Antimicrobial stewardship is designed to decrease unnecessary antibiotic use and overuse which protects residents from harm and to help combat multidrug-resistant organisms. In nursing homes up to 75% of antibiotics are prescribed incorrectly. The seven core elements of commitments and actions of antibiotic stewardship were developed by the CDC to help in the treatment of infections while decreasing adverse reactions. CMS requires antimicrobial stewardship as part of long-term care’s conditions of participation to include protocols and monitoring of antibiotic use. There is not a one size fits all approach. The CDC recommends taking implementation of one or two activities to start the program and slowly increase to the seven core measures.
Core Measures for Antimicrobial Stewardship
- Leadership Commitment
- Accountability
- Drug Expertise
- Action
- Tracking
- Reporting
- Education
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Leadership Commitment
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Facilities should engage owners and administrators, as well as regional and national leaders (if appropriate) to demonstrate their support and do the following:
Write statements: supporting the improvement of antibiotic use. These statements should be shared with all facility staff, residents and families.
Include stewardship-related duties in job descriptions for the medical director, clinical nurse leads, and consulting pharmacists.
Communicate with prescribing providers and nursing, including expectations about use of antibiotics and the monitoring and enforcement of stewardship in the facility.
Create a culture which promotes antibiotic stewardship through messaging, education, and celebrating improvement efforts.
Example: CDC Leadership Commitment Letter >
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Accountability
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Individuals should be identified to be accountable for the antibiotic stewardship activities. These individuals should include the:
Medical director who sets the standards for antibiotic prescribing practices and is accountable for overseeing prescribing adherence.
Director of nursing who sets the practice standards for assessing, monitoring and communicating changes in a resident’s condition by nursing staff. The importance of antibiotic stewardship is conveyed by the expectations set.
Consulting pharmacist who supports antibiotic stewardship oversight through activities such as medication review and reporting of antibiotic use data to the facility.
Infection preventionist who informs leadership, clinical staff and providers strategies to improve antibiotic use. This should include tracking antibiotic starts, monitoring adherence of the program, and treatment of infections and reviews antibiotic resistance patterns.
Consultant laboratory who supports the request for reports and services to help with antibiotic stewardship activities.
Examples of support:
- Alerting the facility if significant multidrug-resistant organisms are identified
- Educate staff on diagnostic tests available for detecting
- Creating a summary report of susceptibility patterns from organisms isolated in cultures.
State and local health departments who offer educational support and resources >
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Drug Expertise
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An individual should be designated to implement antibiotic stewardship activities. This usually is an infectious disease provider and/or a consulting pharmacist.
Ways to establish drug experts:
- Work with a consultant pharmacist
- Partner with leaders at the hospitals within your referral network
- Develop relationships with infectious disease consultants in your community.
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Action
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Policy and practice changes should be implemented to improve antibiotic use. This should be done in a stepwise way, so staff are not overwhelmed.
This should include:
- Policies that support optimal antibiotic use
- Broad interventions to improve antibiotic use
- Pharmacy interventions to improve antibiotic use
- Infection specific interventions to improve antibiotic use.
Agency for Healthcare Research and Quality: Minimum Criteria for Antibiotics Tools
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Tracking
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Antibiotic use practices and outcomes should be monitored. This can be accomplished through feedback with clinical providers and staff.
Examples include tracking:
- How and why antibiotics are prescribed
- How often and how many antibiotics are prescribed
- Adverse outcomes and costs from antibiotics.
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Reporting
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Once tracking has been established the information gained should be reported to leadership, proscribing providers, and clinical staff.
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Education
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Antimicrobial stewardship education should be provided to leadership, providers, clinical staff, residents and families.
Examples of Education
CDC: What to Ask Your Health Care Provider about Antibiotics >
CDC: What You Need to Know About Antibiotics in a Nursing Home >
Johns Hopkins Toolkit to Enhance Nursing and Antibiotic Stewardship Partnership
- Urinary Tract Infections 101 for Nurses Slide Deck >
- Urine Algorithm >
- Pneumonia 101 for Nurses Slide Deck >
- Respiratory Culture Algorithm >
- Penicillin Allergy 101 for Nursing Slide Deck >
- Clostridioides difficile 101 for Nursing Slide Deck >
- SBAR Communication Tool >
- Get the full toolkit >
More Information
CDC: Antibiotic Stewardship in Long-Term Care Facilities: NHSN LTC Training 2019
CDC Checklist: Core Elements of Antibiotic Stewardship in Nursing Homes