CDC Seeks to Improve Antibiotic Prescribing in Nursing Homes

September 16, 2015

Nursing homes are hotbeds of misprescribed antibiotics that breed dreaded superbugs, such as Clostridium difficile, according to the US Centers for Disease Control and Prevention (CDC).

The agency wants nursing homes to be models of antibiotic stewardship instead.

The CDC released recommendations on September 16 for prescribing antibiotics in these long-term care facilities and sparing residents the scourge of antibiotic-resistant infections. The agency is directing its guidance toward nursing-home medical directors and nursing directors, attending physicians, and pharmacists.

Roughly 4.1 million Americans live in or are admitted to nursing homes each year, according to the CDC. Of these individuals, as many as 7 in 10 will receive at least one course of antibiotics, the most commonly prescribed medication in these facilities. However, between 40% and 75% of the prescriptions are either unnecessary or else written for the wrong drug, dose, or duration.

Two practices that contribute to the high error rate are prescribing antibiotics to prevent urinary tract infections and respiratory infections and prescribing them when bacteria have colonized a patient but have not yet made him or her sick.

The CDC is exhorting nursing home medical directors to set standards for antibiotic prescribing and oversee adherence to them. Nursing directors likewise should set standards for nursing staff to "assess, monitor, and communicate changes in a resident's condition that could impact the need for antibiotics."

Sometimes nurses neglect to inform prescribers that the condition of a patient receiving an antibiotic has stabilized, which may signal the need to discontinue the medication, said Naushira Pandya, MD, president of the AMDA, the Society for Post-Acute and Long Term Care Medicine, in an interview with Medscape Medical News. Dr Pandya's group reviewed a draft of the CDC recommendations and commented on them before their release.

Challenges of Implementation

Dr Pandya noted that nursing home residents frequently battle infections for a variety of reasons, not the least of which is that these patients are very sick in the first place. Having to share bedrooms and bathrooms with patients like themselves also contributes to high infection rates, as does widespread incontinence and sometimes lapses in handwashing and other infection control practices committed by busy staff. A high employee turnover rate does not help matters, said Dr Pandya.

She called today's CDC guidance "a good set of tools," but said that implementing the recommendations has its challenges. Nursing home medical directors are not the only clinicians prescribing antibiotics, for example. Attending physicians from the community do so as well, and getting them on the same page antibiotically requires not only a medical director's time and effort but also buy-in from ownership. "The medical director needs to be empowered," she said. Likewise, nursing home operators need to hire personnel with infection-control expertise or else train the people they already have along these lines.

"This is also a matter of staffing, and it can't be solved overnight," Dr Pandya said.

More information about the CDC's recommendations for antibiotic prescribing in nursing homes is available on the agency's website.

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