About the Nursing Home Antimicrobial Stewardship Guide

The Nursing Home Antimicrobial Stewardship Guide (the Guide) provides toolkits to help nursing homes optimize their use of antibiotics.

This page provides information about antimicrobial stewardship and why it is important for nursing homes, and describes how the Guide can be used.

The "Browse Antimicrobial Toolkits" section describes the toolkits, and the "Choosing the Right Toolkit" section provides some ideas to help nursing homes choose toolkits to use. Each toolkit includes an "Overview" that describes why a nursing home might want to use the toolkit, what tools it includes, and provides step-by-step instructions for implementation.

Many of the toolkits have been tested in nursing homes to see whether they had an impact on antibiotic use, and if so, how. Each toolkit includes information about any testing that has been done.

Antimicrobial stewardship is the act of using antibiotics appropriately—that is, using them only when truly needed and using the right antibiotic for each infection. It is called "stewardship" because it protects the effectiveness of the most important tool we have to fight life-threatening bacterial infections: antibiotics.

Antibiotic resistance occurs when bacteria adapt so that the drugs used to treat infections are less effective or do not work at all. Some bacteria have become resistant to multiple types of antibiotics, making infections harder to treat. According to the Centers for Disease Control and Prevention (CDC), at least 2 million people in the United States are infected by antibiotic-resistant bacteria each year, and about 23,000 people die as a result ¹. Antibiotic stewardship can also save money. When examining the cost of antibiotic medications alone, one study showed that antibiotic stewardship saved $28 on antibiotics per resident over the study period and, when taking into consideration the potential costs of treating adverse health events, the cost savings was $1,098 per resident. ²

Antibiotics are one of the most commonly prescribed medications in nursing homes and overuse of antibiotics is recognized as a serious problem. Overexposure to antibiotics allows drug-resistant strains of bacteria and health care-associated infections, such as Clostridium difficile infections, to emerge in the nursing home. When this occurs, it is harder to treat infections, and residents may develop complications. The result is increased resident mortality, hospitalizations, and costs.

Between 25 percent and 75 percent of antibiotics prescribed in nursing homes are unnecessary.³ Because it can be challenging to determine when a resident actually has an infection, prescribing clinicians—doctors, nurse practitioners, and physician assistants—are likely to overuse antibiotics. At the same time, nursing home residents are at high risk for developing complications associated with antibiotic use.

The Guide provides information and tools that nursing homes can use to make antimicrobial stewardship a priority and to select and implement interventions that address the specific needs of their facilities. These interventions have been shown to help prescribing clinicians follow the best guidelines for making clinical decisions about nursing home residents and choose the right antibiotic for each infection.

Using the tools can help nursing homes establish many of the Core Elements of Antibiotic Stewardship for Nursing Homes defined by the CDC, including leadership, accountability, taking action, tracking, reporting, and education.

To make antimicrobial stewardship a priority, the Guide provides toolkits to help nursing homes—

• Establish an antimicrobial stewardship program and choose one or more interventions
• Monitor and sustain antimicrobial stewardship

The intervention toolkits help nursing homes take action to—

• Determine whether antibiotic treatment may be needed for the most common types of suspected infections in nursing homes: urinary tract, respiratory, skin or soft tissue, and gastrointestinal infections
• Document which bacteria are present in a nursing home and which antibiotics are effective for treating an infection
• Educate residents and families about antimicrobial stewardship

The Guide includes a collection of toolkits that provide step-by-step instructions and turnkey materials that nursing homes can use to improve antibiotic use. Each nursing home can choose which toolkits, or parts of toolkits, best suit its needs. Some toolkits contain tools that are meant to be adapted to suit each nursing home.

¹ Centers for Disease Control and Prevention. Delivering safe care for patients: all healthcare providers play a role. Get Smart About Antibiotics Week: November 18–24, 2013. http://www.cdc.gov/getsmart/healthcare/factsheets/hc_providers.html.

² Frentzel E, McMaughan D, Mangrum R, Guo J, Cowans T, Mitchell D, Lucado J. Nursing Home Antimicrobial Stewardship Tools and Guide Project. Prepared under Contract No. HHSA290201000018I, Task Order #2. AHRQ Publication No. 00-0000. Rockville, MD: Agency for Healthcare Research and Quality; September, 2016.

³ Nicolle LE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev. 1996 Jan;9(1):1-17. PMID: 8665472; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172878/pdf/090001.pdf