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Grant R. Barney et al


Fig. 1. Measured and estimated median monthly days of therapy (DOT) rates (per 1,000 resident days) for pneumonia, skin and soft-tissues infections (SSTI) and urinary tract infections (UTI) for the 4 nursing homes.


The measured monthly antibiotic DOT rate varied between the nursing homes (median, 68.9; IQR, 54.4–100.6 per 1,000 resident days). The median monthly antibiotic DOT rate per 1,000 resident days ranged from 7.6 to 16.4 for UTI, 6.8 to 23.8 for SSTI, and 3.7 to 7.9 for pneumonia (Fig. 1). The drug classes also varied by nursing home: the most common antibiotic class in 2 nursing homes was tetracyclines (median monthly DOT rates, 28.3 and 10.8 per 1,000 resident days), whereas first-generation cephalos- porins (median monthly DOT rates, 16.2 and 12.1 per 1,000 resident days) were most common in the other 2 nursing homes. Quinolone use was generally low in all 4 nursing homes due to their involvement in an intervention to reduce quinolone use. The distribution of antibiotic DOT for the 3 common infections varied by nursing home. For UTI and SSTI, cephalosporins were the most common class prescribed in 3 of the nursing homes. For pneumonia, only 1 nursing home commonly prescribed qui- nolones; in another, doxycycline was the preferred agent (Supplemental Fig. 3). The measured and estimated overall monthly DOT rates


did not differ significantly (P range, 0.4227–0.7131). In addi- tion, the monthly antibiotic DOT rate by indication (UTI, SSTI, pneumonia) (Fig. 1) and by antibiotic drug class (Fig. 2) were not statistically different (P ranges, 0.5457–0.9817 and 0.1545–1.0000, respectively) for the 4 nursing homes. The measured and estimated distribution of DOT of antibiotics used for UTI, SSTI, and pneumonia were also similar (Supplemental Fig. 3).


Discussion


We found that a weekly, 1-day point-prevalence survey of antibiotic use accurately estimates a nursing home’stotal


antibiotic burden, measured as DOT per 1,000 resident days. This measure is important because nursing homes with high antibiotic use have increased antibiotic-related adverse events.8 The 1-day point-prevalence survey can also accurately estimate the DOT for common indications and classes of antibiotics. These data can be used to identify targets for intervention and to measure progress over time.9,10 For instance, in one nursing home, quinolone use was common for pneumonia highlighting an antibiotic stewardship need. Notably, DOT can be inflated by prolonged treatment durations and long-term prophylaxis (eg, UTI, pemphigoid), and this is one of the reasons for the observed high DOT rate for doxycycline and SSTI in some nursing homes. Our point-prevalence method is valuable for nursing homes


without electronic medication administration records or with a dispensing pharmacy that is unable to provide data summaries or capture antibiotic indications. We accurately estimated overall DOT as well as DOT by indication and antibiotic class. Other manual antibiotic use measurements include collection of antibiotic starts as part of infection surveillance activities and performing an intermittent point-prevalence survey of antibiotic use.5,9,10 Although antibiotic starts rates are corre- lated with DOT rates,9 this measure cannot assess the impact of an intervention that focuses on reducing antibiotic dura- tion;10 one alternative to address this gap is focusing on antibiotic courses of >7 days duration. Intermittent point prevalence measurements can provide an estimate of the proportion of residents on antibiotics including antibiotics initiated by the hospital and the most common reasons for antibiotic use, but if done infrequently, it cannot assess the total antibiotic burden.3 Our manual weekly count of anti- biotic use and aggregating antibiotic use point-prevalence data at regular intervals can provide an estimate similar to the


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