Identifying Deficiencies in Nursing Home Antibiotic Stewardship Implementation

Nursing homes have long been a target for antibiotic stewardship efforts, but how well are they doing? More than 3 million people receive care at these facilities each year in the United States and many of the residents come directly from other health care settings. Because of this, there is a high prevalence of multidrug-resistant organisms and risk of adverse events from antibiotic use.

In research presented virtually at IDWeek 2021, investigators with the Centers for Disease Control and Prevention (CDC) conducted a review of nursing home antibiotic stewardship citation deficiencies in order to improve implementation.

Here, presenting author Katryna Gouin, MPH, scientific data analyst with the CDC’s Office of Antibiotic Stewardship, details the top takeaways and clinical significance of the review.

Why are nursing homes a prime target in which to focus antibiotic stewardship efforts?

Nursing home residents are at high risk of infection and adverse events associated with antibiotic use including colonization and infection with antibiotic-resistant organisms and Clostridioides difficile. An estimated 50-70% of nursing home residents will be prescribed 1 or more courses of systemic antibiotics in a year. Optimizing antibiotic prescribing in the nursing home setting is crucial to reduce the risk of adverse events from unnecessary or inappropriate antibiotic use. The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of appropriate antibiotic use in this setting and requires antibiotic stewardship programs to be implemented in nursing homes. CMS requirements emphasize that nursing homes should develop and implement antibiotic use protocols and a system to monitor antibiotic use.

Can you summarize the key findings of the citation review?

In our analysis, we performed a quantitative and qualitative review of antibiotic stewardship citation deficiencies issued to nursing homes between September 2018 through July 2019 across 44 states. We found that the 631 nursing homes that received an antibiotic stewardship deficiency citation were more likely to be for-profit or have small bed size (≤ 99) compared with the 14,841 nursing homes that did not receive a citation. After review of 318 randomly selected citation texts, we categorized the citations into 1 or more of 4 main categories based on the CDC’s Core Elements of Antibiotic Stewardship for Nursing Homes.

Deficiencies in Action related to antibiotic prescribing were the most common citation (67%), identified by either missing antibiotic prescribing protocols, missing documentation of criteria for antibiotic initiation, reassessment, or review upon nursing home admission or re-admission. Deficiencies in antibiotic Tracking & Reporting accounted for 40% of citations, in which nursing homes were commonly cited for either missing or incomplete antibiotic or infection surveillance logs. Deficiencies in Leadership & Accountability were identified in 23% of stewardship citations, commonly as the absence of an antibiotic stewardship policy available at the facility. Deficiencies in Education, in which surveyors identified that healthcare professionals lacked appropriate antibiotic stewardship training, accounted for 13% of citations.

Were there any noticeable trends among nursing homes with a high number of citations?

Differences in the number of core element categories cited per nursing home may be related to surveyor variability and different reporting requirements by state and region. We limited this analysis to antibiotic stewardship citations and did not evaluate other types of citation deficiencies in nursing homes. Future evaluations of infection prevention and control citation deficiencies alongside antibiotic stewardship citations could help to identify nursing homes that need additional support in implementing stewardship and infection prevention and control programs.

What are some ways to improve implementation of antibiotic stewardship in nursing homes?

There are several barriers related to implementing antibiotic stewardship in nursing homes, including limited antibiotic stewardship expertise, high rates of staff turnover in this setting, and high medical complexity of residents.

We identified actionable opportunities to improve antibiotic stewardship program implementation in nursing homes, including:

• All facilities should have an antibiotic stewardship policy available that highlights the commitment to program goals, accountable roles, and action steps taken to implement antibiotic stewardship.
• Facilities should implement antibiotic use protocols, which was one of the most common reasons for antibiotic stewardship citations. Protocols requiring documentation of criteria for antibiotic initiation and reassessment should be integrated into nursing home workflows to improve adherence.
• Nursing home staff should receive antibiotic stewardship training to implement the facility policy and prescribing protocols.

This evaluation also highlighted that additional resources are needed to support nursing homes to have a system to monitor antibiotic use, as required by CMS regulations, including:

• Antibiotic use tracking and reporting resources – ideally tracking antibiotic use at the facility level should be automated using either electronic health records or long-term care pharmacy dispensing data because manual tracking of antibiotics is time intensive.
• Training resources for nursing home healthcare professionals to interpret antibiotic use data and identify where further evaluation is needed and opportunities for improvement exist.

The study, “Review of nursing home antibiotic stewardship citation deficiencies to identify opportunities to improve antibiotic stewardship implementation, 2018-2019,” was presented virtually at IDWeek 2021, held September 29-October 3, 2021.