Oral and parenteral antibiotic use in Norwegian nursing homes: are primary care institutions becoming our new local hospitals?

Antibiotic consumption patterns in older adults: a comparative study of people 65 years and older in and outside nursing homes, Belgium, 2016 to 2022

BackgroundInappropriate antimicrobial consumption (AMC) drives the emergence of antimicrobial resistance. Institutionalised, older populations are associated with antimicrobial treatments of longer duration and broader spectrum than recommended, higher rates of multidrug-resistant infections and poorer outcomes for resistant infections. Yet systematic, national monitoring of AMC in nursing home (NH) residents is lacking.AimTo perform a retrospective analysis of antibiotic consumption in Belgian NHs, we compared analogous populations inside and outside NHs. We aimed to provide a blueprint for establishing surveillance of NH AMC, based on national reimbursement data.MethodsThe National Institute for Health and Disability Insurance supplied reimbursement AMC data for outpatients from 2016 to 2022. Data were classified by the Anatomical Therapeutic Chemical system, expressed as defined daily doses (DDD) and aggregated by prescription month, patient age, sex and residency inside/outside a NH. The number of ensured beneficiaries, aggregated by the same demographic variables, was collected from the Intermutualistic Agency. We compared the DDDs per 1,000 beneficiaries per day, along with secondary metrics for national and international targets for analogous populations inside and outside NHs.ResultsTotal antibiotic consumption decreased in both populations but remained twofold higher in NH residents. Proxy prescription quality metrics were consistently less favourable within NHs and diverged further during the COVID-19 pandemic. Distinct consumption patterns and greater seasonal fluctuations were observed in NH residents.ConclusionGiven the different infection risks and higher antibiotic consumption of NH residents, AMC surveillance and antimicrobial stewardship efforts targeting this fragile population are needed.

Antibiotic consumption in French nursing homes between 2018 and 2022: A multicenter survey

OBJECTIVES

Monitoring antibiotic consumption is a key component to steer antimicrobial stewardship programs, including in nursing homes. We analyzed changes in antibiotic consumption in French nursing homes during 5 years, including the COVID-19 pandemic, to identify potential priorities for improvement.

DESIGN

A multicenter survey was conducted between 2018 and 2022.

SETTING

The study was conducted across 220 French nursing homes with on-site pharmacies.

METHOD

Antibiotic consumption data were collected from pharmacy records and are expressed as defined daily doses per 1,000 resident days. Antibiotic indicators promoted by health authorities were calculated from quantitative data to evaluate the quality of prescribing.

RESULTS

Antibiotic consumption significantly decreased between 2018 and 2022, particularly during the coronavirus disease 2019 (COVID-19) pandemic, despite a slight increase in 2022. During the study period, the most used antibiotic classes were penicillins (61.9% in 2022) followed by cephalosporins (10.5%), macrolides-lincosamides-streptogramins (7.3%) then fluoroquinolones (7.0%). Amoxicillin-clavulanic acid was the most consumed antibiotic; amoxicillin and ceftriaxone ranked second and third. Azithromycin consumption increased from 2020, as did the indicator regarding broad-spectrum antibiotics.

CONCLUSIONS

The decreasing trend in antibiotic use and control of fluoroquinolone use over the study period suggest compliance with antibiotic use guidelines. However, changes in the use of broad-spectrum antibiotics and the substantial use of amoxicillin-clavulanic acid, although it is rarely a first-line antibiotic, highlight the need for antimicrobial stewardship activities and the usefulness of antibiotic consumption surveillance to identify priorities.

Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies

BACKGROUND

Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes.

METHOD

We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings.

RESULTS

Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1).

CONCLUSIONS

Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.

A Multifaceted Intervention and Its Effects on Antibiotic Usage in Norwegian Nursing Homes

We explored the impact of an antibiotic quality improvement intervention across 33 nursing homes (NHs) in one Norwegian county, compared against four control counties. This 12-month multifaceted intervention consisted of three physical conferences, including educational sessions, workshops, antibiotic feedback reports, and academic detailing sessions. We provided clinical guiding checklists to participating NHs. Pharmacy sales data served as a measure of systemic antibiotic use. The primary outcome was a change in antibiotic use in DDD/100 BD from the baseline through the intervention, assessed using linear mixed models to identify changes in antibiotic use. Total antibiotic use decreased by 15.8%, from 8.68 to 7.31 DDD/100BD (model-based estimated change (MBEC): -1.37, 95% CI: -2.35 to -0.41) in the intervention group, albeit not a significantly greater reduction than in the control counties (model-based estimated difference in change (MBEDC): -0.75, 95% CI: -1.91 to 0.41). Oral antibiotic usage for urinary tract infections (UTI-AB) decreased 32.8%, from 4.08 to 2.74 DDD/100BD (MBEC: -1.34, 95% CI: -1.85 to -0.84), a significantly greater reduction than in the control counties (MBEDC: -0.9, 95% CI: -1.28 to -0.31). The multifaceted intervention may reduce UTI-AB use in NHs, whereas adjustments in the implementation strategy may be needed to reduce total antibiotic use.

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program - a nested qualitative study

BACKGROUND

Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.

METHODS

After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.

RESULTS

We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.

CONCLUSIONS

Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.