Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

Abstract

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.

Fig. 1

Components of the antibiotic prescribing decision-making process

Fig. 2

Conceptual framework of the factors that influence the decision to initiate antibiotic therapy in nursing homes

Fig. 3

Decision pathway to reduce unnecessary diagnostic testing of urine samples in long-term care facilities (adapted from Crnich and Drinka [94]). CVAT costovertebral angle tenderness, UA urinalysis, UCx urine culture, UTI urinary tract infection