Stewardship in US nursing homes tied to less antibiotic use

Caregiver instructing patient on daily drug regimen
Caregiver instructing older man on daily drug regimen

Biserka Stojanovic / iStock

A new study of more than 400 US nursing homes found that participating in a quality improvement program that frames antibiotic use as a patient safety issue was associated with a reduction in antibiotic use and urine culture collection, researchers reported yesterday in JAMA Network Open.

The study, which assessed the impact of the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use in long-term care (LTC) facilities across the United States, also found that nursing homes that had greater engagement in the program saw more pronounced reductions in antibiotic use.

The authors of the study say the findings suggest that, despite the well-known challenges of developing, implementing, and sustaining antibiotic stewardships programs in LTCs, focusing on antibiotic use as a patient safety issue and engaging all staff members in stewardship activities can produce tangible results.

Stewardship challenges in nursing homes

In the study, a team of US researchers analyzed the implementation of the AHRQ safety program at 523 LTCs across the country from December 2018 to November 2019. Using webinars and additional educational tools, the program aims to assist LTCs in establishing antibiotic stewardship programs by addressing facility culture and technical knowledge around antibiotic prescribing. 

One of the core messages of the program, says lead study author Morgan Katz, MD, MHS, of Johns Hopkins University School of Medicine, is that antibiotics have both benefits and harms.

"The idea was to reframe antibiotic use as a patient safety issue…to change the framework of how we think about antibiotics," Katz told CIDRAP News. "We now realize that antibiotics come with many significant side effects, particularly in older adults, as well as public health implications, such as antibiotic resistance."

While the program has also been implemented in acute care hospitals and ambulatory care practices around the country, it's become increasingly clear that antibiotic stewardship is critically needed in nursing homes. More than 70% of LTC residents receive a course of antibiotics annually, and research has shown that 40% to 75% of those antibiotic prescriptions are inappropriate or not concordant with guidelines. The high level of antibiotic use in nursing homes is also being increasingly linked to carriage of multidrug-resistant bacteria in nursing home residents.

"We are realizing that long-term care facilities and nursing homes are one of the most important reservoirs for multidrug-resistant organisms," Katz said. "That's where many of these resistant organisms are being cultivated. And part of that is due to antibiotic overuse in this setting."

But LTCs present unique challenges for stewardship. Staff turnover is high, resources are limited, and prescribers are typically on site only once or twice a week, Katz and her colleagues note. Residents often have vague clinical symptoms and have trouble communicating, which makes it difficult to determine whether an infection is present. Family members, communicating for their loved ones, sometimes push for antibiotics.

To address those challenges, the AHRQ safety program involves all levels of LTC staff, including administrators, nurses, and certified nursing assistants, and includes training on how to communicate antibiotic prescribing decisions to family members. All of the webinars are free and available online for any LTC that wants to use them.

To gauge the impact of the program, the study evaluated the change in antibiotic starts per 1,000 resident days from the baseline period (January to February 2019) through the completion of the program (November to December 2019). Secondary outcomes included days of antibiotic therapy (DOT) per 1,000 resident-days, the number of urine cultures per 1,000 residents, and Clostridioides difficile cases per 10,000 residents.

Of the 523 eligible LTCs, 439 (83.9%) completed the program, which Katz says is a success in and of itself, given the high attrition rate of nursing homes involved in quality improvement programs.

"We were expecting to lose at least 50% of the nursing homes that we enrolled," she said. "We were really excited about that, because we did not expect to hold on to that many facilities and actually get data from that many facilities."

Among the 410 LTCs that submitted comprehensive antibiotic use data, antibiotic starts decreased from 7.9 to 7.5 per 1,000 resident days (–0.41 starts; 95% confidence interval [CI], –0.76 to –0.07). Similarly, antibiotic DOT declined from 64.1 to 61.0 per 1,000 resident-days (–3.01 DOTs; 95% CI, –6.3 to 0.23), though that reduction was not considered statistically significant. Fluoroquinolone use decreased from 1.5 to 1.3 starts per 1,000 resident-days and from 10.6 to 9.4 DOT per 1,000 resident-days across all sites.

The number of urine cultures per 1,000 resident days decreased from 3.0 to 2.6 (–0.38; 95% CI, –0.61 to –0.15). That's significant, because ordering urine cultures without evidence of infection, Katz explained, can often lead to inappropriate antibiotic treatment of asymptomatic bacteriuria.

There was no change in the rate of C difficile cases.

Higher engagement helps

The study also found that higher engagement with the program produced better results.

In the LTCs where engagement was higher, as measured by the number of webinars attended, reductions in antibiotic use were even greater. Antibiotic starts fell from 8.2 to 7.2 per 1,000 resident-days (–1.12 starts; 95% CI, –1.75 to –0.49) in high-engagement facilities, while antibiotic DOT fell from 71.9 to 61.9 (–9.97 DOTs; 95% CI, –15.4 to –4.6). Low- and no-engagement facilities saw no significant reductions.

"Facilities that had people attending the webinars, downloading the materials, using the materials, and actively uploading their data saw much higher reductions in their antibiotics use," Katz said.

Katz and her colleagues believe a big part of the success of the program is that it's not a top-down approach that focuses only on prescribers. Rather, it recognizes the critical role that nurses and certified nursing assistants play in antibiotic prescribing in nursing homes.

"Those are the people at the bedside. They know the residents, they are talking to family members, they are the ones who really have a significant impact on resident care," Katz said. "Making sure that they're part of the team and that they understand their part in the prescription process is critically important in this setting, because they really are the backbone of the care team."

This week's top reads

Our underwriters