Antibiotic Use in the United States, 2017: Progress and Opportunities
Antibiotic Use By Healthcare Setting
What Do We Know About Antibiotic Use In Nursing Homes?
Current data on antibiotic use in nursing homes is limited so the information here is based on a few small studies. Over the course of a year, approximately 4 million individuals receive care and services in a nursing home. Antibiotics are some of the most commonly prescribed medications in nursing homes with 50 to 70 percent of residents receiving an antibiotic over the course of a year.12,13 Up to 75 percent of antibiotics prescribed in nursing homes are prescribed incorrectly.12,13 The most common prescribing problems in nursing homes are using an antibiotic when not needed, choosing the wrong antibiotic, and using the correct antibiotic but for the wrong dose or duration. Prescribing problems can lead to harm including side effects, allergic reactions, C. difficile infection, and antibiotic-resistant infections. This is especially concerning because nursing home residents are already at high risk for getting a C. difficile infection.
From December 2013 to May 2014, CDC examined the medical records of nine U.S. nursing homes in four different states to assess how many antibiotics residents received in a single day and the documentation for those prescriptions. Researchers found that 11 percent of nursing home residents were on antibiotics on any single day. One in three of these antibiotic prescriptions was for the treatment of urinary tract infections; yet at least half of these prescriptions were for either the wrong drug, dose, or duration. Finally, 38 percent of orders for antibiotics lacked documentation of one or more important prescribing elements.14 CDC is launching a study with a larger number of nursing homes and pursuing partnerships with nursing home networks, pharmacies, and other companies to identify where action is needed most.
To protect nursing home residents, in 2015 CDC released The Core Elements of Antibiotic Stewardship for Nursing Homes. By adapting hospital recommendations to the nursing home setting, the Core Elements guide provides practical ways for nursing homes to initiate or expand antibiotic stewardship activities. The guide provides examples of how antibiotic use can be monitored and improved by nursing home leadership and staff. The companion checklist can be used to assess policies and practices already in place and to review progress in expanding stewardship activities. CDC works to provide support and technical assistance
to health departments and nursing home partners to help implement the Core Elements in nursing homes.
Demonstrate support and commitment to safe and appropriate antibiotic use in your facility.
Identify physician, nursing and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities in your facility.
Establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship for your facility.
Implement at least one policy or practice to improve antibiotic use.
Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in your facility.
Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff.
Provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use.
CDC collaborates with partners to implement appropriate antibiotic use efforts at a local level. CDC funds and supports many state and local health departments and other partners across the country to implement targeted antibiotic stewardship improvements in nursing homes.
Massachusetts Department of Public Health: Reducing C. difficile through Educational Interventions in Nursing Homes
The Massachusetts Department of Public Health extended C. difficile prevention activities from acute care hospitals into nursing homes. Sixteen nursing homes implemented multi-faceted educational interventions to reduce unnecessary antibiotic use for asymptomatic bacteriuria (when bacteria are found in urine without causing symptoms of a urinary tract infection). They conducted inperson trainings on antibiotic use for urinary tract infections and engaged patients and families. After one year, nursing homes experienced:
- Improved urinary tract infection diagnostic practices with a 28 percent decrease in unnecessary urine cultures for patients who did not have symptoms of urinary tract infection.
- Decreased antibiotic use with a 37 percent reduction in antibiotics given to patients experiencing asymptomatic bacteriuria.
- Improved patient outcomes with a 47 percent reduction in healthcare-acquired C.difficile infections.
Presbyterian Senior Care Network: Implementing the Core Elements of Antibiotic Stewardship for Nursing Homes
Presbyterian Senior Care Network is a network of senior care and independent living facilities in Erie, Pennsylvania. The first Antibiotic Stewardship Program team was initiated by two nurses focused on quality care and infection prevention and control. They anticipate all Presbyterian Senior Care Network communities will adopt the program over time. Their activities are based on CDC’s Core Elements of Antibiotic Stewardship for Nursing Homes.
State Policies to Improve Antibiotic Use in Nursing Homes
- State of California: Requiring Antibiotic Stewardship in Nursing Homes
California Senate Bill 361 required skilled nursing facilities to adopt and implement an antibiotic stewardship policy by January 1, 2017. According to the bill, the antibiotic stewardship policy should be consistent with CDC’s Core Elements of Antibiotic Stewardship for Nursing Homes. California was the first state to enact legislation to improve antibiotic use in nursing homes.
What can healthcare providers do to support appropriate antibiotic use and prevent infections in nursing homes?
- Follow clinical guidelines when prescribing antibiotics.
- Use the right antibiotic, at the right dose, for the right duration, and at the right time.
- Review antibiotic therapy 2-3 days after it is started based on the resident’s clinical condition and microbiology culture results.
- Talk to residents and their families about when antibiotics are and are not needed, and discuss possible harms such as allergic reactions, C. difficile and antibiotic resistant infections.
- Ask residents if they have ever had a C. difficile infection, and tailor antibiotic treatment accordingly.
- Be aware of antibiotic resistance patterns in your facility and community; use the data to inform prescribing decisions.
- Follow hand hygiene and other infection prevention measures with every resident.
What can residents and families do to support appropriate antibiotic use and prevent infections in nursing homes?
- Talk to your healthcare provider about when antibiotics will and won’t help, and ask about antibiotic resistance.
- Ask what infection an antibiotic is treating, how long antibiotics are needed, and what side effects might happen.
- Ask what your nursing home is doing to protect you from antibiotic-resistant and C. difficile infections.
- Insist that everyone cleans their hands before touching you.
- Ask visitors and family not to visit when they feel ill.
- Get vaccinated for flu and pneumonia, and encourage others to stay up-to-date on vaccines.