Antibiotic Stewardship

 Welcome and Overview

This session will describe antibiotic stewardship and how it helps to prevent antibiotic resistance and problems associated with antibiotic use. The session will discuss the core elements of an antibiotic stewardship program (leadership, commitment, accountability, drug expertise, actions to improve antibiotic use, tracking, reporting, and education) and the need for community-wide efforts. This session focuses on the practical aspects of stewardship, so you can think about and describe what this looks like in your organization.

This session is one of a series of six sessions for nursing homes to support implementation of principles and practices of antibiotic stewardship and prevention and management of C. difficile infections.


  • Define antibiotic stewardship.
  • Identify elements of an antibiotic stewardship program.
  • Describe the role of antibiotic stewardship in preventing the development of antibiotic resistant bacterial infections.
  • Discuss measures that can be used to determine success of an antibiotic stewardship program.

 How can you use this session?

This session focuses on antibiotic stewardship in the nursing home setting. The material is intended to be useful for guiding individual practice and as an educational resource for staff involved in the care of nursing home residents. Nursing home leaders can review the content in this session and decide which components would be helpful to staff in their facility. The components can be shared and discussed during staff education sessions, or they can be accessed online by staff at any time.

Depending on which components you choose to review and/​or share and discuss with staff, this session may take 30-90 minutes.


Here is an outline of what is in this session. You can click on the hyperlinks to go directly to a section or scroll down below the outline to see all section content.



What is antibiotic stewardship and why is it important?

Watch video CDC Expert Commentary: The Core Elements of Antibiotic Stewardship for Nursing Homes

Is antibiotic stewardship required in nursing homes?

Review short narrative on federal regulations that require antibiotic stewardship

What are the elements of an antibiotic stewardship program in long-term care?

Access publication The Core Elements of Antibiotic Stewardship for Nursing Homes

View slides containing information from the guide

Activity #1


Review checklist to assess policies and practices that are in place

Discussion questions

Action item


How can you measure how you are doing with antibiotic prescribing use and outcomes?

Access publication The Core Elements of Antibiotic Stewardship for Nursing Homes: Appendix B

Watch recorded webinar Measuring Antibiotic use in LTCFs

View slides from recorded webinar Measuring Antibiotic use in LTCFs

Activity #2

Understanding Antibiotic Use in Your Building

Discussion questions

Action item


How should your organization work with others in your community to support antibiotic stewardship?

Review short narrative on working together to support antibiotic stewardship

Activity #3


Take Home Messages

Review short narrative

Optional Tools and Resources

Access additional antibiotic stewardship toolkits, modules, and resources


  What is antibiotic stewardship and why is it important?





Watch this video titled CDC Expert Commentary: The Core Elements of Antibiotic Stewardship for Nursing Homes, presented by Nimalie Stone, MD, MS, a medical officer at the Centers for Disease Control and Prevention (CDC) (5:06). A transcript of the video is also available.

In this video…

  • Dr. Stone, a medical officer at the Centers for Disease Control and Prevention (CDC), talks about antimicrobial stewardship in nursing homes.
  • Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of bacterial infections while reducing the adverse events associated with antibiotic use.
  • Any action to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in nursing homes.

 Is antibiotic stewardship required in nursing homes?

The Centers for Medicare & Medicaid Services (CMS) published a final rule titled Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities on October 4, 2016. The final rule requires an antibiotic stewardship program that includes antibiotic use protocols and systems for monitoring antibiotic use and recording incidents identified under the facility’s infection prevention and control program (IPCP) and the corrective actions taken by the facility.

Specifically, the IPCP would:

  • include infection prevention, identification, surveillance, and antibiotic stewardship;
  • require each facility to periodically review and update its program;
  • require performance of an analysis of the resident population and facility;
  • designate an infection prevention and control officer(s) (IPCO);
  • integrate the IPCO with the facility’s quality assurance and performance improvement (QAPI) program;
  • establish written policies and procedures for the IPCP; and
  • provide the IPCO and facility staff with education or training related to the IPCP.

 What are the elements of an antibiotic stewardship program in long-term care?

Review the guide titled The Core Elements of Antibiotic Stewardship for Nursing Homes.

Published by the Centers for Disease Control and Prevention (CDC), this guide provides examples of how antibiotic use can be monitored and improved by nursing home leadership and staff.

To view slides that walk through the guide, providing examples of strategies to implement these core elements: PDF

Here is a summary of the core elements for antibiotic stewardship in nursing homes:

  • Leadership commitment:
    • Demonstrate support and commitment to safe and appropriate antibiotic use in your facility.
  • Accountability:
    • Identify physician, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities in your facility.
  • Drug expertise:
    • Establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship for your facility.
  • Action:
    • Implement at least one policy or practice to improve antibiotic use.
  • Tracking:
    • Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in your facility.
  • Reporting:
    • Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff.
  • Education:
    • Provide resources to clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improving antibiotic use.

 Activity #1

Complete this two-page checklist to assess policies and practices that are in place and to review progress in expanding stewardship activities on a regular basis: PDF

NOTE: This checklist is contained at the end of the CDC's guide Core Elements of Antibiotic Stewardship for Nursing Homes.


Discussion questions: Discuss the findings from your assessment with your QAPI team.

  1. What do you already do well with antibiotic stewardship?
  2. What might be the hardest pieces or core elements for you to implement and why?
  3. Where are your opportunities?

Action item: Pick one element not currently in place that you would like to take action on.

Resources: These QAPI tools may help you plan your follow-up action. Use your organization’s processes to implement change.


 How can you measure how you are doing with antibiotic prescribing use and outcomes?

Review measures of antibiotic prescribing, use, and outcomes in the publication titled The Core Elements of Antibiotic Stewardship for Nursing Homes: Appendix B.

Published by the National Center for Emerging and Zoonotic Infectious Diseases within the Centers for Disease Control and Prevention (CDC), this resource contains detailed explanations of antibiotic use process and outcome measures, which can be tracked by nursing homes to monitor the impact of their antibiotic stewardship activities.



Watch this recorded webinar titled Measuring Antibiotic Use in LTCFs, presented by Elizabeth Dodds Ashley, PharmD, MHS, Liaison Clinical Pharmacist with Duke University (34:08) (you will need to download Windows Media Player to watch this video).

Presentation objectives:

  • Compare and contrast advantages and disadvantages to various measures of antimicrobial use.
  • Describe unique approaches to measuring antibiotic use in long-term care facilities and describe best practices.
  • Outline key considerations for data validation.
  • Describe strategies to implement change based on antibiotic consumption data.

For the presentation slides: PDF

For the presentation transcript: PDF

Suggested audience:

  • Nurses
  • Administrators
  • Pharmacists
  • Infection control practitioners

Activity #2

Understanding Antibiotic Use in Your Building:

Discussion questions:

  1. Which of the process and/​or outcome measures in Appendix B do you already track?
  2. Do you know the answers to these questions for your building? The answers to these questions can help you to have more meaningful conversations with providers and develop guidelines with their input. Seek to understand why antibiotics are being used; the reasons may be different than your assumptions:
  • (Who) Who is prescribing the antibiotics?
  • (What) What are the most frequently used antibiotics?
  • (Where) Are there units that tend to use the most antibiotics?
  • (When) Are there times when antibiotics are most likely to be prescribed?
  • (Why) Why are the antibiotics being used? What are the most common reasons they are being used?

Action item: Identify 1-2 additional pieces of data or information that you need to further your discussions about antibiotic stewardship, and identify how you will collect that information.


  • Here is an audit tool to help you assess antibiotic prescribing in your organization: Word

NOTE: This tool is also provided in the session Exploring Antibiotics and their Role in Fighting Bacterial Infections.

NOTE: These tools are also used in the session Clostridium difficile Part Two: Strategies to Prevent, Track, and Monitor C. difficile.

 How should your organization work with others in your community to support antibiotic stewardship? 

It is important to coordinate and collaborate with others in your community to support antibiotic stewardship.

By working together, you can more completely address the emergence and spread of antibiotic-resistant bacteria than independent facility – based efforts alone.

  • Identify and get to know infectious disease experts and stakeholders that care about this topic at your state and local public health departments, partner hospitals, long-term acute care hospitals, other skilled nursing and nursing homes, home health agencies, clinics, pharmacists, laboratories, community organizations, and leaders.
  • Work together to understand antibiotic prescribing patterns and practices, causes of antibiotic resistance, patterns of antibiotic resistance across your community, causes and spread of infections across healthcare settings and the community, and healthcare provider and community education needs.
  • If your state already has a coalition to improve antibiotic stewardship, join it.

You are all in this effort to prevent the development and spread of antibiotic resistant bacterial infections, and antibiotic stewardship across the community will play a key role. This should be personal – antibiotic resistance to common and emerging infections is a threat for everyone.

 Activity #3

Consider using one of the two scenarios as a thought-provoking exercise to further discussion among your session participants. The goal is to pull out key aspects of stewardship, so leaders and staff can describe and think about what stewardship does or should look like in the organization. 

Scenario 1: A new administrator has joined Committed to Quality Nursing Home – how would she know whether this facility made antibiotic stewardship a priority area?
  • Nursing staff have structured assessment tools to document and report signs/​symptoms to providers when a resident is suspected of infection.
  • The consultant pharmacist presents a monthly report of antibiotic use by provider during Quality Assurance/​Performance Improvement committee.
  • The laboratory provides a summary report of antibiotic resistance (antibiogram) to the facility every year which is shared with direct care nursing staff and providers.
  • Pamphlets and information about antibiotic stewardship and the harms from antibiotic overuse were discussed with new residents and their families.
  • Other examples taken from the antibiotic stewardship guide or two page checklist on policies and practices for antibiotic stewardship.
Scenario 2: How would staff and providers know a new facility administrator made antibiotic stewardship a priority?
  • She asks what the monthly rate of antibiotic starts/1,000 resident days has been for the past quarter during the first QAPI committee meeting.
  • She provides funding and time for the Director of Nursing to attend a course on antibiotic stewardship being provided during a national conference.
  • She requests the Medical Director provides feedback to prescribing clinicians about their antibiotic use practices each quarter and hosts meetings with the Medical Director and the clinicians who have unusually high prescribing rates.
  • She arranges for the local hospital’s stewardship pharmacist to share strategies with the facility nursing staff about performing an antibiotic review.
  • Other examples taken from the antibiotic stewardship guide or two page checklist on policies and practices for antibiotic stewardship.

 Take Home Messages

  • Antibiotic stewardship helps reduce inappropriate antibiotic use. Inappropriate use causes development of resistant bacteria which can be very difficult and costly to treat.
  • There are strategies that nursing homes can implement to be good stewards of antibiotics. These strategies can be implemented in a step-wise fashion.
  • Everyone in the nursing home plays a role in how antibiotics are used and in preventing antibiotic resistance.
  • Teamwork is required to support the judicious use of antibiotics – key players include prescribing providers, nurses, pharmacists, infection control practitioners, laboratory technicians, and residents and families.
  • Nursing homes need to work together to support prescribing providers in judiciously using antibiotics. Working to prevent antibiotic resistance will take a degree of vigilance and attention to detail that nursing homes may not feel is in their purview, as they feel that they may not have control over prescribers. 
    • But to work as a team and be effective in preventing resistance and promoting antibiotic stewardship, nursing home leaders will have to understand resistance patterns, and to not present situations in a way to prescribing providers that requests or expects an antibiotic, and make sure that cultures are used and that antibiograms are used to help guide empiric treatment.

  Optional Tools and Resources

AHRQ Nursing Home Antimicrobial Stewardship Guide

The Nursing Home Antimicrobial Stewardship Guide provides four toolkits to help nursing homes optimize their use of antibiotics. One of the tool kits is entitled Implement, Monitor, and Sustain an Antimicrobial Stewardship Program and includes two parts: 1) Start an antimicrobial stewardship program and 2) monitor and sustain program.


Minnesota Antimicrobial Stewardship Program Toolkit for Long-Term Care Facilities

Developed by the Minnesota Department of Health, this toolkit was put together in collaboration with several long-term care facility partners to offer concrete tools that could help facilities recognize their baseline antimicrobial stewardship capacity and enhance their existing assessment, documentation, and communication processes. It is organized in a series of appendices.



GNYHA Antimicrobial Stewardship Toolkit

Developed by the Greater New York Hospital Association (GNYHA), with assistance from the United Hospital Fund (UHF), this toolkit assisted a small group of acute care and long-term care (LTC) facilities in establishing antimicrobial stewardship programs (ASPs) within their institutions.




Michigan Toolkit for Long-term Care Facilities to Prevent Antimicrobial Resistance

This project is a collaboration of the Michigan Antibiotic Resistance Reduction (MARR) Coalition, Michigan Department of Community Health, Michigan Society for Infection Prevention and Control (MSIPC), and the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion. It is designed to help LTC facilities implement the 12 Steps to Prevent Antimicrobial Resistance Among Long-Term Care Residents, a set of recommendations developed by the CDC as part of its Campaign to Prevent Antimicrobial Resistance in Healthcare Settings.


Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Published in the Journal of Clinical Infectious Dieases, these key recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.



Rochester Patient Safety C. difficile Prevention Collaborative: Resources and Tools

Funded by the New York State Department of Health, the Long-Term Care Facility (LTCF) Antimicrobial Stewardship aims to reduce the incidence of C. difficile infection in long-term care facilities through antimicrobial stewardship interventions targeting common infectious syndromes.

The Centers for Disease Control and Prevention Print Materials for Everyone

These print materials focus on when it is and is not appropriate to prescribe antibiotics and explain why antibiotic resistance is one of the world's most pressing public health problems.