(See the article by Sloane et al on pages 524–531.)

Antimicrobial stewardship can be implemented in several dimensions: before and after prescription of antimicrobials, streamlining of therapy, and by changing patient and prescriber behavior. Longstanding antimicrobial stewardship programs (ASPs) in acute-care hospitals with dedicated resources and pharmacists and medical directors often use multimodal practices to optimize the use of antibiotics. However, when resources are limited, ASPs must evaluate gaps in prescribing practice and choose interventions. Horizontal and vertical methods of infection control have been described,Reference Septimus, Weinstein, Perl, Goldmann and Yokoe ¹ and this paradigm can also be applied to antimicrobial stewardship. Horizontal approaches in antimicrobial stewardship are broad interventions aimed at lowering overall facility-wide use of inappropriate antibiotics. Horizontal interventions include incorporating an antibiotic time-out into housestaff rounds, alerts for duplicative therapy (eg, double anaerobic coverage) and utilizing formulary restriction. Vertical approaches to antimicrobial stewardship target specific antimicrobials or disease states such as community-acquired pneumonia, skin and soft-tissue infections, or urinary tract infections (UTIs).

Using the Centers for Disease Control and Prevention Core Elements of Hospital Antibiotic Stewardship Programs and identifying major barriers to appropriate prescribing before designing ASP programming, vertical interventions can be potent and less time-intensive than some horizontal methods.Reference Pollack and Srinivasan ² In the long-term care facility (LTCF) setting, where up to 75% of antimicrobials are inappropriately prescribed, a vertical approach can be particularly effective.Reference Katz, Beam, Brand and Boyce ^{3 ,} Reference McMaughan, Nwaiwu and Zhao ⁴ Unnecessary antibiotics for asymptomatic bacteriuria, misdiagnosis of UTI, and overly broad and prolonged antimicrobial courses to treat UTI contribute up to half of all antibiotics prescribed in LTCFs.Reference Loeb, Brazil and Lohfeld ⁵ Interest in stewardship in the LTCF setting is particularly timely because the Centers for Medicare and Medicaid Services (CMMS) has recently issued a rule that LTCFs must have an ASP in place to continue to participate in Medicare or Medicaid. With stretched resources and limited manpower, interventions that can provide the most “bang for the buck” in the LTCF setting are needed.

In this issue of Infection Control Hospital Epidemiology, Sloane et alReference Sloane, Kistler, Reed, Weber, Ward and Zimmerman ⁶ help fill the knowledge gap of why inappropriate treatment of UTIs in LTCFs remains a major problem in antimicrobial stewardship in the LTC setting.Reference Sloane, Kistler, Reed, Weber, Ward and Zimmerman ⁶ Instead of just focusing on outcomes, their work delves into the medical histories of patients to review documentation of the symptoms and vital signs that led to the initial ordering of a urine culture. Recognizing the patient factors that lead to inappropriate prescription helps tailor vertical stewardship interventions, such as those targeting UTIs.

Sloane et al found that mental status change was the most commonly documented sign associated with urine testing. Once testing was ordered, despite what the diagnostics showed, associated antibiotic treatment was often (74% of the time) empirically ordered and completed. An LTCF can be a difficult setting diagnostically and for an ASP. These centers often have limited staff; the labs are frequently offsite with limited microbiology resources; and the primary patient population (older adults) often has multiple comorbidities and multifactorial etiologies for their symptoms. In this unclear setting, it is understandable that unnecessary urine cultures and urinalyses are frequently ordered and are often prematurely acted upon. To break the cycle of unnecessary testing followed by unnecessary antibiotics, Sloane et al suggest a number of UTI-specific stewardship interventions: incorporating guidelines for urine testing, tracking urine culture results and narrowing or discontinuing antibiotics when possible, creating antibiograms, and recommending treatment duration. Some of these approaches are more labor intensive than others: Post-prescriptive review of cultures and recommending a treatment change requires a pharmacist or provider to actively review charts, whereas protocols for diagnostic testing may be computer based. Depending on resources, centers can tailor these vertical stewardship interventions. One intervention that is specifically useful in the LTCF setting is observation or “watchful waiting” for patients with nonspecific or mild symptoms who do not meet guidelines for antibiotic use for UTI. Often when the mental status change or decrease in urine output is caused by a noninfectious cause such as dehydration, watchful waiting allows time for patient improvement.

As with infection control approaches to healthcare-associated infection prevention, no single best stewardship intervention can be applied broadly and nationwide. Each center faces unique challenges that could make horizontal or vertical (or both) approaches to stewardship a best practice. However, the field of LTCF antimicrobial stewardship desperately needs powerful, operational but simple interventions, and UTI antimicrobial stewardship may be the best first step for newer ASPs. Further studies should explore the impact of incorporating UTI-specific interventions into multiple LTCFs. If such interventions are effective, they could lead to other infection-specific interventions to improve prescribing. Patient outcomes and cost-effectiveness of horizontal versus vertical approaches to ASPs in LTCFs and acute-care settings should also be explored. As antimicrobial use is measured nationally and the importance of stewardship is emphasized via regulatory and educational mechanisms, specific stewardship tactics should be thoroughly investigated in well-designed trials in acute-care and LTCF settings to further the scope of stewardship research and best practices. Increasing prevalence of multidrug-resistant organisms in the LTCF setting and health policy and economic regulatory pressures from national funders such as CMMS make LTCF stewardship a subject that needs practical solutions. Targeted vertical approaches in the LTCF setting may be the next best step.