We used data reported from Centers of Medicare and Medicaid (CMS) certified nursing homes on UTI events that occurred between January 2013 and December 2017. All nursing homes that reported at least 1 complete month of UTI surveillance data, both numerator (UTI events) and denominator (resident days and catheter days), were included.

In total, 243 nursing homes from 46 states reported at least 1 month of UTI surveillance data to NHSN. The median nursing home size was 91 beds (range, 9–801); average occupancy was 87%; 220 nursing homes (90%) were dual certified by Medicare and Medicaid; 121 nursing homes (50%) were nonprofit facilities and 80 nursing homes (33%) were independent, freestanding facilities. Most (196, 81%) had laboratory testing performed outside the facility.

This report is the first to summarize the pathogens and antibiotic resistance in UTI events reported by nursing homes to the NHSN LTCF component. The most common UTI causative pathogens identified were E. coli, Proteus spp, and Klebsiella spp, comprising approximately two-thirds of all UTI pathogens. These results are similar to common pathogens reported from either UTI or urine cultures from nursing home residents in other studies.^4,14–18 Within nursing homes, levels of antibiotic resistance, including MDR, were generally higher among the CA-SUTI events than UTIs not associated with catheters, most notably for vancomycin resistance in E. faecium and extended-spectrum cephalosporin and carbapenem resistance in Klebsiella spp. These differences observed among nursing-home UTI event types may be explained by the role that biofilm formation on indwelling devices plays in the selection and emergence of antibiotic resistance.¹⁹ Importantly, these findings highlight the differences in types of pathogens commonly reported as causes of UTI in nursing homes versus hospitals and the rates of antibiotic resistance in infections associated with CA-SUTIs versus SUTIs. Nursing-home data are needed to inform future nursing-home UTI surveillance, infection prevention, and antibiotic stewardship activities, rather than relying on acute-care hospital data as a proxy.

The levels of antibiotic resistance observed demonstrate the importance of monitoring nursing homes and implementing nursing home–specific antibiotic stewardship activities.¹ Notably, approximately half of E. coli isolates from nursing homes were fluroquinolone resistant in both SUTI and CA-SUTI events. Recent publications have reported that fluoroquinolones are the most commonly used antibiotic for UTIs among US nursing home residents and elderly outpatients^20–22 and have been associated with severe adverse events in the elderly.²⁰ The high rate of fluoroquinolone resistance highlights a need for public health officials, infection preventionists, and clinical providers to further reinforce antibiotic stewardship activities aimed at curbing the inappropriate use of fluoroquinolones for UTIs in nursing homes.²⁰

The new regulatory expectations for nursing-home infection prevention programs now include antibiotic stewardship activities.²³ NHSN UTI event reporting can serve as a useful tool for tracking infections, causative pathogens, and antibiotic susceptibility data—all recommended activities for nursing-home antibiotic stewardship programs.¹ In addition, the reporting of pathogens and accompanying susceptibility data to the NHSN allows the generation of regional and national summaries, such as this one, that improve our knowledge and understanding of antibiotic resistance in nursing homes. Individual nursing homes may be unable to generate sufficient susceptibility data within a year to create reliable, facility-specific antibiograms.^16,24 Therefore, pooling of susceptibility data from nursing homes within a geographic region or nationally to track and identify important changes in antibiotic resistance in nursing homes will be necessary.

Our study had several limitations. First, we included data from 243 nursing homes, which represents <2% of Centers for Medicare and Medicaid Services certified nursing homes in the United States. Therefore, these findings may not be generalizable all nursing home facilities. Second, antimicrobial resistance data captured in NHSN represent a variety of laboratories across the country. Differences may exist in the testing and reporting methods among laboratories that could cause inconsistencies in the reported data. The NHSN captures only the category interpretation and not the measured minimum inhibitory concentration; therefore, we were unable to account for differences in the interpretations of breakpoints between laboratories. Third, antimicrobial susceptibility reporting in the LTCF component is based on NHSN acute-care reporting practices. Consequently, antimicrobial susceptibility data for Proteus spp, a key UTI pathogen in nursing homes, could not be summarized because reporting was not required. In addition, because reporting of susceptibility testing results for nitrofurantoin was also not required, limited data on nitrofurantoin were available and susceptibility data were not reported. These observations highlight NHSN system changes that are needed to improve the completeness of data reported and to maximize the usefulness of NHSN susceptibility data for nursing home stakeholders. Finally, due to the low numbers of UTI events reported in the early years of the analysis time period, we did not assess changes in resistance rates over time. We anticipate that, with increasing use of NHSN by nursing homes for UTI surveillance, future data will allow this type of analysis.

Antibiotic resistance is a serious and growing threat in healthcare.^1,2,25 Among a geographically diverse group of nursing homes participating in surveillance for UTI, ~1 in 3 (36%) UTIs were caused by resistant pathogens. Furthermore, the levels of resistance observed are similar to or higher than those reported by acute-care hospitals. Opportunities to modify current NHSN surveillance reporting requirements were identified that will improve the usefulness of the pathogen and susceptibility data generated from the LTCF component. Increased participation in NHSN UTI event reporting by nursing homes has the potential to further our understanding of antibiotic resistance and identify areas to target for intervention within individual facilities, geographic regions, and nationally.