February 2021

GERIATRICS

IMPLEMENTATION OF AN ANTIBIOTIC STEWARDSHIP PROGRAM IN LONG-TERM CARE FACILITIES ACROSS THE US

Featuring: Theresa A Rowe, DO, MS​

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​​Key Points

Question  Is framing antibiotic stewardship as a patient safety issue and emphasizing direct care staff engagement associated with reductions in antibiotic use across US long-term care facilities?

Findings  In this quality improvement study including 439 long-term care facilities, participation in training on antibiotic stewardship from the Agency for Healthcare Research and Quality (AHRQ) was associated with a reduction in antibiotic use and urine culture collection. Fluoroquinolones, an antibiotic class targeted by the AHRQ safety program, had the greatest decrease.
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Meaning  These results suggest that the AHRQ safety program provides a pragmatic framework for the development of antibiotic stewardship programs in long-term care facilities that may reduce antibiotic use.


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Abstract

Importance  Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown.

Objectives  To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings.

Design, Setting, and Participants  This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019.

Interventions  Fifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate.

Main Outcomes and Measures  The primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10 000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time.

Results  Of a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was –0.41 (95% CI, –0.76 to –0.07; P = .02), with fluoroquinolones showing the greatest decrease at –0.21 starts per 1000 resident-days (95% CI, –0.35 to –0.08; P = .002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (–3.05; 95% CI, –6.34 to 0.23; P = .07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, –1.75 to –0.49; P < .001) and 9.97 per 1000 resident-days (95% CI, –15.4 to –4.6; P < .001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, –0.61 to –0.15; P = .001). There was no significant change in facility-onset C difficile laboratory-identified events.

Conclusions and Relevance  Participation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings.

​This abstract was originally published on JAMA Network Open on February 28, 2021. ​
Theresa A Rowe, DO, MS, is an assistant professor of General Internal Medicine and Geriatrics in the department of Medicine.

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