Chicago, Illinois — Seven out of ten nursing home residents receive at least one antibiotic every year. That number alone is striking. What’s worse: according to federal data, four out of ten of those prescriptions are inappropriate — wrong drug, wrong dose, or the wrong duration entirely.
It’s a patient safety crisis hiding in plain sight. And while nursing homes have long been required to maintain infection control programs, clinicians say the sector still hasn’t cracked the code on truly integrating infection prevention with antibiotic stewardship.
“We don’t have to track infections and stewardship separately,” said Dr. Dheeraj Mahajan of CIMPAR, a Chicago-based medical group that works with nursing homes on infection control training. “A lot of that work that gets regulated is under the same bigger umbrella of federal regulation.”
Mahajan, along with registered nurse Sylwia Jasniuk, has spent years pushing for a more unified approach — one where nursing home staff are trained to connect the dots between rising infection rates and antibiotic overuse, rather than treating them as separate compliance boxes to check.
The consequences of getting it wrong are severe. Inappropriate antibiotic use leads to side effects, drug resistance, and the emergence of dangerous organisms like C. difficile and drug-resistant bacterial strains. CIMPAR’s work accelerated after the pandemic exposed how badly many facilities lacked the infrastructure to respond to infectious disease threats.
What Good Stewardship Actually Looks Like
Effective antimicrobial stewardship starts with data. Mahajan describes a few key metrics every nursing home should be tracking: therapy days, antibiotic starts, and point prevalence — the percentage of residents on antibiotics at a given moment in time. That last number is particularly practical because it gives operators a quick, real-world snapshot of their antibiotic burden.
Clinical criteria matter too. Facilities that use structured tools like Loeb’s or McGeer’s criteria to guide antibiotic start decisions tend to make better, more defensible prescribing choices, he said.
There’s also the staffing piece. Having a certified infection preventionist on staff and a board-certified medical director are measurable, structural signals that a facility is serious about this work. “We know from data that’s been published that facilities with certified medical directors tend to have better outcomes when it comes to quality,” Mahajan said.
That’s a connection nursing homes are starting to draw more clearly — quality improvements in areas like infection control have contributed to measurable drops in emergency room visits and hospitalizations.
The Benchmarking Problem
One major gap remains: there’s no comprehensive national database for comparing antibiotic use across nursing homes. Facilities are largely left to self-benchmark over time or collaborate informally with nearby operators and local health departments.
That reluctance to share infection data — once common — is slowly fading, according to Mahajan. “There was a fear of the public health department coming in, if we share our infection rates,” he said. “I think a lot of those worries and fears are going away slowly. People have been more collaborative.”
Industry reports suggest that kind of collaboration, combined with self-benchmarking and working with peer facilities, gives operators a far clearer view of where they stand and where to improve.
CMS already enforces antibiotic stewardship through specific F-tags tied to both infection control and prescribing practices. But the clinical leaders argue that compliance alone isn’t enough — it’s the mindset shift that counts. Antimicrobial stewardship isn’t just paperwork. With drug-resistant strains now outpacing treatment options, it’s become one of the most pressing patient safety priorities in long-term care.
“We have strains that are not susceptible to any antibiotic we have,” Mahajan warned. “So it’s an issue that we need to get on top of.”
