Antibiotic Stewardship Programs Could Affect C. difficile Rates in Nursing Homes

SEPTEMBER 15, 2017
Rachel Lutz
antibiotic stewardship, C. difficile, nursing home, prescriptionsAntibiotic stewardship programs are effective, but still limited within nursing home communities, according to a new report.

Researchers from the University of North Carolina, Chapel Hill, used databases to collect data in order to evaluate the current evidence regarding outcomes of antibiotic stewardship programs in nursing homes. They specifically examined whether antibiotic stewardship programs reduced mortality and/or reduced the incidence of Clostridium difficile (C. difficile) in nursing homes.

The researchers also focused on the program’s impact of health care utilization via emergency department visits, such as suspected bacterial infection like sepsis, pneumonia, urinary tract infection or cellulitis. In total, the investigators found 14 relevant studies published between 2001–2016 which were relatively heterogenic in terms of intervention components and delivery personnel.

The study authors sourced Pub Med, Medline, the Cochrane Library, Embase and CINAHL for relevant studies.

Eight of the studies measured chances in antibiotic prescribing associated with antibiotic stewardship programs. They all reported decreases in either overall or indication-specific antibiotic prescriptions in nursing homes. One study showed a decrease in UTI prescriptions and an overall prescription decrease. Another noted reduced UTI treatment and the total antibiotic days for therapy. A third study showed reduced total antibiotic prescriptions ordered between the baseline and follow up period compared to intervention nursing homes and control nursing homes.

An additional 10 studies reported “guideline adherence” as an outcome, but the guidelines measured were different among the studies. Three studies explored adherence to the Nursing Home Acquired Pneumonia management guideline, but none found a meaningful change in guideline adherence associated with the intervention in their studies. Another study demonstrated a multidisciplinary intervention improved adherence better than an intervention only directed toward prescribers.

Of note, a final study developed a decision making tool for the management of bacterial infections and measured adherence. They learned nursing homes using the tool with low fidelity did not have a decrease in prescriptions for these infections, but nursing homes with high fidelity to the guidelines reduced antibiotic prescribing.

Overall, the study authors did not find evidence that nursing home antibiotic stewardship programs changed the incidence of C. difficile infection, rates of hospitalizations or mortality, they said. None of the studies used in this analysis measured emergency department visits.

However, the researchers said their review indicated that nursing home stewardship programs can change intermediate health outcomes by reducing the number of antibiotic prescriptions in the nursing home and improving adherence to recommended treatment guidelines.

They did not find any changes in C. difficile infection rates in the 2 studies measured — 1 lasting 14 months, and 1 lasting 18 months. Other studies that examined C. difficile infection rates demonstrated it may be as long as 5 years to change the rates.

“The evidence on the effectiveness of antibiotic stewardship programs in nursing homes is encouraging but limited,” the study authors concluded, noting that these programs are now mandated in nursing homes. “These programs can reduce antibiotic prescriptions. This can, theoretically, improve health outcomes for nursing home residents, but results to date have not shown reductions in hospitalizations, emergency department visits, or C. difficile infection rates.”

The paper, titled “Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review,” was published in The Journal of Post-Acute and Long-Term Care Medicine.

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