Antibiotic Prescribing In Nursing Homes Research Articles

Workflow Barriers and Strategies to Reduce Antibiotic Overuse in Nursing Homes.

Antibiotic overuse is a significant problem in nursing homes (NHs). Strategies to improve antibiotic prescribing practices in NHs are a critical need. In this study, we analyzed antibiotic prescribing workflows to identify strategies for improving antibiotic prescribing in NHs. Qualitative descriptive study using prospective field-based assessment of workflows. Six NHs in Wisconsin (n = 3) and Pennsylvania (n = 3). A total of 44 interviews with 68 NH professionals, including leadership, nurses, and prescribers. During a 1-day field visit in each NH, we conducted semistructured interviews with NH professionals, collected artifacts (policies, procedures, and documentation and communication tools), and observed clinical meetings. Study participants were interviewed (30-60 minutes) about antibiotic prescribing workflows in their facility. Information collected during site visits was used to create a representative workflow map of NH antibiotic prescribing. The workflow map guided thematic analysis to identify barriers corresponding to workflow steps across multiple NHs. The representative antibiotic preprescribing workflow map included 17 steps, beginning with resident change in condition and ending with the decision to prescribe an antibiotic. Thematic analysis identified common step-specific barriers to antibiotic stewardship centering on three themes: (A) information barriers, comprising (A1) inconsistent nurse assessment report and (A2) misalignment between the work and tools of information sharing within the facility, (B) communication barriers, comprising (B1) mismatched perception of prescriber information needs and (B2) difficulty reaching prescribers for direct interaction, and (C) professional barriers, comprising (C1) low prescriber confidence in nurse assessment report and (C2) nurse reluctance to express their professional opinions. Strategies addressing workflow barriers are important targets for antibiotic stewardship. Such strategies include structured information tools, nurse and prescriber education, and organizational improvement. Future research can build on combinations of existing and new strategies to measure their effects in improving antibiotic prescribing. J Am Geriatr Soc 68:2222-2231, 2020.

2051. Frequency of Inappropriate Antibiotic Prescribing in Nursing Homes

BackgroundAntibiotics are among the most prescribed medications in nursing homes (NHs). The increasing incidence of multidrug-resistant and C. Difficile infections due to antibiotic overuse has driven the requirement for NHs to establish antibiotic stewardship programs (ASPs). However, estimates of the frequency of inappropriate antibiotic prescribing in NHs have varied considerably between studies. We evaluated the frequency of inappropriate antibiotic prescribing in a multi-state sample of NHs.MethodsWe utilized a retrospective, (20%) random sample of residents of 17 for-profit NHs in Oregon, California, and Nevada who received antibiotics between January 1, 2017 and May 31, 2018. Study NHs ranged in size from 50 to 188 beds and offered services including subacute care, long-term care, ventilator care, and Alzheimer’s/memory care. Data were collected from residents’ electronic medical records. Antibiotic appropriateness was defined using Loeb Minimum Criteria for initiation of antibiotics for residents with indications for lower respiratory tract infection (LRTI), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Residents with other types of infections were excluded from the study.ResultsAmong 232 antibiotic prescriptions reviewed, 61% (141/232) were initiated in the NH. Of these, 65% were for female residents and 81% were for residents above the age of 65. Nearly 70% (98/141) of antibiotic prescriptions were for an indication of an LRTI, UTI, or SSTI of which 51% (57% of LRTIs, 52% of UTIs, and 35% of SSTIs) did not meet the Loeb Minimum Criteria and were determined to be inappropriate. Among antibiotics that did not meet the Loeb Minimum Criteria, more than half were cephalosporins (40%) or fluoroquinolones (14%) and the median (interquartile range) duration of therapy was 7 (5–10) days.ConclusionThese data from a multi-state sample of NHs suggest the continued need for improvement in antibiotic prescribing practices and the importance of ASPs in NHs. Disclosures All authors: No reported disclosures.

2050. Effect of a Stewardship Intervention on Post-Prescriptive Antibiotic Timeouts in Nursing Homes

BackgroundAntibiotic overuse and misuse is a common problem in nursing homes (NHs). Meaningful improvements in the quality of antibiotic prescribing in NHs may be improved through post-prescriptive interventions (antibiotic timeouts) focused on stopping, streamlining and/or shortening ongoing antibiotic treatments. A recently completed trial of a complex antibiotic stewardship intervention provided us with an opportunity to explore to what extent NH providers engaged in antibiotic timeouts at baseline and the effects of the intervention on these behaviors.MethodsData on antibiotic prescriptions in 11 NHs (6 intervention, 5 control) were collected for 12 months prior and 13 months after intervention introduction. We categorized antibiotic change events (ACEs) as: (1) changes in dose, frequency, or route for the same antibiotic, (2) change to another antibiotic with different spectrum, and (3) early discontinuation (stopped after 2 days or less). Modifications considered to be routine (e.g., Azithromycin dose reduction from 500 to 250 mg) were not considered a meaningful ACE. Frequency of ACEs both overall and by type were compared using a difference in difference (DID) approach.ResultsOf 2647 NH initiated antibiotic events, 376 (14.2%) were modified over the study period. The most common type of modification was a change in spectrum (n = 241, 64.1%) followed by early discontinuation of the antibiotic (n = 118, 31.4%). The difference in ACEs before and after the intervention as well as DID estimates are detailed in the Table.ConclusionThe antibiotic stewardship intervention did not impact total ACEs but did appear to increase the frequency of discontinuation ACEs. An inability to capture data on shortening ACEs (e.g., reducing a treatment course from 14 to 7 days) was a limitation of this study. Additional research on how to foster more frequent and effective antibiotic timeouts in NHs is needed. Disclosures All authors: No reported disclosures.

Effect of tailored antibiotic stewardship programmes on the appropriateness of antibiotic prescribing in nursing homes.

To evaluate the effect of tailored interventions on the appropriateness of decisions to prescribe or withhold antibiotics, antibiotic use and guideline-adherent antibiotic selection in nursing homes (NHs). We conducted a quasi-experimental study in 10 NHs in the Netherlands. A participatory action research (PAR) approach was applied, with local stakeholders in charge of selecting tailored interventions based on opportunities for improved antibiotic prescribing that they derived from provided baseline data. An algorithm was used to evaluate the appropriateness of prescribing decisions, based on infections recorded by physicians. Effects of the interventions on the appropriateness of prescribing decisions were analysed with a multilevel logistic regression model. Pharmacy data were used to calculate differences in antibiotic use and recorded infections were used to calculate differences in guideline-adherent antibiotic selection. The appropriateness of 1059 prescribing decisions was assessed. Adjusting for pre-test differences in the proportion of appropriate prescribing decisions (intervention, 82%; control, 70%), post-test appropriateness did not differ between groups (crude: P = 0.26; adjusted for covariates: P = 0.35). We observed more appropriate prescribing decisions at the start of data collection and before receiving feedback on prescribing behaviour. No changes in antibiotic use or guideline-adherent antibiotic selection were observed in intervention NHs. The PAR approach, or the way PAR was applied in the study, was not effective in improving antibiotic prescribing behaviour. The study findings suggest that drawing prescribers' attention to prescribing behaviour and monitoring activities, and increasing use of diagnostic resources may be promising interventions to improve antibiotic prescribing in NHs.