Up to 75% of antibiotic use in nursing homes is inappropriate. Inappropriate antibiotic use increases the nursing home resident's risk of adverse drug events, Clostridium difficile infection and infection with antibiotic- resistant bacteria, whih may then be spread to others. Results of antibiotic stewardship interventions in nursing homes have been mixed. While multi-component interventions targeting provider knowledge and aspects of the work system influencing prescribing decisions appear to reduce inappropriate antibiotic use in nursing homes, the mechanisms by which these interventions work is unclear. In the absence of this knowledge, successful dissemination of these interventions to other nursing home settings will not be possible. Consequently, there is a critical need for nursing home antibiotic stewardship studies that not only evaluate the impact of interventions on prescribing patterns but also evaluate the mechanisms by which they mediate change. Our long-term goal is to reduce inappropriate antibiotic use in nursing homes. Accordingly, our group has developed a novel antibiotic stewardship intervention that targets provider knowledge as well as important work system factors influencing antibiotic decision-making in nursing homes. The objectives of this particular application are to demonstrate the effectiveness of our antibioti stewardship intervention in nursing homes in two states and develop a resource to facilitate dissemination to other nursing home settings. We will achieve the objectives of this project through three specific aims: 1) tailor the antibiotic stewardship intervention for optimal implementation;2) assess its impact on antibiotic use in study nursing homes;and 3) use knowledge gained to develop a dissemination toolkit. In the first aim, we will use human factors analyses to identify barriers and facilitators to implementation of the antibiotic stewardship intervention. Components of the intervention will be tailored to overcome these barriers and an implementation package will be developed with structured input from key informants in study nursing homes. In the second aim, the tailored antibiotic stewardship intervention will be implemented in study nursing homes using a quality improvement collaborative approach pioneered at the University of Wisconsin and antibiotic utilization measures will be compared with control facilities. In the third aim, knowledge generated from a mixed-methods assessment of intervention fidelity, sustainability and mechanisms by with the intervention mediates study outcomes will be used to develop a dissemination toolkit. The methods we will used to tailor our intervention and support its implementation (quality improvement collaborative) as well as the rigorous program evaluation we will employ to develop a dissemination toolkit are all innovative aspects of this proposal. The proposed research is significant;because it is expected to result in a multi-faceted intervention that can be exported broadly to effectively reduce improve antibiotic use in facilities, which will, in turn, will reduce C. difficile infections and the emergence and spread of antibiotic resistance in nursing homes and the communities they serve.

Public Health Relevance

The proposed research is relevant to public health because development of an effective nursing home antibiotic stewardship intervention is ultimately expected to reduce the burden of Clostridium difficile and antibiotic resistance in these facilitie, which, in turn, is expected to facilitate control of these problems in affiliated hospitals and the communities they serve. Thus, the proposed research is directly relevant to the Agency for Healthcare Research and Quality's mission to prevent and reduce healthcare-associated infections.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
Project #
Application #
Study Section
Special Emphasis Panel (HSQR)
Program Officer
Perfetto, Deborah
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of Wisconsin Madison
Internal Medicine/Medicine
Schools of Medicine
United States
Zip Code
Pulia, Michael; Kern, Michael; Schwei, Rebecca J et al. (2018) Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis. Antimicrob Resist Infect Control 7:74
Jump, Robin L P; Crnich, Christopher J; Mody, Lona et al. (2018) Infectious Diseases in Older Adults of Long-Term Care Facilities: Update on Approach to Diagnosis and Management. J Am Geriatr Soc 66:789-803
McElligott, Miranda; Welham, Grace; Pop-Vicas, Aurora et al. (2017) Antibiotic Stewardship in Nursing Facilities. Infect Dis Clin North Am 31:619-638
Jump, Robin L P; Gaur, Swati; Katz, Morgan J et al. (2017) Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings. J Am Med Dir Assoc 18:913-920
Driessen, Julia; Bonhomme, Andro; Chang, Woody et al. (2016) Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations. J Am Med Dir Assoc 17:519-24
Kane-Gill, Sandra L; Hanlon, Joseph T; Fine, Michael J et al. (2016) Physician Perceptions of Consultant Pharmacist Services Associated with an Intervention for Adverse Drug Events in the Nursing Facility. Consult Pharm 31:708-720
Jindai, Kazuaki; Sterkel, Alana K; Reed, Kurt D et al. (2016) Limb Embolism in a 52-Year-Old Woman. Clin Infect Dis 62:1320-1
Jump, Robin L P; Crnich, Christopher J; Nace, David A (2016) Cloudy, Foul-Smelling Urine Not a Criteria for Diagnosis of Urinary Tract Infection in Older Adults. J Am Med Dir Assoc 17:754
Mody, Lona; Crnich, Christopher (2015) Effects of Excessive Antibiotic Use in Nursing Homes. JAMA Intern Med 175:1339-41
Crnich, Christopher J; Jump, Robin; Trautner, Barbara et al. (2015) Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement. Drugs Aging 32:699-716