Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

Abstract

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities

“…Therefore, different physician subgroups should be targeted for interventions aimed at each domain of prescribing behaviour. Given the extensive barriers to appropriate antimicrobial prescribing in long-term care facilities, 4,14,15 some prescriber-level interventions may be labour-intensive or offer only short-lived benefits (e.g., prescriber education and detailing). Perhaps the most pragmatic, effective and scalable intervention would be peer comparison audit and feedback.…”

“…12 Antibiotic stewardship interventions in long-term care have had promising but inconsistent effects on antibiotic use. [13][14][15] Prior initiatives have usually been multifaceted and have included educational sessions, [16][17][18][19][20][21] development of local guidelines, 16,17,[21][22][23] portable reference material, 16,19,23 on-site consultations about infectious diseases 24 or academic detailing. 18 Many of these interventions are labour intensive, and none have reported on cost-effectiveness or sustainability.…”

Effects of Excessive Antibiotic Use in Nursing Homes

“…2 Antibiotics are one of the most frequently prescribed medications in NHs where 6% to 10% of residents are taking antibiotics at any given time and more than half receive at least one antibiotic prescription in a single year. 3 Much of this use is inappropriate. An estimated 25% to 75% of antibiotic prescriptions do not meet clinical guidelines for appropriate prescribing.…”

Nurses’ role in medical prescription: Systematic review

“…However, this act is not done unilaterally by doctors, but it is most often the conjunction of different factors and actors interacting with the final decision that is the sole responsibility of the legal actor. Physicians' decision-making in medical prescribing is influenced not only by their own expertise and beliefs, but also by nurses [4,9]. From this perspective, a systematic review of the literature for the role of nurses in medical prescription and their influence on the physicians' decision appears necessary.…”