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Antimicrobial Use in a Cohort of US Nursing Homes, 2017

Educational Objective
To understand the risks of antimicrobial use in nursing homes.
1 Credit CME
Key Points

Question  How often and which types of antimicrobials were used among US nursing home residents in 2017?

Findings  In this cross-sectional survey that included 15 276 residents of 161 nursing homes, the point prevalence of antimicrobial use was 8.2 per 100 nursing home residents. The most common indication was treatment or prevention of urinary tract infection (29%), and 33% were broad-spectrum antibiotics.

Meaning  This study provides information on prevalence and patterns of antimicrobial use in a cohort of nursing homes in 2017.

Abstract

Importance  Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited.

Objective  To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents.

Design, Setting, and Participants  Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website.

Exposures  Residence in one of the participating nursing homes at the time of the survey.

Main Outcomes and Measures  Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications.

Results  Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics.

Conclusions and Relevance  In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.

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Article Information

Corresponding Author: Nicola D. Thompson, MSc, PhD, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30329 (dvq0@cdc.gov).

Accepted for Publication: February 16, 2021.

Author Contributions: Dr Thompson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Thompson, Stone, Brown, Penna, Bamberg, Clogher, Dumyati, Frank, Lynfield, Maloney, Nadle, Wilson, Magill.

Acquisition, analysis, or interpretation of data: Thompson, Brown, Penna, Eure, Barney, Barter, Clogher, DeSilva, Dumyati, Frank, Felsen, Godine, Irizarry, Kainer, Li, Lynfield, Mahoehney, Maloney, Nadle, Ocampo, Pierce, Ray, Davis, Sievers, Srinivasan, Wilson, Zhang.

Drafting of the manuscript: Thompson, Brown, Penna, Godine, Srinivasan.

Critical revision of the manuscript for important intellectual content: Thompson, Stone, Brown, Penna, Eure, Bamberg, Barney, Barter, Clogher, DeSilva, Dumyati, Frank, Felsen, Irizarry, Kainer, Li, Lynfield, Mahoehney, Maloney, Nadle, Ocampo, Pierce, Ray, Davis, Sievers, Wilson, Zhang, Magill.

Statistical analysis: Thompson, Brown, Penna, Eure, Irizarry.

Obtained funding: Thompson, Bamberg, Dumyati, Maloney, Magill.

Administrative, technical, or material support: Thompson, Stone, Brown, Penna, Eure, Barney, Dumyati, Frank, Felsen, Irizarry, Kainer, Lynfield, Mahoehney, Maloney, Nadle, Pierce, Ray, Davis, Sievers, Srinivasan, Zhang, Magill.

Supervision: Thompson, Bamberg, Dumyati, Kainer, Lynfield, Maloney, Nadle, Pierce, Sievers, Wilson, Magill.

Other: Davis.

Conflict of Interest Disclosures: Dr Bamberg reported receipt of grants to the institution from the Centers for Disease Control and Prevention (CDC) during the conduct of the study. Ms Barter reported grants from the CDC during the conduct of the study. Ms Clogher reported grants from the CDC during the conduct of the study. Dr DeSilva reported grants from the CDC Emerging Infections Program during the conduct of the study. Dr Dumyati reported grants from the CDC and personal fees from Roche Molecular Diagnostics Advisory network during the conduct of the study. Ms Frank reported grants from the CDC Emerging Infections Program cooperative agreement outside the submitted work. Dr Kainer reported grants (for funded staff) and nonfinancial support (for funded travel to Atlanta) from the CDC during the conduct of the study; nonfinancial support from the Council of State and Territorial Epidemiologists (CSTE) (travel support to attend CDC and CSTE meetings), the Society for Healthcare Epidemiology of America (SHEA) (travel support to SHEA as an invited speaker), and the Public Health Association of Australia (registration and travel support as keynote speaker for conference) outside the submitted work; and personal fees from Infectious Diseases Consulting Corpororation (board membership, compensation, travel support), WebMD (for creating continuing medical education ([CME] activity and travel support to create CME material in Atlanta), and Pfizer (honorarium and travel support to provide consultative advice on vaccine in phase 3 trials). Dr Lynfield reported grants from the CDC Emerging Infections Program cooperative agreement during the conduct of the study, and being coeditor of a book on preventive medicine and public health. Ms Maloney reported grants from the CDC Emerging Infections Program cooperative agreement during the conduct of the study and being a recipient of the 2019 Society for Healthcare Epidemiology of America Public Health Scholarship. Ms Nadle reported grants from the CDC Emerging Infections Program cooperative agreement outside the submitted work. Dr Pierce reported grants from the CDC Emerging Infections Program and CDC Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases during the conduct of the study, and personal fees from SHEA (committee member) outside the submitted work. Dr Wilson reported grants from Maryland Department of Health. The federal funding is for this research itself, from CDC to Maryland Department of Health:CDC-RFA-CK17-1701 - CDC Emerging Infections Program, "Healthcare Associated Infections and Community Interface", Infectious Diseases Epidemiology and Outbreak Response Bureau, Prevention and Health Promotion Administration, Maryland Department of Health, Baltimore, MD during the conduct of the study. Ms Zhang reported grants from Centers for Disease Control and Prevention during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by the CDC through the Emerging Infections Program cooperative agreement.

Role of the Funder/Sponsor: Federal government employees had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC or the Agency for Toxic Substances and Disease Registry.

Meeting Presentation: Selected data included in this article have been previously presented in abstract at the IDWeek Conference October 6, 2018; San Francisco, California.

Additional Contributions: We thank the staff and residents in nursing homes who participated in the 2017 prevalence survey. We also thank the following individuals, who received compensation for their work as either CDC or EIP employees or contractors and are acknowledged for their contributions to survey coordination, data collection, data entry, data management, or manuscript review: Ruby Phelps, BS - form and database development, Saran Kabbani, MD - manuscript review (Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention), Karen Click, BA – data acquisition (California Emerging Infections Program), Tolu Oyewami, MBBS, MPH, Navjot Kaur, MPH, Elizabeth Basiliere, AAS, Geoffrey Brousseau, MPH, Helen Johnson, MPH, Sarabeth Friedman, CNM, MSN – data acquisition (Colorado Department of Public Health and Environment), Stacy Carswell, MPH, Lewis Perry, DrPH – data acquisition (Georgia Emerging Infections Program), Raphaelle Beard, MPH, Patricia Lawson, MPH, MSc, Vicky Reed, RN, Daniel Muleta, MD, MPH, Katie Thure, MPH, Colleen Roberts, MPH, Benji Byrd-Warner, BSN – data acquisition (Tennessee Department of Health).

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