Implementation of core elements of antibiotic stewardship in nursing homes—National Healthcare Safety Network, 2016–2018

Abstract Objective: To assess the national uptake of the Centers for Disease Control and Prevention’s (CDC) core elements of antibiotic stewardship in nursing homes from 2016 to 2018 and the effect of infection prevention and control (IPC) hours on the implementation of the core elements. Design: Retrospective, repeated cross-sectional analysis. Setting: US nursing homes. Methods: We used the National Healthcare Safety Network (NHSN) Long-Term Care Facility Component annual surveys from 2016 to 2018 to assess nursing home characteristics and percent implementation of the core elements. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all 7 core elements while controlling for confounding by facility characteristics. Results: We included 7,506 surveys from 2016 to 2018. In 2018, 71% of nursing homes reported implementation of all 7 core elements, a 28% increase from 2016. The greatest increases in implementation from 2016 to 2018 were in education (19%), reporting (18%), and drug expertise (15%). In 2018, 71% of nursing homes reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. Nursing homes that reported at least 20 hours of IPC activity per week were 14% (95% confidence interval, 7%–20%) more likely to implement all 7 core elements when controlling for facility ownership and affiliation. Conclusions: Nursing homes reported substantial progress in antibiotic stewardship implementation from 2016 to 2018. Improvements in access to drug expertise, education, and reporting antibiotic use may reflect increased stewardship awareness and resource use among nursing home providers under new regulatory requirements. Nursing home stewardship programs may benefit from increased IPC staff hours.

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178. Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes – National Healthcare Safety Network (NHSN), 2016–2018

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.222 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S96-S96

Author(s):

Katryna A Gouin ◽

Sarah Kabbani; Angela Anttila ◽

Josephine Mak ◽

Elisabeth Mungai ◽

Ti Tanissha McCray ◽

...

Keyword(s):

Nursing Homes ◽

Antibiotic Stewardship ◽

Care Facility ◽

Antibiotic Use ◽

Infection Prevention And Control ◽

Term Care ◽

Long Term Care Facility ◽

The Core ◽

Use Of Resources ◽

Core Elements

Abstract Background Since 2016, nursing homes (NHs) enrolled in the Centers for Disease Control and Prevention’s NHSN Long-term Care Facility (LTCF) Component have reported on their implementation of the core elements of antibiotic stewardship. In 2016, 42% of NHs reported implementing all seven core elements. Recent regulations require antibiotic stewardship programs in NHs. The objectives of this analysis were to track national progress in implementation of the core elements and evaluate how time dedicated to infection prevention and control (IPC) is associated with the implementation of the core elements. Methods We used the NHSN LTCF 2016–2018 Annual Surveys to assess NH characteristics and implementation of the core elements, defined as self-reported implementation of at least one corresponding stewardship activity. We reported absolute differences in percent implementation. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all seven core elements, while controlling for confounding by facility characteristics. Results We included 7,506 surveys from 2016–2018. In 2018, 71% of NHs reported implementation of all seven core elements, a 28% increase from 2016 (Fig. 1). The greatest increases in implementation from 2016–2018 were in Education (+19%), Reporting (+18%) and Drug Expertise (+15%) (Fig. 2). Ninety-eight percent of NHs had an individual responsible for antibiotic stewardship activities (Accountability), with 30% indicating that the role was fulfilled by an infection preventionist. Furthermore, 71% of NHs reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. NHs that reported at least 20 hours of IPC activity per week were 14% more likely to implement all seven core elements, when controlling for facility ownership and affiliation, 95% CI: (1.07, 1.20). Conclusion NHs reported substantial progress in antibiotic stewardship implementation from 2016–2018. Improvements in accessing drug expertise, providing education and reporting antibiotic use may reflect increased stewardship awareness and use of resources among NH providers under new regulatory requirements. NHs with at least 20 hours dedicated to IPC per week may have greater capacity to implement all core elements. Disclosures All Authors: No reported disclosures

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Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes Enrolled in the National Healthcare Safety Network

Clinical Infectious Diseases ◽

10.1093/cid/ciz102 ◽

2019 ◽

Vol 69 (7) ◽

pp. 1235-1238 ◽

Cited By ~ 2

Author(s):

Danielle L Palms ◽

Sarah Kabbani ◽

Jeneita M Bell ◽

Angela Anttila ◽

Lauri A Hicks ◽

...

Keyword(s):

Nursing Homes ◽

Disease Control ◽

Antibiotic Stewardship ◽

Infection Prevention ◽

Ownership Type ◽

National Healthcare ◽

The Core ◽

National Healthcare Safety Network ◽

Core Elements ◽

Centers For Disease Control

Abstract In 2016, 42% of nursing homes enrolled in the National Healthcare Safety Network reported meeting all 7 of the Centers for Disease Control and Prevention’s Core Elements of Antibiotic Stewardship. Bivariate analyses suggested that implementation of all core elements differed by ownership type and amount of infection prevention staff hours.

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A Qualitative Study of Antibiotic Stewardship Implementation at Arizona Skilled Nursing Facilities

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.602 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s101-s101

Author(s):

Theresa LeGros ◽

Connor Kelley ◽

James Romine ◽

Katherine Ellingson

Keyword(s):

Nursing Homes ◽

Antibiotic Stewardship ◽

Population Level ◽

Skilled Nursing Facilities ◽

Care Transition ◽

Antibiotic Prescribing ◽

Nursing Facilities ◽

Skilled Nursing ◽

The Core ◽

Core Elements

Background: The CDC Core Elements of Antibiotic Stewardship (AS) include 7 evidence-based best practices adapted for a variety of healthcare settings, including nursing homes. We aimed to identify barriers and facilitators related to AS implementation in skilled nursing facilities (SNFs) within 18 months of the CMS mandate for AS implementation in SNFs, and to examine their relevance to the CDC’s Core Elements for Nursing Homes. Methods: We conducted 56 semistructured interviews with administrators, clinicians, and nonclinical staff at 10 SNFs in urban, suburban, rural, and border regions of Arizona. All interviews were recorded, transcribed, and imported into NVivo v12.0 software for constant comparative analysis by 3 researchers using a priori and emergent codes. After iterative coding, we confirmed high interrater reliability (κ = 0.8), finalized the code book, and used matrix coding queries to examine relationships and generate themes. Results: We identified 7 themes as “influencers” that were less (barrier) or more (facilitator) supportive of AS in SNFs. Intra- and interfacility communication were the most frequently described: respondents described stronger communication within the SNF and between the SNF and hospitals, labs, and pharmacies as critical to robust AS implementation. Other influencers included AS education, antibiotic tracking systems, SNF prescribing norms, human resources, and diagnostic resources. The Core Elements were reflected in all influencer themes except interfacility communication between SNFs and hospitals. Additionally, themes pertaining to systems emerged as critical to successful AS implementation, including the need to address: the interactions of multiple roles across the traditional SNF hierarchy, stewardship barriers from the lens of patient-level concerns (as opposed to population-level concerns), the distinction between antibiotic prescribing gatekeepers and stewardship gatekeepers, and care transition policies and practices. The Core Elements target many aspects of these systems themes—for example, they recognize the importance of creating a culture of stewardship. However, they do not address care transition policies or procedures beyond recommending that transfer-initiated antibiotics be tracked and verified. Conclusions: Because the interactions of various agents within and beyond the SNF can facilitate or inhibit stewardship in complex ways, our findings suggest the use of a systems approach to AS implementation that prioritizes communication within the SNF hierarchy, and between SNFs and hospitals, diagnostic facilities, and pharmacies. When followed, the CDC’s Core Elements can provide crucial guidance. However, SNFs need support to overcome the challenges of incorporating these elements into policy and practice. Additionally, more work is needed to understand and enhance stewardship-related care transition, which remains under-addressed by the CDC.Disclosures: NoneFunding: None

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Antibiotic-resistant pathogens associated with urinary tract infections in nursing homes: Summary of data reported to the National Healthcare Safety Network Long-Term Care Facility Component, 2013–2017

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.348 ◽

2020 ◽

Vol 42 (1) ◽

pp. 31-36

Author(s):

Taniece R. Eure ◽

Nimalie D. Stone ◽

Elisabeth A. Mungai ◽

Jeneita M. Bell ◽

Nicola D. Thompson

Keyword(s):

Urinary Tract ◽

Nursing Homes ◽

Long Term Care ◽

Care Facility ◽

Term Care ◽

Long Term Care Facility ◽

National Healthcare ◽

National Healthcare Safety Network ◽

Tract Infections

AbstractObjective:Antibiotic resistance (AR) is a growing and highly prevalent problem in nursing homes. We describe selected AR phenotypes from pathogens causing urinary tract infections (UTIs) reported by nursing homes to the National Healthcare Safety Network (NHSN).Design:Pathogens and antibiotic susceptibility testing results for UTI events in nursing homes between January 2013 and December 2017 were analyzed. The pathogen distribution and pooled mean proportion of isolates that tested resistant to select antibiotic agents are reported.Setting and Participants:US nursing homes voluntarily participating in the Long-Term Care Facility component of the NHSN.Results:Overall, 243 nursing homes reported 1 or more UTIs: 121 (50%) were nonprofit facilities, median bed size was 91 (range: 9–801), and average occupancy was 87%. In total, 6,157 pathogens were reported for 5,485 UTI events. Moreover, 9 pathogens accounted for 90% of all reported UTIs; the 3 most frequently identified were Escherichia coli (41%), Proteus species (14%), and Klebsiella pneumoniae/oxytoca (13%). Among E. coli, fluoroquinolone, and extended-spectrum cephalosporin resistance were most prevalent (50% and 20%, respectively). Although Staphylococcus aureus and Enterococcus faecium represented <5% of pathogens reported, they had the highest rates of resistance (67% methicillin resistant and 60% vancomycin resistant, respectively). Multidrug resistance was most common in Pseudomonas aeruginosa (11%). For the resistant phenotypes we assessed, 36% of all UTIs reported were associated with a resistant pathogen.Conclusions:This is the first summary of AR among common pathogens causing UTIs reported to NHSN by nursing homes. Improved understanding of the resistance burden among common infections helps inform facility infection prevention and antibiotic stewardship efforts.

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Assessment of Adherence to the Core Elements of Hospital Antibiotic Stewardship Programs: A Survey of the Tertiary Care Hospitals in Punjab, Pakistan

Antibiotics ◽

10.3390/antibiotics10080906 ◽

2021 ◽

Vol 10 (8) ◽

pp. 906

Author(s):

Naeem Mubarak ◽

Asma Sarwar Khan ◽

Taheer Zahid ◽

Umm e Barirah Ijaz ◽

Muhammad Majid Aziz ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Tertiary Care ◽

Antibiotic Use ◽

Public Hospitals ◽

Categorical Variables ◽

Current Response ◽

The Core ◽

Significant Difference ◽

Core Elements ◽

Tertiary Care Hospitals

Background: To restrain antibiotic resistance, the Centers for Disease Control and Prevention (CDC), United States of America, urges all hospital settings to implement the Core Elements of Hospital Antibiotic Stewardship Programs (CEHASP). However, the concept of hospital-based antibiotic stewardship programs is relatively new in Low- and Middle-Income Countries. Aim: To appraise the adherence of the tertiary care hospitals to seven CEHASPs. Design and Setting: A cross-sectional study in the tertiary care hospitals in Punjab, Pakistan. Method: CEHASP assessment tool, (a checklist) was used to collect data from the eligible hospitals based on purposive sampling. The check list had 19 statements to cover seven CEHASPs: Hospital Leadership Commitment, Accountability, Pharmacy Expertise, Action (Implement Interventions to Improve Antibiotic Use), Tracking Antibiotic Use and Outcomes, Reporting Antibiotic Use and Outcomes, and Education. For each statement, a response of “YES”, “NO” or “Under Process” constituted a score of 2, 0 and 1, respectively, where the higher the scores the better the adherence. Categorical variables were described through descriptive statistics, while independent t-test computed group differences. Result: A total of 68 hospitals (n = 33 public, n = 35 private) participated with a response rate of 79.1%. No hospital demonstrated “Perfect” adherence. Roughly half private (48.6%) and more than half public (54.5%) sector hospitals were “Poor“ in adherence. Based on the mean score, there was no significant difference between the private and the public hospitals in terms of comparison of individual core elements. The two most neglected core elements emerged as top priority area were: Reporting Antibiotic Use and Outcomes and Tracking Antibiotic Use and Outcomes.Conclusion: The current response of Pakistan to implement hospital-based antibiotic stewardship programs is inadequate. This study points out significant gaps of practice both in public and private tertiary care hospitals. A majority of the core elements of antibiotic stewardship are either absent or ”Under Process”. The deficiency/priority areas mentioned require immediate attention of the concerned stakeholders in Pakistan.

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Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists’ Perspectives

Hospital Pharmacy ◽

10.1177/0018578718781916 ◽

2018 ◽

Vol 54 (4) ◽

pp. 250-258 ◽

Cited By ~ 5

Author(s):

Haley J. Appaneal ◽

Megan K. Luther ◽

Tristan T. Timbrook ◽

Kerry L. LaPlante ◽

David M. Dosa

Keyword(s):

New England ◽

Organizational Structure ◽

Antibiotic Stewardship ◽

Medical Center ◽

Qualitative Interviews ◽

Antibiotic Use ◽

Term Care ◽

Protected Time ◽

Medical Centers ◽

Core Elements

Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.

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Trends in antibiotics use among long-term US nursing-home residents

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.422 ◽

2020 ◽

pp. 1-7

Author(s):

Catherine C. Cohen ◽

Andrew W. Dick ◽

Mansi Agarwal ◽

Tadeja Gracner ◽

Susan Mitchell ◽

...

Keyword(s):

Nursing Home ◽

Cognitive Impairment ◽

Nursing Homes ◽

Antibiotic Stewardship ◽

Nursing Home Residents ◽

Antibiotic Use ◽

Cognitive Status ◽

Cross Sectional ◽

Data Set

Abstract Objectives: Antibiotics are overly prescribed in nursing homes. Recent antibiotic stewardship efforts attempt to reduce inappropriate use. Our objective was to describe antibiotic use from 2012 to 2016 among nursing-home residents with various health conditions. Design: Retrospective, repeated cross-sectional analysis. Setting and participants: All long-term residents in a random 10% sample of national nursing homes: 2,092,809 assessments from 319,615 nursing-home residents in 1,562 nursing homes. Measurements: We calculated a 1-day antibiotic prevalence using all annual and quarterly clinical assessments in the Minimum Data Set (MDS) from April 2012 through December 2016. We calculated prevalence of antibiotic use overall and within conditions of interest: Alzheimer’s disease and related dementias (ADRD), advanced cognitive impairment (ACI), and infections likely to be treated with antibiotics. We applied logistic regressions with nursing-home cluster, robust standard errors to assess changes in conditions and antibiotic use 2012–2016. Results: Overall, antibiotic use did not change (2012 vs 2016, adjusted odds ratio [AOR], 1.00; 95% CI, 0.97–1.03). Antibiotic use was higher in 2016 versus 2012 among assessments with any infection (AOR, 1.10; 95% CI, 1.04–1.16), urinary tract infection (AOR, 1.18; 95% CI, 1.12–1.25), and no infection (AOR, 1.13; 95% CI, 1.09–1.17). Results were similar by cognitive status. Conclusions: The increased proportion of assessments recording antibiotics but no infection may not be clinically appropriate. Higher antibiotic use among infected residents with advanced cognitive impairment is also concerning. Further efforts to understand mechanisms driving these trends and to promote antibiotic stewardship in nursing homes are warranted.

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Urinary tract infection treatment practices in nursing homes reporting to the National Healthcare Safety Network, 2017

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.49 ◽

2021 ◽

pp. 1-3

Author(s):

Sarah Kabbani ◽

Danielle Palms ◽

Jeneita M. Bell ◽

Lauri A. Hicks ◽

Nimalie D. Stone

Keyword(s):

Urinary Tract Infection ◽

Urinary Tract ◽

Nursing Homes ◽

Tract Infection ◽

Antibiotic Stewardship ◽

Treatment Practices ◽

National Healthcare ◽

National Healthcare Safety Network ◽

Infection Treatment

Abstract We describe differences between urinary tract infection treatment and events reported by nursing homes enrolled in the National Healthcare Safety Network. In 2017, almost 4 times as many antibiotic starts as infection events were reported, suggesting that opportunities exist for antibiotic stewardship and improvement of urinary tract infection reporting.

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Uropathogens and Antibiotic Resistance Among Nursing Home Residents - National Healthcare Safety Network (NHSN)

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx162.120 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S51-S51

Author(s):

Taniece Eure ◽

Nimalie D Stone ◽

Nicola D Thompson ◽

Jeneita Bell ◽

Elisabeth Mungai

Keyword(s):

Antibiotic Resistance ◽

Nursing Homes ◽

Methicillin Resistance ◽

Bacterial Species ◽

Nursing Home Residents ◽

Care Facility ◽

Antibiotic Prescribing ◽

Term Care ◽

National Healthcare ◽

National Healthcare Safety Network

Abstract Background Knowledge of urinary tract infection (UTI) pathogen and susceptibility patterns is necessary to inform antibiotic prescribing and monitor resistance. We describe bacterial pathogens and UTI antibiotic resistance patterns among residents in nursing homes (NHs) reporting to the National Healthcare Safety Network (NHSN) long-term care facility (LTCF) component. Methods All UTI events from January 1, 2013 to December 31, 2016 were included; up to three organisms per UTI event may be reported. Pathogen susceptibility results for selected antibiotics are reported as: Susceptible (S), Intermediate (I), Resistant (R), or Not tested (N). For this analysis, resistance was defined as I or R. We described pathogens and summarized antibiotic resistance only when ≥100 isolates of a bacterial species had susceptibility test results for a particular antibiotic reported to NHSN. Results In 166 NHs located in 37 states, a total of 4,054 pathogens were reported for 2,827 residents. Six organisms accounted for 81% of all UTI events (n = 3,599) (Table). A large proportion of Escherichia coli isolates, which accounted for 41% of uropathogens, were resistant to trimethoprim-sulfamethoxazole (35%) and levofloxacin (50%). Among Proteus mirabilis isolates, 53% were resistant to levofloxacin (Figure). Methicillin resistance was 74% among Staphylococcus aureus, and vancomycin resistance among Enterococcus spp. was 18%. Conclusion This is the first summary of UTI pathogens and susceptibility data from U.S. nursing homes reporting to a national surveillance system. Resistance to antibiotics commonly used to treat UTIs was high. Tracking and preventing resistance for key pathogens is a CDC priority and NHSN reporting by NHs provides a crucial opportunity to track antibiotic resistance, highlighting the importance of enrolling more NHs into NHSN. Disclosures All authors: No reported disclosures.

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88. Review of nursing home antibiotic stewardship citation deficiencies to identify opportunities to improve antibiotic stewardship implementation, 2018-2019

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.088 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S55-S56

Author(s):

Katryna A Gouin ◽

Andrea J Cool ◽

Nimalie D Stone ◽

Lauri Hicks ◽

Kara M Jacobs Slifka ◽

...

Keyword(s):

Nursing Home ◽

Nursing Homes ◽

Antibiotic Stewardship ◽

Core Element ◽

Qualitative Review ◽

For Profit ◽

Core Elements ◽

Barriers To Implementation ◽

Facility Level ◽

Level Training

Abstract Background Centers for Medicare & Medicaid Services (CMS) set standards for nursing homes (NH) and conduct inspections to assess adherence to regulatory requirements, including antibiotic stewardship implementation. NHs not meeting requirements are issued a citation. We reviewed text summaries for citations related to antibiotic stewardship to assess implementation in NHs. Methods We obtained publicly available antibiotic stewardship deficiency citations issued to NHs from 9/2018—7/2019 and NH characteristics data from CMS Nursing Home Compare. We used the χ2 test to compare characteristics of NHs with and without citations. We did a qualitative review of a randomly selected subset (318/635) of antibiotic stewardship citations and classified citations into one or more of four categories based on Centers for Disease Control and Prevention’s Core Elements of Antibiotic Stewardship: 1) Leadership & Accountability, 2) Action, 3) Tracking & Reporting, 4) Education (Fig 1). We developed subcategories based on our iterative review process to further describe the citations. Each citation was reviewed by two reviewers and yielded 95% agreement in categorization. Discordant citations were reviewed by a third reviewer, and core element categories with agreement by ≥2/3 reviewers were assigned, resulting in 99% agreement. Antibiotic Stewardship Citation Deficiency Category Common Themes and Examples from Citation Text from Qualitative Review of Antibiotic Stewardship Citation Deficiencies. Results There were 635 NH stewardship citation deficiencies across 44 states from 9/2018—7/2019. NHs with a citation were more likely to have < 100 beds (60% vs. 50%) and for-profit ownership (75% vs. 70%) (Table 1). Of the 318 reviewed citations, Action was cited in 67% of NHs; 115/213 had missing or incomplete criteria documented for antibiotic initiation. Tracking & Reporting was cited in 40% of NHs; 117/126 had missing or incomplete antibiotic or infection tracking logs. Leadership & Accountability was cited in 23% of NHs; 41/72 NHs had no stewardship policy available. Education was cited in 13% of NHs (Fig 2). Table 1. Characteristics of US Nursing Homes With and Without an Antibiotic Stewardship Citation Deficiency from 9/2018-7/2019. Figure 2. Types of Antibiotic Stewardship Citation Deficiencies in US Nursing Homes, 2018-2019, N=318. Conclusion The most common opportunities for improvement fell under appropriate assessment and documentation of criteria for antibiotic initiation at the resident and facility-level. Training NH staff to use available resources for antibiotic stewardship activities may improve implementation. Further evaluation to identify barriers to implementation is needed. Disclosures David Gifford, MD, MPH, American Healthcare Association (Employee)

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