The Centers for Medicare and Medicaid Services (CMS) has finalized a new rule that will require nursing homes to have an antibiotic stewardship program.

The rule is part of a package of changes to improve the care and safety of the nearly 1.5 million residents in the 15,000 US long-term care facilities that participate in the Medicare and Medicaid programs. The changes are aimed at improving the quality of care and strengthening safety measures for residents, and reducing unnecessary hospital readmissions and infections. Nursing homes, skilled nursing facilities, and assisted-living facilities must meet these new standards to receive Medicare and Medicaid payments.

Antibiotic use in long-term care facilities is an issue that most experts agree needs to be addressed as part of the nationwide effort to slow the emergence of antibiotic-resistant bacteria. According to the Centers for Disease Control and Infection (CDC), an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year.

"That tells us that antibiotics are being prescribed quite frequently for this patient population," David Hyun, MD, senior officer with the Pew Charitable Trusts' antibiotic resistance project, told CIDRAP News.

This is because long-term care facility residents are often frail and have underlying chronic conditions that make them more vulnerable to infections, especially involving the skin, urinary tract, and respiratory tract. In addition, bacterial infections tend to spread rapidly in these facilities because of patient proximity and frequent nurse-resident contact.

Overuse and misuse

Yet Hyun said a range of studies have indicated that anywhere from 40% to 70% of those antibiotic prescriptions are inappropriate and put residents at risk of developing drug-resistant infections. That fact, along with the high rates of infection, has raised the concern that nursing homes are becoming a significant reservoir of multidrug-resistant bacteria in the community. And given that long-term care facility residents are frequently transferred to acute care facilities, those bugs can then spread into healthcare settings.

This is why infection prevention efforts and antibiotic stewardship programs in long-term care facilities are considered long overdue. In 2015, the CDC released a set of recommendations to help nursing homes improve antibiotic prescribing and help protect residents from drug-resistant infections. The list included getting commitments from nursing home leadership to improve antibiotic prescribing, identifying experts to be responsible for stewardship activities, and monitoring antibiotic use practices and outcomes.

But if implementing an antibiotic stewardship program in a hospital is challenging, it's even more so in long-term care facilities. Financial resources, antibiotic stewardship expertise, and diagnostic and support services are scarce. In addition, medical care is often poorly coordinated.

The American Health Care Association (AHCA), which represents the nation's long-term and post–acute care facilities, acknowledged this challenge in a statement on the new rules. "Even CMS admits this new wave of regulations will bring with it hundreds of millions in additional costs without any new funding streams," said AHCA President and CEO Mark Parkinson.

Hyun agrees that it will be a challenge. "Long-term care facilities are not always going to have an infectious disease doctor on staff, and they're not going to have a pharmacist on site all the time," he said.

But he noted there are effective stewardship activities that can be implemented with limited resources. A case study published by Pew earlier this year, for example, found that a long-term care facility in Wisconsin had been able to reduce inappropriate prescriptions in part by tracking the prescribing patterns of its physicians and providing individualized feedback. In addition, the facility made the nursing staff a bigger part of its stewardship efforts.

"There are ways this can be adapted," Hyun said, adding that more research on practical and feasible antibiotic stewardship strategies for long-term care facilities will be needed going forward.

See also:

Sep 28 CMS press release

Sep 2015 CDC recommendations on antibiotic stewardship for nursing homes

Sep 29 AHCA press release

April 2016 Pew Charitable Trusts report