Associations Between Antibiotic Stewardship Policies and Antibiotic Use in U.S. Nursing Homes

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      Nursing homes (NHs) are implementing antibiotic stewardship programs due to recent federal regulations. We sought to evaluate if NH antibiotic stewardship policies change antibiotic use in NH residents.


      Antibiotic stewardship policy data were collected from nationally-representative samples of NHs in 2013 and 2017. An aggregate antibiotic stewardship intensity index, ranging from 0-100, was calculated from five antibiotic stewardship policy measures. Survey data were merged with concurrent MDS 3.0 data and antibiotic use was defined as a one-day prevalence from annual and quarterly assessments. Multivariable models, overall and stratified by infection type, were used to estimate antibiotic use as a function of antibiotic stewardship intensity, NH and resident characteristics, and time. The total adjusted change in antibiotic use was calculated as the difference in predicted use after setting time and stewardship intensity to 2013 values and then to 2017 values, adjusting for 2017 characteristics. The isolated contribution of antibiotic stewardship intensity was calculated as the predicted antibiotic use when time is set to 2013 and policy intensity to 2017 divided by the total adjusted change in antibiotic use.


      Data from 584,540 resident assessments from 1,825 NHs were analyzed. On average, antibiotic stewardship intensity in NHs increased significantly from 2013 to 2017 (µ=33.08 to µ=67.94, p < 0.001). The observed prevalence of antibiotic use decreased by 2.9% (8.29% to 8.05%, p=0.001). The total adjusted decline in antibiotic use given similar characteristics was 5.3% from 2013 to 2017. Increases in policy intensity accounted for 37% of this decline. Antibiotic stewardship intensity was negatively associated with antibiotic use overall and in cases with active diagnoses of urinary tract infection or septicemia.


      Improved antibiotic stewardship programs have resulted in a modest decline in antibiotic use, suggesting that the full extent of the translation from antibiotic stewardship policy to practice remains to be seen.
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