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Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders.
A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models.
In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5–10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software).
Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.
Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug–drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.
Background: Pneumonia (PNA) is an important cause of morbidity and mortality among nursing home residents. The McGeer surveillance definitions were revised in 2012 to help NHs better monitor infections for quality improvement purposes. However, the concordance between surveillance definitions and clinically diagnosed PNA has not been well studied. Our objectives were to identify nursing home residents who met the revised McGeer PNA definition, to compare them with residents with clinician documented PNA, and determine whether modifications to the surveillance criteria could increase concordance. Methods: We analyzed respiratory tract infection (RTI) data from 161 nursing homes in 10 states that participated in a 1-day healthcare-associated infection point-prevalence survey in 2017. Trained surveillance officers from the CDC Emerging Infections Program collected data on residents with clinician documentation, signs, symptoms, and diagnostic testing potentially indicating an RTI. Clinician-documented pneumonia was defined as any resident with a diagnosis of pneumonia identified in the medical chart. We identified the proportion of residents with clinician documented PNA who met the revised McGeer PNA definition. We evaluated the criteria reported to develop 3 modified PNA surveillance definitions (Box), and we compared them to residents with clinician documented PNA.
Results: Among the 15,296 NH residents surveyed, 353 (2%) had >1 signs and/or symptoms potentially indicating RTI. Among the 353 residents, the average age was 76 years, 105 (30%) were admitted to postacute care or rehabilitation, and 108 (31%) had clinician-documented PNA. Among those with PNA, 28 (26%) met the Revised McGeer definition. Among 81 residents who did not meet the definition, 39 (48%) were missing the chest x-ray requirement, and among the remaining 42, only 3 (7%) met the constitutional criteria requirement (Fig. 1). Modification of the constitutional criteria requirement increased the detection of clinically documented PNA from 28 (26%) to 36 (33%) using modified definition 1; to 51 (47%) for modified definition 2; and to 55 (51%) for modified definition 3. Conclusions: Tracking PNA among nursing home residents using a standard definition is essential to improving detection and, therefore, informing prevention efforts. Modifying the PNA criteria increased the identification of clinically diagnosed PNA. Better concordance with clinically diagnosed PNA may improve provider acceptance and adoption of the surveillance definition, but additional research is needed to test its validity.
Background: Catheter-associated symptomatic urinary tract infections (CA-SUTIs) are a common adverse healthcare event in nursing homes and have been the focus of multiple prevention strategies.1 In 2012, the CDC launched the NHSN Long-Term Care Facility (LTCF) Component, which nursing homes, the CDC, and prevention collaborators can use to monitor nursing home CA-SUTI incidence and prevention progress.2 The objective of this analysis was to compare CA-SUTI rates and reporting patterns of nursing homes between 2013–2015 and 2016–2018. Methods: We analyzed CA-SUTI data from nursing homes reporting to the NHSN during 2013–2018. Consistent reporters submitted ≥6 months of complete data in any calendar year during the period. To potentially confirm patterns in CA-SUTI rates, we defined “consecutive” reporters, as nursing homes that submitted data for ≥6 months each year during 2013–2018. CA-SUTI incidence rates were calculated as the number of CA-SUTI events divided by the number of catheter days multiplied by 1,000. Likelihood ratio tests using negative binomial regression were used to compare CA-SUTI rates from 2016–2018 and 2013–2015 among both consistent and consecutive reporters. Results: During 2013–2018, the number of nursing homes submitting at least 1 month of CA-SUTI data to NHSN increased from 60 to 120 (Fig. 1). Among these nursing homes, 194 (88%) were consistent reporters. The pooled CA-SUTI rate of 1.77 per 1,000 catheter days in 2016–2018 was significantly lower than the pooled CA-SUTI rate of 2.45 per 1,000 catheter days in 2013–2015 among consistent reporters by ~24% (Table 1). Also, 50 consecutive reporters submitted CA-SUTI data during 2013–2018. Among these consecutive reporters, the pooled CA-SUTI rate of 2.11 per 1,000 catheter days in 2016–2018 was significantly lower than the rate of 2.53 per 1,000 catheter days in 2013–2015 by ~21% (Table 1). Conclusions: This analysis suggests that nursing homes using NHSN for CA-SUTI surveillance have made progress in prevention efforts. During 2013–2018, evidence showed that CA-SUTI incidence rates declined among consistent reporters between the 2 reporting periods. This decrease was verified among consecutive reporters. Additional study is needed to determine which factors account for varying reporting patterns and differential CA-SUTI incidence.