Creating reasonable antibiograms for antibiotic stewardship programs in nursing homes: Analysis of 260 facilities in a large geographic region, 2016–2017

Abstract

Objective:To determine the best nursing home facility characteristics for aggregating antibiotic susceptibility testing results across nursing homes to produce a useful annual antibiogram that nursing homes can use in their antimicrobial stewardship programs.Design:Derivation cohort study.Setting:Center for Medicare and Medicaid Services (CMS) certified skilled nursing facilities in Georgia (N = 231).Participants:All residents of eligible facilities submitting urine culture specimens for microbiologic testing at a regional referral laboratory.Methods:Crude and adjusted metrics of antibiotic resistance prevalence (percent of isolates testing susceptible) for 5 bacterial species commonly recovered from urine specimens were calculated using mixed linear models to determine which facility characteristics were predictive of testing antibiotic susceptibility.Results:In a single year, most facilities had an insufficient number of isolates tested to create facility-specific antibiograms: 49% of facilities had sufficient Escherichia coli isolates tested, but only about 1 in 10 had sufficient isolates of Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, or Pseudomonas aeruginosa. After accounting for antibiotic tested and age of the patient, facility characteristics predictive of susceptibility were: E. coli, region, year, average length of stay; K. pneumoniae, region, bed size; P. mirabilis, region; and for E. faecalis or P. aerginosa no facility parameter remained in the model.Conclusions:Nursing homes often have insufficient data to create facility-specific antibiograms; aggregating data across nursing homes in a region is a statistically sound approach to overcoming data shortages in nursing home stewardship programs.

Antibiotic-resistant pathogens associated with urinary tract infections in nursing homes: Summary of data reported to the National Healthcare Safety Network Long-Term Care Facility Component, 2013–2017

“…These results are similar to common pathogens reported from either UTI or urine cultures from nursing home residents in other studies. 4,[14][15][16][17][18] Within nursing homes, levels of antibiotic resistance, including MDR, were generally higher among the CA-SUTI events than UTIs not associated with catheters, most notably for vancomycin resistance in E. faecium and extended-spectrum cephalosporin and carbapenem resistance in Klebsiella spp. These differences observed among nursing-home UTI event types may be explained by the role that biofilm formation on indwelling devices plays in the selection and emergence of antibiotic resistance.…”

Are Antibiograms Ready for Prime Time in the Nursing Home?

“…More recently, investigators in Georgia evaluated 231 nursing homes and found that only 10% of nursing homes had sufficient test results from common urinary pathogens in a given year to fulfill the CLSI guidance. 25 Sputum and skin cultures were even less frequent. The risks inherent when using unreliable estimates (ie, fewer than 30 isolates) includes inappropriately using potentially more toxic and/or ineffective agents during empiric therapy.…”

“…Based on the Georgia nursing home study, combining 3 years of data for urinary pathogens would allow enough isolates for the majority of nursing homes. 25 Although this may obscure some shifts in resistance patterns, it is unlikely to be of clinical significance in such a short time period. This is probably the most inherently reliable method for the laboratory to perform.…”

“…Data from multiple nursing homes in Georgia was combined to create a regional nursing home antibiogram. 25 Modeling demonstrated that resistance patterns of common urinary isolates differed only slightly between geographically defined groupings of nursing homes, yet yielded robust estimates of resistance for use by individual nursing homes. 25 Facilities would need to share data as a regional approach to addressing the resistance problem as promoted by CDC.…”

“…25 Modeling demonstrated that resistance patterns of common urinary isolates differed only slightly between geographically defined groupings of nursing homes, yet yielded robust estimates of resistance for use by individual nursing homes. 25 Facilities would need to share data as a regional approach to addressing the resistance problem as promoted by CDC. 11,30 Such sharing has been attempted in small hospitals and statewide.…”