The Case for Consultant Pharmacists as Key Players in Nursing Home Antibiotic Stewardship Programs

Facility-Level Antibiotic Prescribing Rates and the Use of Antibiotics Among Nursing Home Residents

BACKGROUND

The high frequency of antibiotic use in U.S. nursing homes is a public health concern and target of antimicrobial stewardship efforts. Facility-level prescribing patterns may provide a measure for antibiotic stewardship targeting.

METHODS

An analysis of 2018 and 2019 data from four linked files from the Centers for Medicaid and Medicare was conducted. Multilevel generalized linear models were used to calculate odds ratios for antibiotic receipt for calendar year 2019 using the 2018 facility prescribing rate, controlling for facility and individual-level factors.

RESULTS

In 2019, 186,274 (19%) study residents were prescribed an antibiotic. The most frequently prescribed class of antibiotics were cephalosporins (26%) and the average duration of antibiotic use was 9 days. Residents who were dually eligible for Medicare and Medicaid had 37% increased odds of antibiotic receipt (All aOR: 1.37, 95%CI: 1.35,1.39). The 2018 facility prescribing rate was associated with 14% increased odds of antibiotic receipt in 2019 in nursing homes in the medium (11.9-20.2%) prescribing category (All aOR: 1.14, 95%CI: 1.11,1.17) and 36% increased odds of antibiotic receipt in nursing homes in the high (>20.3%) prescribing category (All aOR: 1.36, 95%CI: 1.32,1.40) when compared to the lowest (0-11.8%) prescribing category.

CONCLUSIONS

Antibiotic stewardship strategies should target nursing homes with high antibiotic prescribing rates and high populations of dually eligible patients to improve care in this population.

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19

Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2 decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.

Impact of the Antimicrobial Stewardship Mandate on Multidrug-Resistant Organisms and Clostridioides difficile Infection Among Long-term Care Facility Residents

Objective To determine whether the long-term care facility (LTCF) Centers for Medicare & Medicaid Services (CMS) Antimicrobial Stewardship (AMS) mandate was associated with a change in the combined rate of LTCF-acquired multidrug-resistant organism infection or colonization (MDRO-I/C) and Clostridioides difficile infection (CDI). Design Retrospective quasi-experimental study. Setting A 233-bed community hospital. Participants LTCF residents 75 years of age and older with MDRO-I/C or CDI admitted to the hospital before the AMS mandate in 2015 through 2016 or after the mandate in 2018 through 2019. Intervention LTCF CMS AMS mandate. Main Outcomes Measures Rates of LTCF-acquired MDRO-I/C and CDI. MDRO-I/C were defined by a culture positive for methicillin-resistant Staphylococcus aureus or extended-spectrum beta-lactamase-producing Enterobacterales. CDI was defined by a positive test for C. difficile using a multistep algorithm of toxin, glutamate dehydrogenase, and nucleic acid amplification tests. These specimens must have been collected within 48 hours of hospital admission. Results There were 33 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 205 hospitalized residents with MDRO-I/C or CDI in 2015 and 2016, resulting in a rate of 16.10%. In comparison, there were 38 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 253 hospitalized residents with MDRO-I/C or CDI in 2018 and 2019 resulting in a rate of 15.02%. The difference in the combined rate of LTCF-acquired MDRO-I/C and CDI was -1.08% (P = 0.75). Conclusion The AMS mandate was not associated with a significant change in the combined rate of LTCF-acquired MDRO-I/C and CDI, suggesting a need for more robust AMS programs in LTCFs.