Original Study| Volume 23, ISSUE 3, P482-487, March 2022

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Nursing Home Antibiotic Stewardship Policy and Antibiotics Use: 2013–2017



      Reducing inappropriate nursing home (NH) antibiotic usage by implementing stewardship programs is a national priority. Our aim is to evaluate the influence of antibiotic stewardship programs on antibiotic use rates in NHs over time.


      Retrospective, repeated cross-sectional analysis.

      Setting and Participants

      Long-term residents not receiving hospice care in freestanding NHs that participated in 1 or both surveys in 2013 and 2017.


      Survey data were merged with the Minimum Data Set and the Certification and Survey Provider Enhanced Reporting data. Our outcome was a binary indicator for antibiotic use. The main predictor was the NH antibiotic stewardship policy intensity. Using multivariate linear regression models adjusting for resident and facility characteristics that differed between the 2 years, we calculated antibiotic use rates in 2013 and 2017 for all residents, those with Alzheimer's disease, and those with any infection including urinary tract infections (UTIs).


      Our sample included 317,003 resident assessments from 2013 and 267,537 assessments from 2017, residing in 953 and 872 NHs, respectively. NH antibiotic stewardship policy intensity increased from 2013 to 2017 (P < .01) and among all NH residents, including those with Alzheimer's disease, antibiotic use rate decreased (P < .05), with 45% of the decline attributable to strengthening stewardship programs. For most residents, policy intensity was associated with decreased usage in residents with UTI. However, among Alzheimer's disease residents with a UTI, this association did not persist.

      Conclusions and Implications

      Although there was a decrease in antibiotic use in 2017, more time is needed to see the full impact of antibiotic stewardship policy into practice. Adjustments to programs that directly address barriers to implementation and appropriate UTI antibiotic use for residents with Alzheimer's disease are necessary to continue strengthening NH antibiotic stewardship and improve care.


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        • Herzig C.T.A.
        • Dick A.W.
        • Sorbero M.
        • et al.
        Infection trends in US nursing homes, 2006-2013.
        J Am Med Dir Assoc. 2017; 18 (635.e639-635.e620)
        • Cohen C.C.
        • Dick A.W.
        • Agarwal M.
        • et al.
        Trends in antibiotics use among long-term US nursing-home residents.
        Infect Control Hosp Epidemiol. 2021; 42: 311-317
        • Mitchell S.L.
        • Shaffer M.L.
        • Loeb M.B.
        • et al.
        Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia.
        JAMA Intern Med. 2014; 174: 1660-1667
        • Cortes-Penfield N.W.
        • Trautner B.W.
        • Jump R.L.P.
        Urinary tract infection and asymptomatic bacteriuria in older adults.
        Infect Dis Clin North Am. 2017; 31: 673-688
        • Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society
        Policy statement on antimicrobial stewardship by the society for Healthcare Epidemiology of America (SHEA), the infectious diseases society of America (IDSA), and the pediatric infectious diseases society (PIDS).
        Infect Control Hosp Epidemiol. 2012; 33: 322-327
        • Stone P.W.
        • Herzig C.T.A.
        • Agarwal M.
        • et al.
        Nursing home infection control program characteristics, CMS citations, and implementation of antibiotic stewardship policies: A national study.
        Inquiry. 2018; 55 (46958018778636)
        • Agarwal M.
        • Dick A.W.
        • Sorbero M.
        • et al.
        Changes in US nursing home infection prevention and control programs from 2014 to 2018.
        J Am Med Dir Assoc. 2020; 21: 97-103
        • Herzig C.T.
        • Stone P.W.
        • Castle N.
        • et al.
        Infection prevention and control programs in US nursing homes: Results of a national survey.
        J Am Med Dir Assoc. 2016; 17: 85-88
        • Stone P.W.
        • Agarwal M.
        • Ye F.
        • et al.
        Integration of palliative care and infection management at the end of life in U.S. nursing homes.
        J Pain Symptom Manage. 2019; 58: 408-416.e401
        • Centers for Medicare & Medicaid Services
        QIO Program: Quality Innovation Network - Quality Improvement Organizations, Better Health, Better Care, Lower Cost.
        Centers for Medicare & Medicaid Services, US Department of Health and Human Services, Baltimore, MD2014
      1. Centers for Disease Control and Prevention. National Healthcare safety Network (NHSN). Available at: Accessed January 26, 2021.

        • Saliba D.
        • Buchanan J.
        Making the investment count: Revision of the Minimum data set for nursing homes, MDS 3.0.
        J Am Med Dir Assoc. 2012; 13: 602-610
      2. Hospice care.
        (Available at:)
        • Research Data Assistance Center (ResDAC)
        N0410F medications received: Antibiotic number days.
        (Available at:)
        • Centers for Disease Control and Prevention, US Department of Health and Human Services
        The Core Elements of Antibiotic Stewardship for Nursing Homes.
        The National Center for Emerging and Zoonotic Infectious Diseases within the Centers for Disease Control and Prevention, Atlanta, GA2015
        • Centers for Medicare & Medicaid Services
        Five-star quality rating system.
        (Available at:)
        • Joint Commission on Hospital Accreditation
        Approved: New antimicrobial stewardship standard.
        Jt Comm Perspect. 2016; 36: 3-4
        • Barlam T.F.
        • Cosgrove S.E.
        • Abbo L.M.
        • et al.
        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-e77
        • AHRQ. Nursing
        Home antimicrobial stewardship guide.
        (Available at:)
        Date: 2017
        Date accessed: February 5, 2021
      3. Promoting wise antibiotic use in nursing homes.
        (Available at:)
        Date accessed: February 5, 2021
        • Seshadri S.
        • Felsen C.B.
        • Sellers C.R.
        • Dumyati G.K.
        There is no one to pick up the pieces": Sustainability of antibiotic stewardship programs in nursing homes.
        Infect Control Hosp Epidemiol. 2021; 42: 440-447
        • Fu C.J.
        • Mantell E.
        • Stone P.W.
        • Agarwal M.
        Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey.
        Am J Infect Control. 2020; 48: 13-18
        • Zabarsky T.F.
        • Sethi A.K.
        • Donskey C.J.
        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
        • Quigley D.D.
        • Dick A.
        • Agarwal M.
        • et al.
        COVID-19 preparedness in nursing homes in the midst of the pandemic.
        J Am Geriatr Soc. 2020; 68: 1164-1166
        • Sanchez G.V.
        • Biedron C.
        • Fink L.R.
        • et al.
        Initial and repeated point prevalence surveys to inform SARS-CoV-2 infection prevention in 26 skilled nursing facilities – detroit, Michigan, march-may 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 882-886
        • Centers for Disease Control and Prevention
        Antibiotic use in the United States, 2020 update: Progress and opportunities.
        (Available at:)
        • Centers for Disease Control and Prevention
        FastStats: Alzheimer's disease.
        (Available at:)
        Date: 2021
        Date accessed: February 5, 2021
        • Agency for Healthcare Research and Quality
        Toolkit 1.
        Suspected UTI SBAR Toolkit, 2016 (Available at:)
        • Hendricksen M.
        • Habtemariam D.
        • D'Agata E.M.C.
        • Mitchell S.L.
        Factors associated with antimicrobial use in nursing home residents with advanced dementia.
        J Am Med Dir Assoc. 2021; 22: 178-181