OBJECTIVES To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN Two‐year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS Nursing staff and medical care providers in the participating NHs. INTERVENTION Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin‐resistant Staphylococcus aureus (MRSA) infections. RESULTS Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69‐0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65‐0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92‐0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2‐year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46–54, 2019

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Objective: A two-year cluster randomized trial of Mouth Care Without a Battle © (MCWB) was conducted in nursing homes (NHs) to determine if recommended mouth care practices provided by NH staff could improve residents' oral hygiene and denture outcomes.Design: Cluster randomized trial of NHs.Setting and Participants: Seven MCWB NHs and six control NHs. A total of 219 NH residents completed baseline and 24-month oral exams and if applicable, denture assessments (control=98, intervention=121). Intervention:The intervention consisted of training NH staff in the MCWB protocol, and providing support in its use for two years.Measures: Descriptive data from the Minimum Data Set and clinical oral health assessments: the Plaque Index for Long-Term Care (range 0-3; PI-LTC), the Gingival Index for Long-Term Care (range 0-4; GI-LTC), and the Denture Plaque Index (range 0-4, DPI), with lower scores indicating better oral health.Results: There were no significant demographic or health differences between groups at baseline. Residents' mean age (SD) was 77.6 (13.7), 71% were female, and 49% had cognitive impairment. At 24 months, there were significant improvements in oral and denture hygiene in the intervention group compared to control (all p < .05) with mean changes in indices that were 0.44 (PI-LTC), 0.55 (GI-LTC), and 0.67 (DPI) points lower in intervention NHs than control NHs.

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