Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities

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.

Assessing the Appropriateness of Antimicrobial Prescribing in the Community Setting: A Scoping Review

Background

This scoping review examined the concept and scope of appropriateness of antimicrobial prescribing in the community setting and how it has been measured.

Methods

Utilizing the Joanna Briggs Institute's methodology, we appraised peer-reviewed articles and unpublished studies, focusing on the US, UK, Canada, and Australia, with no limit to date.

Results

Four basic components of antimicrobial prescribing to be evaluated during assessment of antimicrobial appropriateness in the community setting were identified: diagnosis for infection or indication for antimicrobial therapy, choice of antimicrobial therapy, dosing, and duration of therapy. The benchmark for definition of appropriateness is crucial in assessing antimicrobial prescribing appropriateness. The use of recommended guidelines as a benchmark is the standard for appropriate antimicrobial therapy, and when necessary, susceptibility testing should be explored.

Conclusions

Studies evaluating the appropriateness of antimicrobial prescribing should assess these components of antimicrobial prescribing, and this should be clearly stated in the aim and objectives of the study.

Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents

One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

Older patients are at high risk of infections, which often present atypically and are associated with high morbidity and mortality. Antimicrobial treatment in older individuals with infectious diseases represents a clinical challenge, causing an increasing burden on worldwide healthcare systems; immunosenescence and the coexistence of multiple comorbidities determine complex polypharmacy regimens with an increase in drug-drug interactions and spread of multidrug-resistance infections. Aging-induced pharmacokinetic and pharmacodynamic changes can additionally increase the risk of inappropriate drug dosing, with underexposure that is associated with antimicrobial resistance and overexposure that may lead to adverse effects and poor adherence because of low tolerability. These issues need to be considered when starting antimicrobial prescriptions. National and international efforts have been made towards the implementation of antimicrobial stewardship (AMS) interventions to help clinicians improve the appropriateness and safety of antimicrobial prescriptions in both acute and long-term care settings. AMS programs were shown to decrease consumption of antimicrobials and to improve safety in hospitalized patients and older nursing home residents. With the abundance of antimicrobial prescriptions and the recent emergence of multidrug resistant pathogens, an in-depth review of antimicrobial prescriptions in geriatric clinical practice is needed. This review will discuss the special considerations for older individuals needing antimicrobials, including risk factors that shape risk profiles in geriatric populations as well as an evidence-based description of antimicrobial-induced adverse events in this patient population. It will highlight agents of concern for this age group and discuss interventions to mitigate the effects of inappropriate antimicrobial prescribing.

A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Inappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types.

METHODS

This protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the 'AMS ENGAGEMENT bundle', will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship. The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field.

DISCUSSION

A structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes.

TRIAL REGISTRATION

US National Library of Medicine Clinical Trials.gov ( NCT04705259 ). Prospectively registered in 12th of January 2021.

Comparison of criteria for determining appropriateness of antibiotic prescribing in nursing homes

BACKGROUND

Measuring the appropriateness of antibiotic prescribing in nursing homes remains a challenge. The revised McGeer criteria, which are widely used to conduct infection surveillance in nursing homes, were not designed to assess antibiotic appropriateness. The Loeb criteria were explicitly designed for this purpose but are infrequently used outside investigational studies. The extent to which the revised McGeer and Loeb criteria overlap and can be used interchangeably for tracking antibiotic appropriateness in nursing homes remains insufficiently studied.

METHODS

We conducted a cross-sectional chart review study in 5 Wisconsin nursing homes and applied the revised McGeer and Loeb criteria to all nursing home-initiated antibiotic treatment courses. Kappa (κ) statistics were employed to assess level of agreement overall and by treatment indications.

RESULTS

Overall, 734 eligible antibiotic courses were initiated in participating nursing homes during the study period. Of 734 antibiotic courses, 372 (51%) satisfied the Loeb criteria, while only 211 (29%) of 734 satisfied the revised McGeer criteria. Only 169 (23%) of 734 antibiotic courses satisfied both criteria, and the overall level of agreement between them was fair (κ = 0.35). When stratified by infection type, levels of agreement between the revised McGeer and Loeb criteria were moderate for urinary tract infections (κ = 0.45), fair for skin and soft-tissue infections (0.36), and slight for respiratory tract infections (0.17).

CONCLUSIONS

Agreement between the revised McGeer and Loeb criteria is limited, and nursing homes should employ the revised McGeer and Loeb criteria for their intended purposes. Studies to establish the best method for ongoing monitoring of antibiotic appropriateness in nursing homes are needed.

Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis

BACKGROUND

Long-term care facilities (LTCFs) are health-care settings with high antimicrobial consumption and hence need to develop effective antimicrobial stewardship programmes (ASPs).

OBJECTIVE

To assess the effects of ASPs on care-related, clinical and ecological outcomes in LTCFs.

METHODS

Data sources were PubMed, EMBASE, CINAHL and SCOPUS. Study eligibility criteria were original research articles (controlled clinical trials or controlled before and after studies) published up to 1 October 2020. Participants were adult residents of LTCFs, residential aged-care facilities, nursing homes, veterans' homes, skilled nursing facilities and assisted living facilities for older people. Interventions included ASPs versus standard care. Outcomes assessed were antimicrobial consumption and appropriateness, infections, hospital admissions and mortality. Available data were pooled in a meta-analysis, and inconsistency between studies was evaluated using the I² statistic. Certainty of evidence was assessed using the GRADE approach.

RESULTS

Of the 3111 papers identified, 12 studies met the inclusion criteria. All of them analysed the impact of interventions on antimicrobial use based on consumption-related variables (n = 8) and/or percentage of inappropriate prescriptions (n = 6). Pooled data showed a mean difference of -0.47 prescriptions per 1000 resident-days in favour of ASPs (95% CI -0.87 to -0.07, I² = 71%). Five studies analysed the clinical effect of ASPs on the number of hospital admissions and/or resident mortality. The meta-analysis showed a mean difference of 0.17 hospital admissions per 1000 resident-days (95% CI -0.07 to 0.41, I² = 17%) and a mean difference of -0.02 deaths per 1000 resident-days (95% CI -0.14 to 0.09, I² = 0%). Only two studies included infections as a study outcome.

CONCLUSIONS

ASPs appear to improve antimicrobial use in this setting without increasing hospital admissions or deaths, indicating that these programmes do not lead to under-treatment of infections. Nonetheless, further higher-quality clinical trials are required to understand the effects of ASPs in LTCFs.

PROSPERO REGISTRATION NUMBER

CRD42021225127.

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration

OBJECTIVE

Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones.

DESIGN

Quasi-experimental, pre- and post-intervention study.

SETTING AND PARTICIPANTS

Six NHs in Monroe County, NY.

METHODS

A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time.

RESULTS

Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042).

CONCLUSIONS AND IMPLICATIONS

A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

Description of antibiotic use variability among US nursing homes using electronic health record data

Background:

Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders.

Methods:

A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models.

Results:

In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5–10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software).

Conclusions:

Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review

Background

Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities’ antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes.

Method

A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as ‘very promising’ (all outcomes statistically significant), ‘quite promising’ (some outcomes statistically significant), or ‘not promising’ (no outcomes statistically significant). ‘Promise ratios’ (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2.

Results

Twenty studies (of19 interventions) were included. Seven interventions (37%) were ‘very promising’, eight ‘quite promising’ (42%) and four ‘not promising’ (21%). Most promising intervention types were ‘persuasion’ (n = 12; promise ratio (PR) = 5.0), ‘enablement’ (n = 16; PR = 4.33) and ‘education’ (n = 19; PR = 3.75). Most promising behaviour change techniques were ‘feedback on behaviour’ (n = 9; PR = 8.0) and ‘restructuring the social environment’ (e.g. staff role changes; n = 8; PR = 7.0).

Conclusion

Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Effect of antibiotic time-outs on modification of antibiotic prescriptions in nursing homes

BACKGROUND

Antibiotic overuse and misuse is a common problem in nursing homes. Antibiotic time-out (ATO) interventions have led to improvements in antibiotic uses in hospitals, but their impact in nursing homes remain understudied.

OBJECTIVE

To evaluate the impact of a stewardship intervention, promoting use of ATOs on the frequency and types of antibiotic change events (ACEs) in nursing homes.

DESIGN

Controlled before-and-after intervention study.

SETTING

Nursing homes in Wisconsin and Pennsylvania.

METHOD

Data on antibiotic prescriptions in 11 nursing homes were collected for 25 months. We categorized ACEs as (1) early discontinuation, (2) class modification, or (3) administration modification. Class modification ACEs were further classified based on whether the change narrowed, expanded, or had no effect on bacterial spectrum coverage. Analyses were performed using a difference-in-difference (DiD) approach.

RESULT

Of 2,647 antibiotic events initiated in study nursing homes, 376 (14.2%) were associated with an ACE. The overall proportion of ACEs did not significantly differ between intervention and control nursing homes. Early discontinuation ACEs increased in intervention nursing homes (DiD, 2.5%; P = .01), primarily affecting residents initiated on broad-spectrum antibiotics (DiD, 2.9%; P < .01). Class modification ACEs decreased in intervention nursing homes but remained unchanged in control nursing homes.

CONCLUSION

The impact of an ATO intervention in study nursing homes was mixed with increases in early discontinuation ACEs offset by reductions in class modification ACEs. More research on the potential value of ATO interventions in nursing homes is warranted.

Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial

Background

Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting.

Methods/design

A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no).

Discussion

This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results.

Trial registration

Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.

Antibiotic Stewardship in Nursing Facilities

Misuse and overuse of antibiotic therapy is a frequent cause of resident harm in nursing facilities. As a result, newly released policy and regulatory initiatives will require antibiotic stewardship programs (ASPs) in nursing facilities. Although implementing ASPs can be challenging, improving the quality of antibiotic prescribing is achievable in this setting. The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.

Inappropriate Use of Antimicrobials for Lower Respiratory Tract Infections in Elderly Patients: Patient- and Community-Related Implications and Possible Interventions

The elderly are more susceptible to infections, which is reflected in the incidence and mortality of lower respiratory tract infections (LRTIs) increasing with age. Several aspects of antimicrobial use for LRTIs in elderly patients should be considered to determine appropriateness. We discuss possible differences in microbial etiology between elderly and younger adults, definitions of inappropriate antimicrobial use for LRTIs currently found in the literature, along with their results, and the possible negative impact of antimicrobial therapy at both an individual and community level. Finally, we propose that both antimicrobial stewardship interventions and novel rapid diagnostic techniques may optimize antimicrobial use in elderly patients with LRTIs.

Explicit definitions of potentially inappropriate prescriptions of antibiotics in older patients: a compilation derived from a systematic review

Potentially inappropriate prescriptions (PIPs) of antibiotics (antibiotic-PIPs) are generally detected by applying implicit definitions based on expert opinion. Explicit definitions are less frequently used, even though this approach would enable the automated detection of antibiotic-PIPs in electronic health records. Here, explicit definitions of antibiotic-PIPs used in studies of older adults were systematically reviewed. The MEDLINE^®, Scopus^® and Web of Science^TM core collection databases were searched with a combination of three terms and their synonyms: 'potentially inappropriate prescription' AND 'antibiotic treatment' AND 'older patients'. Following standardised selection of publications, explicit definitions of antibiotic-PIPs were extracted and were classified into infectious diseases domains and subdomains. A total of 600 search queries identified 4270 records, 93 of which were selected for review. A total of 160 mentions of antibiotic-PIPs were found, corresponding to 62 distinct definitions in 19 infectious diseases domains. Nearly one-half of the definitions were related to upper respiratory tract infections (n = 11 definitions; 17.7%), lower respiratory tract infections (n = 8; 12.9%) and drug-drug interactions (n = 11; 17.7%). Almost 75% of definitions (n = 46) were mentioned in a single study only. Only three definitions concerned critically important antibiotics such as third-generation cephalosporins and fluoroquinolones. This systematic review identified 62 explicit definitions of antibiotic-PIPs. Most of the definitions were not found in more than one study and they varied in the degree of precision. We advocate the implementation of an expert consensus on explicit definitions of antibiotic-PIPs that correspond to today's challenges in public health.

Nursing home nurses' and community-dwelling older adults' reported knowledge, attitudes, and behavior toward antibiotic use

BACKGROUND

Antibiotic overuse causes antibiotic resistance, one of the most important threats to human health. Older adults, particularly those in nursing homes, often receive antibiotics when they are not indicated.

METHODS

To understand knowledge, attitudes, and behaviors of nursing home (NH) nurses and community-dwelling older adults towards antibiotic use, especially in clinical situations consistent with antibiotic overuse, we conducted a mixed-method survey in two NHs and one Family Medicine clinic in North Carolina, among English-speaking nurses and community-dwelling, cognitively intact adults aged 65 years or older. Based on the Knowledge-Attitude-Practice model, the survey assessed knowledge, attitudes, and behavior towards antibiotic use, including three vignettes designed to elicit possible antibiotic overuse: asymptomatic bacteriuria (ASB), a viral upper respiratory illness (URI), and a wound from a fall.

RESULTS

Of 31 NH nurses and 66 community-dwelling older adults, 70% reported knowledge of the dangers of taking antibiotics. Nurses more often reported evidence-based attitudes towards antibiotics than older adults, except 39% agreed with the statement "by the time I am sick enough to go to the doctor with a cold, I expect an antibiotic", while only 28% of older adults agreed with it. A majority of nurses did not see the need for antibiotics in any of the three vignettes: 77% for the ASB vignette, 87% for the URI vignette, and 97% for the wound vignette. Among older adults, 50% did not perceive a need for antibiotics in the ASB vignette, 58% in the URI vignette, and 74% in the wound vignette.

CONCLUSIONS

While a substantial minority had no knowledge of the dangers of antibiotic use, non-evidence-based attitudes towards antibiotics, and behaviors indicating inappropriate management of suspected infections, most NH nurses and community-dwelling older adults know the harms of antibiotic use and demonstrate evidence-based attitudes and behaviors. However, more work is needed to improve the knowledge, attitudes and behaviors that may contribute to antibiotic overuse.

Changes in vital signs as predictors of bacterial infection in home care: a multi-center prospective cohort study

OBJECTIVES

To explore whether the combination of changes in heart rate and body temperature can predict bacterial infection in home care patients.

METHODS

This multicenter, prospective cohort study was conducted in Japan from March 2012 through December 2013 and involved three clinics. The study population comprised all patients who received regular home visit services for at least 3 months and met one of the following inclusion criteria: 1) fever over 37.5°C at home visit, 2) physician's clinical suspicion of fever, or 3) physician's suspicion of bacterial infection. We collected temperature and heart rate data on the day of enrollment, and determined the probable causes of fever after treatment of febrile episodes. We defined the combination of changes in heart rate and body temperature as delta HR/BT. We calculated two types of delta HR/BT, averaged and assumed, using different baseline values for heart rate and body temperature.

RESULTS

A total of 124 patients were enrolled and 194 episodes of fever were analyzed during the study period. The sensitivity, specificity, positive predictive value, and negative predictive value for the average delta HR/BT with a cut-off ≥ 20 were 20.4% (95% CI, 16.7-23.3), 84.2% (95% CI, 75.2-91.0), 75.7% (95% CI, 61.8-86.2), and 30.6% (95% CI, 27.3-33.0), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the assumed delta HR/BT with a cut-off ≥ 5 was 91.2% (95% CI, 89.2-94.0), 8.9% (95% CI, 4.1-15.7), 70.9% (95% CI, 69.3-73.0), and 29.4% (95% CI, 13.6-51.8), respectively.

CONCLUSIONS

The combination of changes in heart rate and body temperature could help physicians determine whether home care patients have bacterial infections.

Constitutional Symptoms Trigger Diagnostic Testing Before Antibiotic Prescribing in High-Risk Nursing Home Residents

OBJECTIVES

To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia.

DESIGN

Prospective longitudinal study nested within a randomized trial, using data from control sites.

SETTING

Six NHs in southeast Michigan.

PARTICIPANTS

NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection).

MEASUREMENTS

Clinical and demographic data-including information on incident infections, antibiotic use, and results of diagnostic tests-were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year.

RESULTS

One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection.

CONCLUSION

Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions.

Healthcare-associated infections in the elderly: what's new

PURPOSE OF REVIEW

The high-risk population and current lack of knowledge regarding appropriate infection prevention in the long-term care (LTC) setting has contributed to substantial rates of resistance and healthcare-associated infections in this arena. More evidence-based research on LTC is necessary, particularly now that the elderly population is increasing.

RECENT FINDINGS

Proposed government mandates highlight the urgent need to combat antimicrobial resistance in the LTC setting. Recent studies focusing on unique strategies for the prevention of transmission and infection with multidrug-resistant organisms in nursing homes are discussed, as well as attempts to formulate clear antimicrobial stewardship programs.

SUMMARY

The long-term setting has unique challenges to instituting effective infection control precautions, therefore current accepted methods used in acute-care facilities need to be modified. Recent data suggest that prevention of transmission in LTC may be achieved with focus on high-risk patients or specific care-based activities rather than colonization status. Antimicrobial stewardship and consultation with specialized physicians may be important measures to combat resistance and adverse events in LTC. The prevention of unnecessary antibiotic use in palliative care may reduce rates of resistance as well as discomfort for terminal patients.

Antimicrobial Stewardship in Long-Term Care: Metrics and Risk Adjustment

An antimicrobial stewardship program (ASP) has been recommended for long-term care facilities because of the increasing problem of antibiotic resistance in this setting to improve prescribing and decrease adverse events. Recommendations have been made for the components of such a program, but there is little evidence to support any specific methodology at the present time. The recommendations make minimal reference to metrics, an essential component of any ASP, to monitor the results of interventions. This article focuses on the role of antibiotic use metrics as part of an ASP for long-term care. Studies specifically focused on development of antibiotic use metrics for long-term care are reviewed. It is stressed that these metrics should be considered as an integral part of an ASP in long-term care. In order to develop benchmarks for antibiotic use for long-term care, there must be appropriate risk adjustment for interfacility comparisons and quality improvement. Studies that have focused on resident functional status as a risk factor for infection and antibiotic use are reviewed. Recommendations for the potentially most useful and feasible metrics for long-term care are provided along with recommendations for future research.

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.

Race/Ethnicity and overuse of care: a systematic review

POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.

CONTEXT

The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.

METHODS

We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.

FINDINGS

We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.

CONCLUSIONS

Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.

Antibiotic prescribing in Dutch nursing homes: how appropriate is it?

OBJECTIVE

To investigate the appropriateness of decisions to prescribe or withhold antibiotics for nursing home (NH) residents with infections of the urinary tract (UTI), respiratory tract (RTI), and skin (SI).

DESIGN

Prospective study.

SETTING

Ten NHs in the central-west region of the Netherlands.

PARTICIPANTS

Physicians providing medical care to NH residents.

MEASUREMENTS

Physicians completed a registration form for any suspected infection over an 8-month period, including patient characteristics, signs and symptoms, and treatment decisions. An algorithm, developed by an expert panel and based on national and international guidelines, was used to evaluate treatment decisions for appropriateness of initiating or withholding antibiotics.

RESULTS

Appropriateness of 598 treatment decisions was assessed. Overall, 76% were appropriate, with cases that were prescribed antibiotics judged less frequently "appropriate" (74%) compared with cases in which antibiotics were withheld (90%) (P = .003). Decisions around UTI were least often appropriate (68%, compared with 87% for RTI and 94% for SI [P < .001]). The most common situations in which antibiotic prescribing was considered inappropriate were those indicative of asymptomatic bacteriuria or viral RTI.

CONCLUSION

Although the rate of appropriate antibiotic prescribing in Dutch NHs is relatively high compared with previous studies in other countries, our results suggest that antibiotic consumption can be reduced by improving appropriateness of treatment decisions, especially for UTI. Given the current antibiotic resistance developments in long-term care facilities, interventions reducing antibiotic use for asymptomatic bacteriuria and viral RTI are warranted.

Evidence-based diagnosis and management of acute bronchitis

Acute bronchitis is a common respiratory infection seen in primary care settings. This article examines the current evidence for diagnosis and management of acute bronchitis in adults and provides recommendations for primary care clinical practice.

Role of body temperature in diagnosing bacterial infection in nursing home residents

OBJECTIVES

To provide empirically based recommendations for incorporating body temperature into clinical decision-making regarding diagnosing infection in nursing home (NH) residents.

DESIGN

Retrospective.

SETTING

Twelve North Carolina NHs.

PARTICIPANTS

NH residents (N = 1,007) with 1,858 randomly selected antibiotic prescribing episodes.

MEASUREMENTS

Maximum prescription-day temperature plus the three most recent nonillness temperatures were recorded for each prescribing episode. Two empirically based definitions of fever were developed: population-based (population mean nonillness temperature plus 2 population standard deviations (SDs)) and individualized (individual mean nonillness temperature plus 2 population SDs). These definitions were used along with previously published fever criteria and Infectious Diseases Society of America (IDSA) criteria to determine how often each prescribing episode was associated with a "fever" according to each definition.

RESULTS

Mean population nonillness temperature was 97.7 ± 0.5 ºF. If "normal" were defined as less than 2 SDs above the mean, fever would be defined as any temperature above 98.7 ºF, and the previously published fever cutpoints and the IDSA criteria are 4.8 SDs above this mean. Between 30% and 32% of the 1,858 prescribing episodes examined were associated with temperatures more than 2 SDs above the population mean nonillness temperature, whereas only 10% to 11% of episodes met the previously published and IDSA fever definitions.

CONCLUSION

Clinicians should apply empirically based definitions to assess fever in NH residents. Furthermore, low fever prevalence in residents treated with antibiotics according to all definitions suggests that some prescribing may not be associated with acute bacterial infection.

Influenza-like illness sentinel surveillance in one hospital in Medellin, Colombia. 2007-2012

BACKGROUND

The city of Medellin in Colombia has almost no documentation of the causes of acute respiratory infections (ARIs). As part of an ongoing collaboration, we conducted an epidemiologic surveillance for influenza and other respiratory viruses. It described the influenza strains that were circulating in the region along with their distribution over time, and performing molecular characterization to some of those strains. This will contribute to the knowledge of local and national epidemiology.

OBJECTIVES

To analyze viral etiologic agents associated with influenza like illness (ILI) in participants reporting to one General hospital in Medelllin, Colombia.

RESULTS

From January 2007 to December 2012, a total of 2039 participants were enrolled. Among them, 1120 (54.9%) were male and 1364 (69%) were under the age of five. Only 124 (6%) were older than the age of 15. From all 2039 participants, 1040 samples were diagnosed by either isolation or RT-PCR. One or more respiratory viruses were found in 737 (36%) participants. Of those, 426 (57.8%) got influenza A or B. Adenoviral and parainfluenza infections represented 19.1% and 14.9% of viral infections, respectively. Influenza A was detected almost throughout the whole year except for the first quarter of 2010, right after the 2009 influenza A pandemic. Influenza B was detected in 2008, 2010, and 2012 with no pattern detected. During 2008 and 2010, both types circulated in about the same proportion. Unusually, in many months of 2012, the proportion of influenza B infections was higher than influenza A (ranging between 30% and 42%). The higher proportion of adenovirus was mainly detected in the last quarter of years 2007 and 2010. Adenoviral cases are more frequent in participants under the age of four.

CONCLUSIONS

The phylogenetic analysis of influenza viruses shows that only in the case of influenza A/H1N1, the circulating strains totally coincide with the vaccine strains each year.

Impact of implementation of a novel antimicrobial stewardship tool on antibiotic use in nursing homes: a prospective cluster randomized control pilot study

OBJECTIVES

To evaluate the impact of 'Resident Antimicrobial Management Plan' (RAMP), a novel antimicrobial stewardship tool on systemic antibiotic use for treatment of infection in nursing homes (NHs).

METHODS

A pilot cluster randomized control study was conducted in 30 NHs in London. Pre-intervention, we collected point prevalence data on antimicrobial use on three occasions and total antimicrobial consumption for a 12 week period. Post-intervention data were collected in the same manner and included assessment of compliance with RAMP in the intervention group (IG).

RESULTS

The number of residents included was 1628 pre-intervention [825 IG/803 control group (CG)] and 1610 post-intervention (838 IG/772 CG). The corresponding pre- and post-intervention point prevalence of systemic antibiotic prescribing for treatment of infection was 6.46% and 6.52% in the IG [estimated prevalence ratio: 1.01 (95% CI: 0.81-1.25), P = 0.94] compared with 5.27% and 5.83%, respectively, in the CG [estimated prevalence ratio: 1.11 (95% CI: 0.87-1.41), P = 0.4]. Total antibiotic consumption was 69.78 defined daily doses/1000 residents/day (DRD) pre-intervention and 66.53 DRD post-intervention in the IG compared with 49.68 and 51.92 DRD, respectively, in the CG. There was a significant decrease of 4.9% (3.25 DRD) in the IG (95% CI: 1.0%-8.6%) (P = 0.02) compared with a significant increase of 5.1% (2.24 DRD) in the CG (95% CI: 0.2%-10.2%) (P = 0.04). Main indications for antibiotics were lower respiratory tract infections (34.1%), urinary tract infections (28.5%) and skin/soft tissue infections (25.1%).

CONCLUSIONS

This pilot study demonstrated that use of RAMP was associated with a statistically significant decrease in total antibiotic consumption and has the potential to be an important antimicrobial stewardship tool for NHs.

Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives

Residential aged care facilities are increasingly identified as having a high burden of infection, resulting in subsequent antibiotic use, compounded by the complexity of patient demographics and medical care. Of particular concern is the recent emergence of multidrug-resistant organisms among this vulnerable population. Accordingly, antimicrobial stewardship (AMS) programs have started to be introduced into the residential aged care facilities setting to promote judicious antimicrobial use. However, to successfully implement AMS programs, there are unique challenges pertaining to this resource-limited setting that need to be addressed. In this review, we summarize the epidemiology of infections in this population and review studies that explore antibiotic use and prescribing patterns. Specific attention is paid to issues relating to inappropriate or suboptimal antibiotic prescribing to guide future AMS interventions.

The effect of interventions to reduce potentially inappropriate antibiotic prescribing in long-term care facilities: a systematic review of randomised controlled trials

BACKGROUND

The prevalence of antibiotic use in long-term care facilities (LTCF) is high and in many cases it may not be in accordance with local guidelines. It is important to review interventions that aim to improve the quality of antibiotic prescribing in this setting.

OBJECTIVE

The objective of this systematic review was to collect and interpret the results of studies of interventions to improve the quality of, or appropriateness of antibiotic prescribing in LTCF in order to determine the key components for a successful intervention.

DATA SOURCES

A search of The Cochrane Library, PubMed, EMBASE, ISI Web of Knowledge, International Pharmaceutical Abstracts, the Database of Abstracts of Review of Effects (DARE), the Health Technology Assessments (HTA) at the Centres for Reviews and Dissemination (CRD) and Google Scholar was conducted from their inception to August 2012. A manual search of the grey literature and relevant journals was also conducted.

STUDY SELECTION

Studies were selected that were randomised controlled trials of an intervention to improve the quality of antibiotic prescribing, or increase adherence to a prescribing guideline or reduce the amount of antibiotic prescribing. All studies were conducted in the long-term care setting. The search strategy found four randomised controlled trials that met the inclusion criteria, from an initial 1,904 titles.

STUDY APPRAISAL AND SYNTHESIS METHODS

The risk of bias assessment of the included studies was conducted using the Cochrane Risk of Bias Table. Due to the heterogeneity of the interventions, study designs and outcome measures, a meta-analysis was not conducted.

RESULTS

Four studies met the inclusion criteria for this review. Three studies directed educational material and sessions at physicians and nurses, with one of the three studies providing prescribing feedback as well. The fourth study provided educational material and prescribing feedback for physicians only. Due to the mixed and modest effects of the interventions and the variety of interventions implemented, it is difficult to attribute the success of any intervention to just one component alone. It seems that a multifaceted intervention involving small group educational sessions and the provision of educational materials is generally acceptable to nurses and physicians in LTCF. The involvement of local consensus procedures when developing guidelines and interventions may improve the success of the intervention.

LIMITATIONS

A limitation of this systematic review is the small number of studies that met the inclusion criteria.

CONCLUSION

Interventions in the long-term care setting involving local consensus procedures, educational strategies, and locally developed guidelines may improve the quality of antibiotic prescribing, but the quality of the evidence is low. Due to the poor quality of evidence and mixed results, no definitive conclusion can be reached about the effect of the interventions. Future research in this area needs to include process evaluation research in order to define the characteristics contributing to the success or failure of any intervention. The contribution of a multidisciplinary antibiotic management team, which could include a pharmacist, a nurse and specialists in microbiology and infectious diseases and geriatrics, needs further investigation in order to improve antibiotic prescribing practices in LTCF.