director in preparing staff to use antibiograms.
    
2. Work with your laboratory to create an antibiogram report. Tool 2 provides step-by-step information on how to work with your lab to obtain an antibiogram report that will help prescribing clinicians. In many cases, the medical director can simply make a phone call to the lab to request an antibiogram. In some cases, the creation of the annual antibiogram may require a formal letter of agreement or a change to the contract with the lab. A sample letter of agreement is provided in tool 3. Changes to the contract or the use of a letter of agreement should be approved by the nursing home's management before any agreement with a laboratory is finalized.

   Some labs can also create alerts about resistant organisms that have been detected based on the nursing home's culture results. These alerts are similar to the “cautionary statement” included in tool 4

3. Choose a format for the antibiogram report and provide written instructions about its use. Sample antibiograms and suggested instructions are provided in tool 4. The laboratory will likely have an antibiogram report format that they recommend. The medical director should work with the lab to determine the best options for the nursing home.
    
4. Inform nursing home staff, prescribing clinicians, and local hospitals about the plans to use an antibiogram, and provide training as needed. Information or training should be provided to nurses, members of any quality assurance committees, and the infection preventionist. You can provide basic information in the form of a written policy in a letter to clinicians or hospitals. A sample policy letter is provided (tool 5).  You can provide the antibiogram and instructions for use with the policy letter, and invite clinicians or hospital staff to contact the medical director with questions. You can also offer an in-person presentation to physicians to distribute the antibiogram and go over the procedures the nursing home will follow for using it.

   Staff can be informed during regular training or staff meetings prior to the arrival of the first antibiogram. However, it is a good idea to conduct a brief training specific to the antibiogram and how it will be used. Face-to-face communication works well for answering questions and addressing concerns about workflow.

5. Plan the distribution of the antibiogram. It is a good idea to develop a written plan to guide distribution. Ask the laboratory if they can help with this, as your lab may be able to distribute the antibiogram or resistance alerts to other health care facilities for you. A distribution planning tool is provided in tool 6. Antibiograms should be shared with all health care providers who may prescribe antibiotics for residents, and can be posted online if the nursing home has a Web site. This includes residents’ physicians, but may also include local hospitals, urgent care facilities, or other inpatient facilities to which residents may be transferred. Each nursing home is different and nursing home leadership should determine the best way to distribute information to prescribing clinicians and nursing home staff.
    
6. Update the antibiogram. Updating the antibiogram annually will help maintain its value.

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