Antimicrobial Stewardship for Prevention of CDI 
Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities

Besides using contact and isolation precautions and properly cleaning the environment, there are other ways to prevent CDI in LTCF. One of the most important ways is antibiotic stewardship. Antibiotic stewardship refers to programs and activities that promote the appropriate selection and use of antibiotics. Stewardship activities include limiting the use of antibiotics when they are not needed, and minimizing the frequency, duration, and number of antibiotics prescribed. Stewardship can improve the outcomes for residents who need antibiotics and prevent the unintended consequences of antibiotic use such as side effects, the development of antibiotic resistant bacteria, and the replacement of normal bacteria with those which cause infections, such as C. difficile.

Many residents with C. difficile infection have had exposure to antibiotics within 28 days prior to the onset of symptoms. CDI risk increases when taking multiple antibiotics or taking long courses of an antibiotic. Studies show that 25% to 75% of LTCF residents receive at least one course of antibiotics per year. Of these, it is estimated that 8% to 33% acquire C. difficile. Antibiotic stewardship can be an effective prevention strategy for the reduction of CDI.

There are seven Core Elements of Antibiotic Stewardship for Nursing Homes (CDC):

• Leadership Commitment: Dedicating necessary human, financial and information technology resources
• Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective
• Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use
• Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours)
• Tracking: Monitoring antibiotic prescribing and resistance patterns
• Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff
• Education: Educating clinicians about resistance and optimal prescribing

Antibiotics should only be prescribed if residents meet the Minimum Criteria for Initiation of Antibiotics in Long-Term care Residents, also known as the Loeb Criteria. Although these criteria were developed by consensus and are not based on evidence, they help guide prescribing practices in long-term care facilities. Use of the criteria helps to decrease the amount of antimicrobials prescribed, which in turn, reduces the risk of a resident getting CDI.

• Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities
  Review this toolkit for more comprehensive information on antimicrobial stewardship.