United States: Resistance Is Futile: CMS Gets Serious About Antibiotic-Resistant Bacteria

Antibiotics and similar drugs, known more broadly as antimicrobial agents, are an instrumental weapon in the healthcare armory, rendering once-lethal infections treatable, and dramatically reducing instances of sepsis and secondary infections associated with cancer chemotherapy and organ transplants. However, sub-therapeutic use of antimicrobial agents in livestock, over-prescription, bacterial evolution and myriad other factors have contributed to the emergence of resistance in the infections that these agents are intended to combat. Antibiotic-resistant bacteria pose a critical threat to the global healthcare system. According to the Centers for Disease Control and Prevention, at least 2 million people become infected with bacteria that are resistant to antibiotics each year in the United States, and at least 23,000 people die annually as a result of these infections. As part of a government-wide response, CMS has proposed a series of measures to combat antibiotic resistance in healthcare facilities.

Long-Term Care Facilities

On October 4, 2016, CMS published a Final Rule to revise Medicare and Medicaid participation requirements for skilled nursing facilities and nursing homes (collectively, long-term care facilities). The Final Rule requires that long-term care facilities establish and maintain an Infection Prevention and Control Program (IPCP) by November 28, 2016 that includes "[a] system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment . . . and following accepted national standards."

By November 28, 2017, facilities must establish an "antibiotic stewardship program" as part of the IPCP, and the program must include antibiotic use protocols and a system for monitoring their use. These requirements are significant, with CMS estimating that implementing such a program and ensuring proper oversight would cost long-term care facilities $19,000 per year, which CMS hopes will be greatly offset by the savings achieved through lowered rates of infection, a cost estimated to range between $4,000 and $11,000 per patient.

To help achieve compliance by the deadline, the Agency for Healthcare Research and Quality (AHRQ) has created a Nursing Home Antimicrobial Stewardship Guide to help long-term care facilities improve antibiotic use and decrease harms caused by inappropriate prescribing.

The guide's four toolkits are designed to help facilities:

  • Implement, monitor and sustain an antimicrobial stewardship program.
  • Determine whether it is necessary to treat a potential infection with antibiotics.
  • Create antibiograms (a table of antibiotics to which a bacterial strain is resistant or susceptible) to help prescribing clinicians choose the right antibiotic to treat a particular infection.
  • Educate and engage residents and family members on proper use and risks associated with antibiotics.

Long-term care facilities are not alone. Starting next year, CMS plans to include hospitals as another front in the government-wide attempt to rein in the problem of antibiotic-resistant bacterial infection.

Hospital and Critical Access Hospitals

Beginning in FY 2017, as part of the Hospital Acquired Conditions Reduction Program, hospitals and critical access hospitals (CAH) will be required to report MRSA bacteremia and Clostridium difficile infections in addition to central line-associated blood stream infections, catheter-associated urinary tract infections and surgical site infections. These data, along with a hospital or CAH's Patient Safety Indicator-90 composite measure, will be used to rank facilities on Hospital Compare. Low-ranking facilities will have their Medicare payments reduced.

Additionally, on June 16, 2016, CMS released a proposed rule to improve antibiotic-prescribing practices and mitigate patient risk for infections, which would require hospitals and CAHs to:

  • Have hospital-wide infection prevention and control, and antibiotic stewardship programs for the surveillance, prevention and control of healthcare-associated infections and other infectious diseases, and for the appropriate use of antibiotics.
  • Designate leaders of the IPCP and the antibiotic stewardship program who are qualified through education, training, experience, or certification. This requirement allows for flexibility in staffing in order to suit the needs of each hospital or CAH.

CMS estimates that these revisions, which would apply to approximately 6,200 hospitals and CAHs, would produce savings of up to $284 million. These proposed regulations are very similar to provisions recently finalized for long-term care facilities. We would not be surprised if these conditions of participation were finalized and implemented in largely the same form as their proposed version.

Physicians (MACRA)

Beginning in 2017, physicians will have a part to play as well. As part of the switch to the Medicare Access and Chip Reauthorization Act of 2015 (MACRA), data regarding the treatment of infections will be incorporated into the MACRA quality measures, potentially having a major impact on how physicians will be paid. Under MACRA, physicians may earn a payment adjustment based on evidence-based and practice-specific quality data. The program includes measures aimed at combating the spread of infection generally (e.g., surgical site infections) as well as measures specifically tied to combating overuse of antibiotics, such as:

  • Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse).
  • Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients With Acute Bacterial Sinusitis (Appropriate Use).\
  • Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus Bacteremia.
  • Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response.

In addition to Quality Measures, development of an antibiotic stewardship program is included as one of the potential MACRA Improvement Activities, where clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety.

While many of the required elements of the IPCP policies and procedures are likely reflected in facilities' existing infection control plans, some requirements will almost certainly be new for many facilities. It may be difficult to determine whether existing practices will meet CMS's requirements and Medicare's Conditions of Participation, given that much of the guidance and training has yet to be developed. However, one thing is certain: Going forward, CMS expects providers to get serious about antibiotic resistance.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

In association with
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement

Mondaq.com (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of www.mondaq.com

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about Mondaq.com’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to unsubscribe@mondaq.com with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to webmaster@mondaq.com.

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to EditorialAdvisor@mondaq.com.

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at enquiries@mondaq.com.

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at problems@mondaq.com and we will use commercially reasonable efforts to determine and correct the problem promptly.