Abstract
Introduction
Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the
appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance.
These programs are now mandated in nursing homes (NHs) but it is unclear if these
programs improve resident outcomes. This systematic review evaluated the current evidence
regarding outcomes of ASPs in the NH.
Methods
PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for
intervention trials of ASPs performed in NHs that evaluated final health outcomes
(mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital
admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence
to recommended guidelines).
Results
A total of 14 studies rated good or fair quality were included. Eight studies reported
a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines
proposed by the studied ASP. None reported a statistically significant change in NH
mortality rates, C. difficile infection rates, or hospitalizations.
Discussion
The limited research to date suggests that NH ASPs can affect intermediate health
outcomes, but not key health outcomes or health care utilization.
Conclusion
Larger trials evaluating more intensive interventions over longer durations may be
needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.
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References
- The National Nursing Home Survey: 2004 overview.Vital Health Stat. 2009; 13: 1-155
- Functional disability and nursing resource use are predictive of antimicrobial resistance in nursing homes.J Am Geriatr Soc. 2015; 63: 659-666
- Colonization of skilled-care facility residents with antimicrobial-resistant pathogens.J Am Geriatr Soc. 2001; 49: 270-276
- Infections in nursing homes: Epidemiology and prevention programs.Clin Geriatr Med. 2016; 32: 585-607
- Antimicrobial stewardship in long term care facilities: What is effective?.Antimicrob Resist Infect Control. 2014; 3: 6
- Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents.JAMA Intern Med. 2015; 175: 1331-1339
Centers for Disease Control and Prevention. Overview and Evidence to Support Stewardship. Available at: https://www.cdc.gov/getsmart/healthcare/evidence.html. 2017. Accessed May 31, 2017.
- Urinary and fecal incontinence in nursing home residents.Gastroenterol Clin North Am. 2008; 37 (x): 697-707
- Medicare and Medicaid programs; reform of requirements for long-term-care facilities. 2016 (Available at:) (Accessed May 31, 2017)
- Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: e51
- Prevalence, expenditures, and complications of multiple chronic conditions in the elderly.Arch Intern Med. 2002; 162: 2269-2276
- Bacterial skin and soft tissue infections in older adults.Clin Geriatr Med. 2013; 29: 443-459
CMS Nursing Home Data Compendium, 2015. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/nursinghomedatacompendium_508-2015.pdf. Accessed May 31, 2017.
- Prevalence and severity of dementia in nursing home residents.Dement Geriatr Cogn Disord. 2015; 40: 166-177
- Predictive value of nonspecific symptoms for acute illness in nursing home residents.J Am Geriatr Soc. 2003; 51: 1111-1115
- Rates, patterns, causes, and costs of hospitalization of nursing home residents: A population-based study.Am J Public Health. 1994; 84: 1615-1620
- The relationship between registered nurses and nursing home quality: An integrative review (2008-2014).Nurs Econ. 2015; 33 (116): 95-108
- The need for higher minimum staffing standards in U.S. nursing homes.Health Serv Insights. 2016; 9: 13-19
- New acquisition of antibiotic-resistant organisms in skilled nursing facilities.J Clin Microbiol. 2012; 50: 1698-1703
- A targeted infection prevention intervention in nursing home residents with indwelling devices: A randomized clinical trial.JAMA Intern Med. 2015; 175: 714-723
- Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: Results of a consensus conference.Infect Control Hosp Epidemiol. 2001; 22: 120-124
- Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria.Infect Control Hosp Epidemiol. 2012; 33: 965-977
- How often do clinically diagnosed catheter-associated urinary tract infections in nursing homes meet standardized criteria?.J Am Geriatr Soc. 2017; 65: 395-401
- Evaluation and management of the nursing home resident with respiratory symptoms and an equivocal chest x-ray report.J Am Med Dir Assoc. 2016; 17: 1164.e1-1164.e5
- Does adherence to the Loeb minimum criteria reduce antibiotic prescribing rates in nursing homes?.J Am Med Dir Assoc. 2013; : 309.e1-309.e7
- Constitutional symptoms trigger diagnostic testing before antibiotic prescribing in high-risk nursing home residents.J Am Geriatr Soc. 2016; 64: 1975-1980
- Role of body temperature in diagnosing bacterial infection in nursing home residents.J Am Geriatr Soc. 2014; 62: 135-140
United Nations Development Programme. 2016 Human Development Report. Available at: www.hdr.undp.org/en/2016-report. Accessed May 31, 2017.
- Quality assessment of controlled intervention studies.2014 (Available at:) (Accessed May 31, 2017)
- Quality assessment tool for before-after (pre-post) studies with no control group.2014 (Available at:) (Accessed May 31, 2017)
- Implementation of an antimicrobial stewardship program targeting residents with urinary tract infections in three community long-term care facilities: A quasi-experimental study using time-series analysis.Antimicrob Resist Infect Control. 2015; 4: 54
- Impact of implementation of a novel antimicrobial stewardship tool on antibiotic use in nursing homes: A prospective cluster randomized control pilot study.J Antimicrob Chemother. 2014; 69: 2265-2273
- A multifaceted intervention to implement guidelines improved treatment of nursing home-acquired pneumonia in a state veterans home.J Am Geriatr Soc. 2006; 54: 1694-1704
- A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia.J Am Med Dir Assoc. 2011; 12: 499-507
- Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: Keeping a LID on antibiotic use.Infect Control Hosp Epidemiol. 2012; 33: 1185-1192
- Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia.Am J Geriatr Pharmacother. 2011; 9: 442-450.e1
- Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial.BMJ. 2005; 331: 669
- Impact of a decision-making aid for suspected urinary tract infections on antibiotic overuse in nursing homes.BMC Geriatr. 2016; 16: 81
- Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities.J Am Geriatr Soc. 2007; 55: 1231-1235
- Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia.J Am Geriatr Soc. 2001; 49: 1020-1024
- Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial.J Antimicrob Chemother. 2011; 66: 2659-2666
- Effect of tailored antibiotic stewardship programmes on the appropriateness of antibiotic prescribing in nursing homes.J Antimicrob Chemother. 2015; 70: 2153-2162
- Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention.Am J Infect Control. 2008; 36: 476-480
- Successfully reducing antibiotic prescribing in nursing homes.J Am Geriatr Soc. 2014; 62: 907-912
- Evidence-based guidelines for management of nursing home-acquired pneumonia.J Fam Pract. 2002; 51: 709-716
- Outcome of nursing home acquired pneumonia: Derivation and application of a practical model to predict 30-day mortality.J Am Geriatr Soc. 2000; 48: 1292-1299
- Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America.J Am Geriatr Soc. 2009; 57: 375-394
- Interventions to improve antibiotic prescribing practices for hospital inpatients.Cochrane Database Syst Rev. 2017; : CD003543
- Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella.JAMA. 1998; 280: 1233-1237
- Control of an outbreak of an infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach.CID. 2007; 45: 1266-1273
- Antimicrobial stewardship in long-term care facilities.Infect Dis Clin North Am. 2014; 28: 237-246
- Mixed-methods pilot study to assess perceptions of antimicrobial stewardship in nursing homes.J Am Geriatr Soc. 2017; 65: 1073-1078
Article info
Publication history
Published online: August 07, 2017
Footnotes
The authors declare no conflicts of interest.
Identification
Copyright
© 2017 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
