Implementation of a 2-year antibiotic stewardship program was found to be a low-cost means to reduce antibiotic prescribing in nursing homes, according to the results of a study published in the Journal of the American Geriatric Society.1
Nursing homes have high rates of antibiotic resistance, in large part because of the “chronically ill population, frequent antibiotic use, and the fact that they are being used for posthospitalization management,” the authors noted. To address this issue, the Centers for Medicare & Medicaid Services has mandated that nursing homes establish antibiotic stewardship programs.2
To evaluate the use of such programs in nursing homes, the investigators recruited nursing homes in North Carolina: a chain nursing home group and a medical provider group. The chain group consisted of 14 for-profit nursing homes, whereas the medical provider group had 13 medical directorship facilities in North Carolina and employed 12 physicians, 13 nurse practitioners, and 6 physician assistants.
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The antibiotic stewardship intervention lasted for 18 months, with a 6-month follow-up and data collection. Intervention components included training modules for medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit.
The mode of information delivery differed between the 2 study groups: the point person for the chain group was the corporate vice president of clinical services and nursing leadership, whereas for the medical provider group, it was the medical director and other medical care providers (physicians, nurse practitioners, and physician assistants).
The primary outcome was the rate of systemic antibiotic prescriptions per 1000 resident-days. Secondary outcomes included rates of antibiotic prescribing for presumed urinary tract, respiratory, skin/soft tissue, and other infections; the rate of urine culture ordering; the incidence of infections with methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile; and the rates of hospitalization and of 30-day readmissions.
Participating nursing homes were largely for-profit, had a mean bed size of 102, and had 16% of beds licensed for short-term rehabilitation. During the 2-year intervention and follow-up period, staff turnover was higher in the chain group. None of the primary or secondary outcomes significantly differed across study groups with respect to change in prescribing rates from baseline.
Total systemic antibiotic prescriptions per 1000 resident-days decreased 16% at 12 months and 20% at 24 months. This reduction related to a significant decrease in prescribing for presumed urinary tract infections, incidence of C difficile and MRSA infections, hospitalizations, and hospital readmissions.
Staff turnover and antibiotic prescribing were not significantly associated in the total sample, but for the nursing home chain group, a negative correlation was found between nurse turnovers and prescribing changes during year 1 and between medical director turnover and year 2 change. When included in multivariable models, neither staff turnover variable was significant.
“This 2-year implementation trial in 27 [nursing homes] demonstrated that, even in highly varied, community [nursing homes], significant reductions in antibiotic prescribing can be achieved by a low-cost, standardized antibiotic stewardship program,” the authors concluded.
References
1. Sloane PD, Zimmerman S, Ward K, et al. A 2-year pragmatic trial of antibiotic stewardship in 27 community nursing homes. J Am Geriatr Soc. 2020;68(1):46-54.
2. Medicare and Medicaid Programs. Medicare and Medicaid Programs; Reform of Requirements for LongTerm Care Facilities. https://www.govinfo.gov/content/pkg/FR-2016-10-04/pdf/2016-23503.pdf. Accessed March 4, 2020.
