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Skilled Nursing Facility Antibiotic Stewardship Program Implementation Toolkit

The CDPH skilled nursing facility (SNF) antibiotic stewardship program (ASP) toolkit compiles resources for California SNF to implement ASP. The toolkit can be used by SNF medical directors, administrators, directors of nursing or staff development, infection preventionists, pharmacy consultants, and any other staff seeking guidance, resources, and practical examples for developing ASP practices.

ASP optimize the treatment of infections and reduce unnecessary antibiotic use. Improving antibiotic use can reduce adverse events including Clostridioides difficile infections, prevent emergence of resistance, and lead to better outcomes for SNF residents.

In California, all SNF are required by law to implement an antibiotic stewardship policy consistent with guidelines developed by the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services, the Society for Healthcare Epidemiology of America, or similar recognized professional organizations. This toolkit is aligned with the CDC “Core Elements of Antibiotic Stewardship for Nursing Homes (PDF)". The toolkit includes suggestions for implementing the core elements as well as webinar recordings, examples and tools shared by SNF.


​Element 1. Leadership Commitment

SNF leadership commitment support helps ensure adequate  funding and staffing of the ASP, and facilitates buy-in among clinicians.
    • Create a written statement in support of ASP, including demonstration of adequate funding and staffing resources to support the program
    • Establish antibiotic stewardship as a Performance Improvement Program under the facility Quality Assurance-Performance Improvement (QAPI) initiative as recommended by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC)
    • Routinely review ASP activities during the facility quality improvement committee meetings
  • Webinar recording: Leadership Support for Nursing Home Antimicrobial Stewardship (link opens in YouTube)
  • Example 1.1: Statement of Leadership Support (PDF), Sharp Coronado Hospital and Villa Long Term Care

​Element 2. Accountability

A SNF leader should be accountable for ASP outcomes and their effectiveness assessed through clear performance standards. ASP leaders serve as liaisons and champions to promote stewardship education and practices across disciplines. 
    • Convene a physician-supervised multidisciplinary antibiotic stewardship committee, subcommittee, or workgroup






​Element 3. Drug Expertise

SNF should establish access to individuals with antibiotic expertise to implement antibiotic stewardship activities.
    • Obtain ASP support from a physician or pharmacist who has attended specific training on antibiotic stewardship. The trained physician or pharmacist may be consultant pharmacy staff trained or experienced in antibiotic stewardship, an external infectious disease stewardship consultant, or part of the stewardship team at a referral hospital

ASP training is available through various continuing educations programs including those offered by:








​Element 4. Action

SNF should implement at least one intervention to improve antibiotic use. New policies and procedures should be introduced in a step-wise fashion so staff become familiar with, and not overwhelmed by, new changes in practice. Prioritize interventions based on the prescribing and resistance patterns or most prevalent antibiotic adverse events (e.g., Clostridioides difficile infections) at the facility.
    • Develop reports summarizing the antibiotic susceptibility patterns observed at the facility (e.g., facility antibiogram)
    • Partner with ASP physician or pharmacy consultant to use the antibiogram to reevaluate the antibiotic formulary and develop facility-specific treatment recommendations for common infection syndromes
    • Develop a facility-specific algorithm and communication tool for assessing residents suspected of having an infection
    • Develop facility-specific algorithms for appropriate diagnostic testing (e.g., obtaining cultures) for specific infections
    • Require prescribers to document a dose, duration, and indication for all antibiotic prescriptions
    • Implement an antibiotic review process or “antibiotic time out” at 48-72 hours after initiation of antibiotics to reevaluate treatment based on clinical response and culture results
    • Implement a process for communicating or ensuring receipt of antibiotic use information when residents are transferred to and from other healthcare facilities








​Element 5. Tracking

SNF should monitor both antibiotic use practices and outcomes related to antibiotics to guide practice changes and track the impact of new interventions. Tracking clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether interventions are effective in changing prescribing behaviors.
    • Monitor outcomes of antibiotic use. Options include:
      • Rates of C. difficile infection
      • Rates of antibiotic-resistant organisms
      • Rates of adverse drug events due to antibiotics
    • Monitor measures of antibiotic use.
      • Adherence to clinical assessment documentation (e.g., signs/symptoms, vital signs, physical exam findings)
      • Adherence to prescribing documentation (e.g., dose, duration, indication)
      • Adherence to facility-specific treatment recommendations
      • Rates of new antibiotic starts per 1000 resident-days
      • Rates of antibiotic days per 1000 resident days.


​Element 6. Reporting

Regular reporting of information on antibiotic use, including adherence to antibiotic prescribing policies, to physicians, nurses, and relevant staff engages and motivates them to meet ASP goals.    
    • Regularly provide written summaries of antibiotic stewardship goals, antibiotic use, and outcome measurements to prescribers and nursing staff
    • Conduct real-time audits/reviews of individual prescriber practices and provide personalized feedback to clinical providers







​Element 7. Education

SNF ASP should educate both clinical providers and nursing staff on the rationale and goals of antibiotic stewardship interventions, and the responsibility of each group for ensuring implementation. SNF should also engage residents and their family members in antibiotic use and stewardship education to ensure their support when clinicians make appropriate antibiotic use decisions.
    • Regularly provide education  and updates about antibiotic resistance and opportunities for improving use to clinical providers, nursing staff, residents, and families
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