Innovative methods to summarize nursing home antibiotic data

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration

OBJECTIVE

Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones.

DESIGN

Quasi-experimental, pre- and post-intervention study.

SETTING AND PARTICIPANTS

Six NHs in Monroe County, NY.

METHODS

A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time.

RESULTS

Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042).

CONCLUSIONS AND IMPLICATIONS

A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

Challenges in Tracking and Reporting Antibiotic Use in Long-Term Care

The contemporary long-term care provider and interdisciplinary team are well aware of the recent focus on antibiotic use in their settings. Regulatory changes implemented by Centers for Medicare and Medicaid Services beginning in 2016 have required long-term care settings to look at antibiotic use in a more comprehensive way and to align their programs with the Centers for Disease Control and Prevention's Core Elements for Antibiotic Stewardship for Nursing Homes. As long-term care settings have worked to develop antibiotic stewardship programs over the past several years, there have been many discoveries about the processes involved in gathering data about antibiotic use and associated attributes, including dose, duration of therapy, and indication for use. Attempts to align these attributes with appropriateness may require integration of data elements from pharmacy records and the individual resident's electronic medical record. In this article, we systematically discuss relevant antibiotic use metrics, sources of antibiotic use data, collecting and reporting antibiotic use data, concluding with implications for policy, practice, and research. Only by measuring antibiotic use can we start to assess the effectiveness of antibiotic stewardship program to induce meaningful change in the care of residents in long-term care.