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A 2‐Year Pragmatic Trial of Antibiotic Stewardship in 27 Community Nursing Homes
Author(s) -
Sloane Philip D.,
Zimmerman Sheryl,
Ward Kimberly,
Kistler Christine E.,
Paone Deborah,
Weber David J.,
Wretman Christopher J.,
Preisser John S.
Publication year - 2020
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/jgs.16059
Subject(s) - medicine , antibiotic stewardship , medicaid , rate ratio , medical prescription , antimicrobial stewardship , clostridium difficile , family medicine , quality management , incidence (geometry) , nursing , emergency medicine , confidence interval , antibiotics , health care , antibiotic resistance , service (business) , physics , optics , microbiology and biotechnology , economics , biology , economic growth , economy
OBJECTIVES To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN Two‐year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS Nursing staff and medical care providers in the participating NHs. INTERVENTION Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin‐resistant Staphylococcus aureus (MRSA) infections. RESULTS Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69‐0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65‐0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92‐0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2‐year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46–54, 2019