Training program

Stewardship training program reduces antibiotic use in nursing homes

March 10, 2022

4 minute read


Disclosures: Crnich and Taylor report no relevant financial information. Katz reports receiving grants from the CDC and NIH and personal fees from Artis Senior Living. Please see the study for relevant financial information from all other authors.


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According to results published in JAMA network open.

“Improving the use of antibiotics in nursing homes is of crucial importance, both for the individual resident, who may suffer side effects from unnecessary antibiotics, and for public health,” Morgan J. Katz, MD, MHS, an assistant professor of medicine at Johns Hopkins Medicine, told Healio.


Katz MJ, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.0181.

“Older people are most susceptible to the adverse effects of antibiotic use,” she added. “They are often on multiple medications, which can lead to dangerous interactions such as kidney damage, arrhythmias or bleeding problems.”

The elderly are also particularly susceptible to serious infections by Clostridioides Dfictional, which can occur with the use of antibiotics, according to Katz. The use of antibiotics can lead to bacterial resistance, which makes it difficult to treat infections.

Morgan Katz

Morgan J. Katz

Antibiotic Stewardship Program

In a quality improvement study, Katz and colleagues investigated outcomes following the implementation of the Agency for Healthcare Research and Quality (AHRQ) safety program for the improvement of Antibiotic Use, a free resource for developing and maintaining antibiotic stewardship programs in long-term care facilities.

“The goal of the program is to reframe antibiotic use as a patient safety issue, with the understanding that any antibiotic prescription may pose a risk to the patient and should be considered,” Katz said.

The AHRQ program was implemented in 439 long-term care facilities in the United States between December 2018 and November 2019. The trainings emphasized the “four moments of antibiotic decision-making” framework through presentations, posters and pocket cards administered during 15 webinar sessions over a 12 month period. All clinical staff in long-term care facilities were encouraged to participate; however, the trainings were optional.

In addition to antibiotic use, the researchers also assessed changes in urine collection.

“The common misperception by direct care staff or family members that changes in the appearance of urine (eg, smelly, cloudy) indicates a urinary tract infection (UTI) may lead to the Obtaining unnecessary urine cultures to assess UTIs Up to 50% of nursing home residents will have bacteria in their urine, and prescribers often feel inclined to process a positive culture even if antibiotics are not not indicated,” Katz and colleagues wrote. “We targeted misconceptions about when to test for and treat UTIs by educating direct caregivers about sending urine cultures only when specific signs and symptoms were present.”

Results following the intervention

From baseline to end of study, antibiotic initiation decreased from 7.9 to 7.5 per 1000 resident days (mean difference = -0.41; 95% CI, -0.76 to -0.07), according to the researchers. Fluoroquinolones showed the greatest decrease from 1.5 to 1.3 per 1000 resident-days (mean difference = -0.21; 95% CI, -0.35 to -0.08).

Although there was no significant difference in the number of antibiotic therapy days per 1,000 resident days (–3.05; 95% CI, -6.34 to 0.23), the researchers found that reductions in antibiotic initiation and use were greatest at facilities with program commitment, which was measured by webinar attendance. Katz and colleagues reported that antibiotic starts and days of antibiotic therapy decreased by 1.12 (95% CI, -1.75 to -0.49) and by 9.97 per 1000 days- residents (95% CI, -15.4 to -4.6;) in facilities with high participation. . Additionally, urine cultures decreased by 0.38 (95% CI, -0.61 to -0.15) per 1000 resident days.

The implications of the findings are significant, according to Katz.

“We’ve used a top-down approach to antibiotic management for too long and haven’t put enough emphasis on involving the whole healthcare team, rather than just prescribers, in the prescribing process” , she said. “In the long-term care setting, nurses and certified practical nurses are the backbone of the care team; they are the ones who are at the bedside and often have conversations with families. By taking the time to educate and engage these staff, we can significantly reduce the use of unnecessary diagnostic tests and antibiotics, which can certainly lead to cost savings for the facility over time. »

Undetermined causal relationship

In a related comment, Lindsay N. Taylor, MD, an infectious disease physician, and Christopher J. CrnichMD, PhD, an associate professor of infectious diseases, both from the University of Wisconsin School of Medicine and Public Health, discussed the implications of the findings as well as the limitations of the study.

They noted that antibiotic initiations and days of antibiotic treatment per 1,000 resident-days decreased by approximately 5% and the number of urine cultures collected decreased by approximately 13% compared to the value initial. However, the study design makes it difficult to establish a causal relationship to the intervention, according to Taylor and Crnich. Further research involving antibiotic stewardship programs is needed to build on the findings of Katz and his colleagues, they wrote.

More research will “accelerate our understanding of needed improvements in nursing home antibiotic management infrastructure and help identify interventions with the greatest impact on critical antibiotic use and outcome measures.” they wrote.

Taylor and Crnich also clarified that antibiotic resistance threatens other health care settings in addition to long-term care facilities. A previous 5-year national study evaluated the AHRQ initiative in ambulatory care. Healio reported that the results of this study indicate that antibiotic stewardship programs in ambulatory care settings resulted in nine fewer antibiotic prescriptions per 100 visits.

Still, “stewardship programs remain immature in most facilities,” wrote Taylor and Crnich.

The references:

Katz MJ, et al. JAMA Network Open. 2022;doi:10.1001/jamanetworkopen.2022.0181.

Taylor LN, Crnich CJ. JAMA Network Open. 2022;doi:10.1001/jamanetworkopen.2022.0211.