Core Elements of Antibiotic Stewardship for Nursing Homes

Nimalie Stone, MD, MS


September 21, 2015

Editorial Collaboration

Medscape &

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Hello. I'm Dr Nimalie Stone, a medical officer at the Centers for Disease Control and Prevention (CDC). I am pleased to speak with you as part of the CDC Expert Commentary Series on Medscape. Today I would like to talk about antimicrobial stewardship in nursing homes.

Improving the use of antibiotics to protect patients and reduce the threat of antibiotic resistance is a national priority.[1,2] In 2014, CDC recommended that all acute care hospitals implement an antibiotic stewardship program with commitments and activities designed to "optimize the treatment of infections while reducing the adverse events associated with antibiotic use."[1] CDC also recommends that all nursing homes take steps to implement antibiotic stewardship activities.

Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics in a year.[3,4] Similar to the findings in acute care hospitals[5,6] studies have shown that 40%-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate.[3,4]

This high level of exposure to antibiotics can lead to serious adverse events and consequences for the individual and the community, such as Clostridium difficile, (C diff) infections, drug-drug interactions, and colonization or infection with antibiotic-resistant organisms.[7,8,9]

C diff infection is the most common—and sometimes fatal—cause of antibiotic-related acute diarrhea in nursing homes.[10,11] Colonization with C diff or antibiotic-resistant organisms poses the risk for transmission to other residents and patients, including when colonized residents transfer to other healthcare settings.[12]

To support nursing home efforts to improve antibiotic use, CDC published a new resource, CDC Core Elements of Antibiotic Stewardship for Nursing Homes. 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 that are in place and to review progress in expanding stewardship activities on a regular basis.

The core elements of antibiotic stewardship are the same for both hospitals and nursing homes; however, facilities may have differences in the implementation of these elements. Nursing home antibiotic stewardship activities should, at a minimum, include seven basic elements:

  1. Leadership commitment through demonstration of a facility's support of safe and appropriate antibiotic use

  2. Accountability through identification of leaders responsible for promoting and overseeing stewardship activities

  3. Drug expertise in antibiotic use and stewardship, which is available for the facility

  4. Action to implement the recommended policies or practices to improve use, such as requiring an "antibiotic time-out" or review for all new antibiotic prescriptions

  5. Tracking measures of antibiotic use practices and outcomes

  6. Reporting data on antibiotic prescribing and appropriateness of use to facility staff

  7. Education for clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improving use

Nursing homes are encouraged to work in a step-wise fashion to expand their stewardship efforts. As policies and practices are successfully implemented, new strategies can be added to ensure that, over time, activities for each element are put into place. Any action to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in nursing homes.

Web Resources

Nimalie Stone, MD, is the medical epidemiologist for long-term care in the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). She is a board-certified infectious disease physician who has a research and clinical background in managing infections and antibiotic-resistant pathogens in older adults and long-term care settings. She completed her internal medicine residency at Johns Hopkins University and an infectious disease fellowship at Emory University.

In her role at the CDC, Dr Stone develops guidelines, educational resources, and quality-improvement programs to reduce healthcare-associated infections in long-term care facilities. She was the lead author of the revised McGeer surveillance definitions of infections in long-term care facilities and the chair of the workgroup that developed the resources and tools for the infections goal in the Advancing Excellence Campaign. She works with state and federal programs to increase awareness and resources for infection surveillance and prevention activities by long-term care facilities, and supports long-term care facilities enrolled and reporting infections into the CDC's National Healthcare Safety Network.

Dr Stone collaborates with many partners who are engaged in preventing healthcare-associated infections and improving antibiotic stewardship in the long-term care setting, including the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Healthcare Association (AHCA), the National Association of Directors of Nursing Administration in Long-term Care (NADONA/LTC), and the AMDA Society for Post-acute and Long-term Care Medicine (AMDA).