Antibiotics are among the most important tools we have to treat infections and save lives. But in nursing homes, these powerful drugs are often used when they shouldn’t be—or used in ways that do more harm than good. Overuse and misuse of antibiotics can lead to serious problems, including dangerous side effects for residents and the growth of antibiotic-resistant bacteria that threaten everyone’s health.

That’s why antibiotic stewardship—using antibiotics only when needed and in the right way—is so important in nursing homes. But stewardship doesn’t mean withholding necessary treatment. Instead, it’s about finding the balance: keeping residents safe from infection while protecting them from unnecessary antibiotic use.

Why Is Antibiotic Stewardship So Important in Nursing Homes?

Nursing home residents are often frail, with multiple medical conditions. Many rely on medical devices like catheters or feeding tubes that increase infection risk. Infections are common—and sometimes deadly—in this setting. So it’s no surprise that antibiotics are among the most frequently prescribed drugs in long-term care.

But here’s the problem:

• Up to 75% of antibiotic use in nursing homes may be inappropriate.
  This can mean giving antibiotics for conditions that aren’t bacterial infections (like viral respiratory infections), treating asymptomatic bacteriuria (bacteria in the urine without signs of infection), or choosing the wrong drug, dose, or duration.

• Overuse leads to resistance.
  When antibiotics are used too much or incorrectly, bacteria evolve to resist them. These antibiotic-resistant bacteria are hard to treat and can spread in the facility.
• Harm to residents.
  Antibiotics have side effects, including allergic reactions, kidney damage, and Clostridioides difficile (C. diff) infection—a potentially deadly diarrhea that can sweep through a facility.

Antibiotic stewardship is the strategy to address these risks while still making sure residents who need antibiotics get them promptly.

The Challenge: Diagnosing Infections in Older Adults

One major barrier to good antibiotic stewardship is the difficulty of diagnosing infections in elderly nursing home residents. Unlike younger people, older adults often don’t show clear signs of infection.

For example:

• Fever may be absent or low-grade.
• Confusion or delirium might be the only symptom.
• Chronic urinary colonization is common—bacteria in the urine even when there’s no true infection.

This diagnostic uncertainty can lead providers to “play it safe” and prescribe antibiotics just in case. But blanket prescribing creates more problems than it solves.

Tools for Better Decisions: McGeer and Loeb Criteria

To help clinicians decide when antibiotics are really needed, experts have developed decision-making criteria for nursing homes. Two commonly used sets are:

• McGeer Criteria: Originally developed for surveillance, these criteria help identify when infections are present in long-term care residents for tracking purposes.
• Loeb Criteria: Designed specifically to guide bedside prescribing decisions.

For example, the Loeb Criteria for starting antibiotics for a suspected urinary tract infection (UTI) in a resident without a catheter include:

• Acute dysuria (painful urination) or
• Fever plus at least one urinary symptom (urgency, frequency, suprapubic pain).

If these signs aren’t present, antibiotics shouldn’t be started. Instead, staff should monitor closely. Using these criteria isn’t about denying care—it’s about making sure antibiotics are truly needed.

The Role of Nursing Staff in Stewardship

Nursing staff are the front line for infection detection and monitoring. They play a crucial role in stewardship by:

• Accurate assessment and documentation.
  Documenting vital signs, symptoms, mental status changes, and risk factors clearly helps providers make better decisions.
• Communication with providers.
  Using structured communication tools like SBAR (Situation, Background, Assessment, Recommendation) helps ensure key information is shared.
• Monitoring residents on antibiotics.
  Watching for side effects, C. diff symptoms, and improvement (or lack of improvement) to inform possible therapy changes.
• Educating residents and families.
  Helping them understand why antibiotics aren’t always the right choice and what alternative monitoring may look like.

Best Practices for Nursing Home Antibiotic Stewardship

CMS requires nursing homes to have antibiotic stewardship programs as part of the Requirements of Participation.

But that doesn’t mean it’s just a regulatory box to check. An effective program is part of providing high-quality, resident-centered care.

Here are practical best practices facilities can use:

1. Establish a Stewardship Team

• Include the medical director, consultant pharmacist, infection preventionist, nursing leadership, and frontline staff.
• Meet regularly to review prescribing patterns and identify improvement opportunities.

2. Create Facility-Specific Guidelines

• Develop or adopt guidelines for common infections, such as UTIs, respiratory infections, and skin infections.
• Include diagnostic criteria, recommended empiric antibiotics, and durations of therapy.

3. Review and Track Antibiotic Use

• Monitor which antibiotics are prescribed, why, and for how long.
• Share data with prescribers to identify trends, such as overuse of broad-spectrum agents or excessive durations.

4. Provide Education

• Train staff on recognizing infections in older adults.
• Teach providers and nurses about diagnostic criteria and stewardship principles.
• Offer ongoing refreshers as guidelines evolve.

5. Engage Prescribers

• Involve them in developing guidelines.
• Share performance feedback and data.
• Encourage use of decision criteria to reduce unnecessary prescribing.

6. Monitor Outcomes

• Track C. diff infections, antibiotic resistance rates, and adverse drug events.
• Use this data to drive further improvements.

Case Example: Reducing Unnecessary UTI Treatment

One common area of improvement is treating asymptomatic bacteriuria (ASB) in nursing home residents. Many residents have bacteria in their urine without any signs of infection. Treating ASB doesn’t reduce infections but does increase resistance risk and C. diff rates.

By training staff and providers on Loeb Criteria and implementing protocols, facilities can dramatically reduce unnecessary urine cultures and antibiotic starts. For example, one quality improvement project reduced ASB treatment by over 50% in six months through education and culture change alone.

Balancing Stewardship and Resident Safety

Some staff worry that focusing on antibiotic reduction could mean missing real infections. That’s a valid concern—but stewardship doesn’t mean ignoring infection signs. Instead, it means:

• Using structured criteria to make better diagnostic calls.
• Starting antibiotics quickly when they are truly needed.
• Choosing the right drug, dose, and duration to minimize harm.
• Monitoring residents carefully to catch changes early.

This balanced approach helps protect both the individual resident and the broader facility community from the harms of overuse and resistant infections.

Conclusion: A Shared Responsibility

Antibiotic stewardship in nursing homes isn’t just the responsibility of prescribers. It’s a team effort that involves:

• Nurses who assess, document, and communicate resident status.
• Providers who use evidence-based criteria to guide prescribing.
• Pharmacists who review orders and suggest alternatives.
• Administrators who support education, policy development, and monitoring.
• Infection preventionists who track trends and ensure best practices.

Together, these efforts help ensure that residents receive the best care: antibiotics when needed, avoided when not, and always with safety in mind. By prioritizing stewardship, nursing homes can protect their residents today while helping preserve antibiotic effectiveness for the future.

The Compliance Store Can Help

The Compliance Store provides information, CDC recommendations, CMS requirements, as well as tools and materials to effectively implement and monitor the necessary Antibiotic Stewardship Program in your nursing facility. We continuously research, subscribe and publish any important changes and alert you. Call us today at 1-877-582-7347 or contact us online to see how we can help your team and your residents!