Reducing potentially inappropriate antibiotic prescribing in nursing homes

As concern regarding antibiotic-resistant organisms has reached global proportions, attention has become focused on nursing homes (NH) where prescribing is high and often inappropriate. To examine the extent of potentially inappropriate antibiotic prescribing and the efficacy of educational efforts, we conducted and evaluated a quality improvement (QI) program in six North Carolina NHs. The program had four components: 1) training physicians in antibiotic prescribing criteria, specifically, the Loeb criteria; 2) training nurses in the use of a Medical Care Referral Form (MCRF) to report signs and symptoms of the Loeb criteria; 3) providing antibiotic information to residents, their families, and other NH staff; and 4) maintaining contact with physicians and NH staff during a six-month QI program. At baseline, monthly antibiotic prescriptions (unadjusted) ranged from 26-52 across the six NHs. Within three months of program initiation, five of the six settings evidenced reduced prescribing ranging from 19-41%. Adherence to the Loeb criteria increased for urinary tract infections (8% at baseline to 12% at follow-up), respiratory infections (2% at baseline to 8% at follow-up) and especially for skin infections (41% at baseline to 82% at follow-up). The MCRF was used to report information for only a minority of treated infections (from 0 to 17%). Antibiotic prescribing may be reduced in NHs through concerted efforts including prescriber training, focused staff-prescriber communication, and patient and family education. While not all treated infections should meet published criteria for appropriateness, further reduction in prescribing that does not meet criteria would likely constitute optimal care.