In October 2016, the Centers for Medicare & Medicaid Services adopted a final rule to make major changes and updates to the federal regulations surrounding long-term care facilities, its most comprehensive update since 1991.

To  comply with these new CMS regulations, nursing facilities must adopt an Antibiotic Stewardship Program in conjunction with an Infection Prevention and Control Program, which includes antibiotic use protocols and a system for monitoring antibiotic use, by November 28, 2017.

Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections and reduce adverse events with a goal of slowing the emergence of resistant bacteria and preventing the spread of resistant infections.

The Centers for Disease Control and Prevention has found that antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of nursing home residents receiving at least one course of antibiotics per year. In addition:

  • In nursing homes, approximately 20% of healthcare providers account for 80% of antibiotics prescribed.

  • Forty percent to 75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate.

  • Antibiotic resistance is associated with two million resistant infections, 23,000 deaths, and $20 billion in costs annually.

Core elements of antibiotic stewardship

The CDC has developed Core Elements of Antibiotic Stewardship for Nursing Homes to serve as a guide for progressively implementing such a program in a skilled nursing facility. Furthermore, CMS has referenced the Core Elements in the most recent revisions to the guidance section of the State Operations Manual.

The core elements of antibiotic stewardship for nursing homes are:

  1. Leadership Commitment: Dedicating necessary human, financial and information technology resources

  2. Accountability: Appointing a single leader (successful programs show that a physician leader is effective) responsible for program outcomes

  3. Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use

  4. Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (e.g. “antibiotic time out” after 48 hours)

  5. Tracking: Monitoring antibiotic prescribing and resistance patterns

  6. Reporting:  Regularly reporting information on antibiotic use and resistance to doctors, nurses and relevant staff

  7. Education: Educating clinicians about resistance and optimal prescribing

Roles of each participant

Nursing home regulations by CMS have included requirements to review and monitor antibiotic use (previous F-tags 441, 329, and 428, along with future F-Tags 880, 757, and 756). 

F-Tag 881 has been assigned to the Antibiotic Stewardship Program with recent updates to the State Operations Manual, effective November 28, 2017.

Each leader in the long-term care setting has specific roles and tasks that can be implemented to effectively establish an Antibiotic Stewardship Program. While there is no single method to implement a program since each facility must tailor its efforts based on its specific characteristics, experience has shown that the programs are more successful when a multidisciplinary approach is taken with defined leadership and leadership roles.

My next blog will focus on actions that can be taken to support your efforts in establishing an effective Antibiotic Stewardship Program by November 28, 2017.

Sonja Quale, Pharm.D. is the vice president and chief clinical officer at PharMerica Corporation.