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Matovelle P, Olivan-Blázquez B, Magallón-Botaya R, García-Sangenís A, Monfà R, Morros R, Navarro Sanmartín A, Mateos-Nozal J, Sáez Bejar C, Rodríguez Jiménez C, López Pérez E, Llor C. Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis. Antibiotics (Basel) 2024; 13:152. [PMID: 38391537 PMCID: PMC10885965 DOI: 10.3390/antibiotics13020152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.
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Affiliation(s)
- Priscila Matovelle
- Geriatrics Department, Hospital San Juan de Dios, 50006 Zaragoza, Spain
- Geriatrics Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Bárbara Olivan-Blázquez
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Rosa Magallón-Botaya
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Medicine Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Ana García-Sangenís
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | - Ramon Monfà
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | | | - Jesús Mateos-Nozal
- Geriatrics Department, Hospital Universitario Ramón y Cajal (IRYCIS), 28034 Madrid, Spain
| | - Carmen Sáez Bejar
- Internal Medicine Department, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria (IIS-Princesa), 28006 Madrid, Spain
- Research Institute of Princesa (IIS Princesa), 28006 Madrid, Spain
| | - Consuelo Rodríguez Jiménez
- Pharmacology Department, Complejo Hospitalario Universitario de Canarias, 38320 Santa Cruz de Tenerife, Spain
| | | | - Carl Llor
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
- Institut Català de la Salut, 08038 Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark
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Inacio MC, Davies L, Jorissen R, Air T, Eshetie T, Mittinty M, Caughey G, Miller C, Wesselingh S. Excess mortality in residents of aged care facilities during COVID-19 in Australia, 2019-22. Int J Epidemiol 2024; 53:dyad168. [PMID: 38102926 DOI: 10.1093/ije/dyad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND To date, the excess mortality experienced by residential aged care facility (RACF) residents related to COVID-19 has not been estimated in Australia. This study examined (i) the historical mortality trends (2008-09 to 2021-22) and (ii) the excess mortality (2019-20 to 2021-22) of Australian RACF residents. METHODS A retrospective population-based study was conducted using the Australian Institute of Health and Welfare's GEN website data (publicly available aged care services information). Non-Aboriginal, older (≥65 years old) RACF residents between 2008-09 and 2021-22 were evaluated. The observed mortality rate was estimated from RACF exits compared with the RACF cohort yearly. Direct standardization was employed to estimate age-standardized mortality rates and 95% CIs. Excess mortality and 95% prediction intervals (PIs) for 2019-20 to 2021-22 were estimated using four negative binomial (NB) and NB generalized additive models and compared. RESULTS The age-standardized mortality rate in 2018-19 was 23 061/100 000 residents (95% CI, 22 711-23 412). This rate remained similar in 2019-20 (23 023/100 000; 95% CI, 22 674-23 372), decreased in 2020-21 (22 559/100 000; 95% CI, 22 210-22 909) and increased in 2021-22 (24 885/100 000; 95% CI, 24 543-25 227). The mortality rate increase between 2020-21 and 2021-22 was observed in all age and sex groups. All models yielded excess mortality in 2021-22. Using the best-performing model (NB), the excess mortality for 2019-20 was -160 (95% PI, -418 to 98), -958 (95% PI, -1279 to -637) for 2020-21 and 4896 (95% PI, 4503-5288) for 2021-22. CONCLUSIONS In 2021-22, RACF residents, who represented <1% of the population, experienced 21% of the Australian national excess mortality (4896/22 886). As Australia adjusts to COVID-19, RACF residents remain a population vulnerable to COVID-19.
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Affiliation(s)
- Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, SA, Australia
| | - Ling Davies
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, SA, Australia
- School of Public Health, University of Adelaide, Adelaide, SA, Australia
| | - Robert Jorissen
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Tracy Air
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Tesfahun Eshetie
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, SA, Australia
- Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Murthy Mittinty
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Gillian Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, SA, Australia
| | - Caroline Miller
- School of Public Health, University of Adelaide, Adelaide, SA, Australia
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Steve Wesselingh
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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3
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Hibbert PD, Molloy CJ, Cameron ID, Gray LC, Reed RL, Wiles LK, Westbrook J, Arnolda G, Bilton R, Ash R, Georgiou A, Kitson A, Hughes CF, Gordon SJ, Mitchell RJ, Rapport F, Estabrooks C, Alexander GL, Vincent C, Edwards A, Carson-Stevens A, Wagner C, McCormack B, Braithwaite J. The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study). BMC Med 2024; 22:22. [PMID: 38254113 PMCID: PMC10804560 DOI: 10.1186/s12916-023-03224-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia.
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia.
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia.
| | - Charlotte J Molloy
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA, 5000, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, Faculty of Medicine and Health, University of Sydney, Kolling Institute, Reserve Rd, St Leonards, NSW, 2065, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital Campus, Woolloongabba, QLD, 4102, Australia
| | - Richard L Reed
- Discipline of General Practice, College of Medicine and Public Health, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Louise K Wiles
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Rebecca Bilton
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Ruby Ash
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Andrew Georgiou
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Alison Kitson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Clifford F Hughes
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Susan J Gordon
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, SA, 5042, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
| | - Carole Estabrooks
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | | | - Charles Vincent
- Department of Experimental Psychology, Radcliffe Observatory, University of Oxford, Woodstock Road, Oxford, OX2 6GG, England, UK
| | - Adrian Edwards
- PRIME Centre Wales & Division of Population Medicine, Cardiff University, 8Th Floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, CF14 4YS, UK
| | - Andrew Carson-Stevens
- PRIME Centre Wales & Division of Population Medicine, Cardiff University, 8Th Floor Neuadd Meirionnydd, Heath Park, Cardiff, Wales, CF14 4YS, UK
| | - Cordula Wagner
- Netherlands Institute for Health Services Research, Otterstraat 118, Utrecht, 3513 CR, The Netherlands
- Amsterdam University Medical Center/VU University, Van Der Boechorststraat 7, 1081 HV, Amsterdam, The Netherlands
| | - Brendan McCormack
- The Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, City Road, Sydney, NSW, 2006, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2109, Australia
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Rutten JJS, Smalbrugge M, van Buul LW, van Eijk J, Geerlings SE, Natsch S, Sloane PD, van der Wouden JC, Hertogh CMPM, Gerritsen DL. A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes. J Am Med Dir Assoc 2024; 25:146-154.e9. [PMID: 38173264 DOI: 10.1016/j.jamda.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention. DESIGN Mixed-methods process evaluation study. SETTING AND PARTICIPANTS Physicians, nursing staff, client council members, and residents of Dutch NHs. METHODS We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members. RESULTS Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture. CONCLUSIONS AND IMPLICATIONS Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
| | - Jorna van Eijk
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of General Practice, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community care, Radboudumc Alzheimer Center, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
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.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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6
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Smit CCH, Rogers K, Robertson H, Taxis K, Pont LG. Real-World Data about Commonly Used Antibiotics in Long-Term Care Homes in Australia from 2016 to 2019. Antibiotics (Basel) 2023; 12:1393. [PMID: 37760690 PMCID: PMC10525936 DOI: 10.3390/antibiotics12091393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
In this study, we use real-world data to explore trends in antibiotic use in a dynamic cohort of long-term care (LTC) residents. A cross-sectional retrospective analysis of pharmacy medication supply records of 3459 LTC residents was conducted from 31 May 2016 to 31 May 2019. The primary outcome was the monthly prevalence of residents with an antibiotic episode. Secondary outcomes were the type of antibiotic used and duration of use. Over the three-year study period, residents were supplied 10460 antibiotics. On average, 18.9% of residents received an antibiotic monthly. Antibiotic use decreased slightly over time with a mean of 168/1000 (95% CI 146-177) residents using at least one antibiotic per month in June 2016 to 148/1000 (95% CI 127-156) in May 2019. The total number of antibiotic days per 100 resident days remained relatively constant over the study period: 8.8 days in 2016-2017, 8.4 in 2017-2018 and 6.4 in 2018-2019. Prolonged durations exceeding 100 days were seen for a small percentage of residents. We found extensive antibiotic use, which is a recognized contributor to antimicrobial resistance development, underscoring the necessity for quality treatment guidelines in this vulnerable population.
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Affiliation(s)
- Chloé C. H. Smit
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia
| | - Kris Rogers
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia
| | - Hamish Robertson
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Katja Taxis
- Department of PharmacoTherapy, Epidemiology and Economics, Faculty of Science and Engineering, University of Groningen, 9713 AV Groningen, The Netherlands
| | - Lisa G. Pont
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia
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7
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Carpenter L, Shoubridge AP, Flynn E, Lang C, Taylor SL, Papanicolas LE, Collins J, Gordon D, Lynn DJ, Crotty M, Whitehead C, Leong LEX, Wesselingh SL, Ivey K, Inacio MC, Rogers GB. Cohort profile: GRACE - a residential aged care cohort examining factors influencing antimicrobial resistance carriage. BMC Geriatr 2023; 23:521. [PMID: 37641010 PMCID: PMC10464000 DOI: 10.1186/s12877-023-04215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 08/03/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The emergence of antimicrobial-resistant bacteria represents a considerable threat to human health, particularly for vulnerable populations such as those living in residential aged care. However, antimicrobial resistance carriage and modes of transmission remain incompletely understood. The Generating evidence on antimicrobial Resistance in the Aged Care Environment (GRACE) study was established to determine principal risk factors of antimicrobial resistance carriage and transmission in residential aged care facilities (RACFs). This article describes the cohort characteristics, national representation, and planned analyses for this study. METHODS Between March 2019 and March 2020, 279 participants were recruited from five South Australian RACFs. The median age was 88.6 years, the median period in residence was 681 days, and 71.7% were female. A dementia diagnosis was recorded in 54.5% and more than two thirds had moderate to severe cognitive impairment (68.8%). 61% had received at least one course of antibiotics in the 12 months prior to enrolment. RESULTS To investigate the representation of the GRACE cohort to Australians in residential aged care, its characteristics were compared to a subset of the historical cohort of the Registry of Senior Australians (ROSA). This included 142,923 individuals who were permanent residents of RACFs on June 30th, 2017. GRACE and ROSA cohorts were similar in age, sex, and duration of residential care, prevalence of health conditions, and recorded dementia diagnoses. Differences were observed in care requirements and antibiotic exposure (both higher for GRACE participants). GRACE participants had fewer hospital visits compared to the ROSA cohort, and a smaller proportion were prescribed psycholeptic medications. CONCLUSIONS We have assembled a cohort of aged care residents that is representative of the Australian aged care population, and which provides a basis for future analyses. Metagenomic data isolated from participants and built environments will be used to determine microbiome and resistome characteristics of an individual and the facility. Individual and facility risk exposures will be aligned with metagenomic data to identify principal determinants for antimicrobial resistance carriage. Ultimately, this analysis will inform measures aimed at reducing the emergence and spread of antimicrobial resistant pathogens in this high-risk population.
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Affiliation(s)
- Lucy Carpenter
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Andrew P Shoubridge
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - Erin Flynn
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Catherine Lang
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Steven L Taylor
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Lito E Papanicolas
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- SA Pathology, Adelaide, SA, Australia
| | - Josephine Collins
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
| | - David Gordon
- SA Pathology, Adelaide, SA, Australia
- Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, SA, Australia
| | - David J Lynn
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Computational & Systems Biology Programme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Maria Crotty
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Southern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Craig Whitehead
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Southern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | | | - Steve L Wesselingh
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Kerry Ivey
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Geraint B Rogers
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, 5D332, Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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8
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Huang Y, Wei WI, Correia DF, Ma BHM, Tang A, Yeoh EK, Wong SYS, Ip M, Kwok KO. Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis. J Hosp Infect 2023; 131:107-121. [PMID: 36202187 DOI: 10.1016/j.jhin.2022.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization. METHODS MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year. RESULTS In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia. CONCLUSION The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.
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Affiliation(s)
- Y Huang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - W I Wei
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - D F Correia
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - B H M Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - A Tang
- College of Computing and Informatics, Sungkyunkwan University, Seoul, Republic of Korea
| | - E K Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - S Y S Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - M Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - K O Kwok
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Shenzhen Research Institute of the Chinese University of Hong Kong, Shenzhen, China; Hong Kong Institute of Asia-Pacific Studies, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
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9
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Hashan MR, Chapman G, Walker J, Jayne Davidson S, Auriac J, Smoll N, Kirk M, Akbar D, Booy R, Khandaker G. Protocol on establishing a prospective enhanced surveillance of vaccine preventable diseases in residential aged care facilities in Central Queensland, Australia: an observational study. BMJ Open 2022; 12:e060407. [PMID: 36691252 PMCID: PMC9171214 DOI: 10.1136/bmjopen-2021-060407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/29/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Infectious diseases are a major cause of mortality and morbidity among the highly vulnerable occupants of residential aged care facilities (RACFs). The burden of vaccine preventable diseases (VPDs) among RACFs residents is mostly unknown and there is a lack of quality data from population-based prospective VPD surveillance in RACFs. The increasing burden of emerging and existing VPDs (eg, COVID-19, influenza, pneumococcal, pertussis and varicella-zoster) necessitates the establishment of an active enhanced surveillance system to provide real-time evidence to devise strategies to reduce the burden of VPDs in RACFs. METHOD AND ANALYSIS This study proposes a prospective active enhanced surveillance that will be implemented in RACFs across the Central Queensland (CQ) region. The study aims to measure the burden, identify aetiologies, risk factors, predictors of severe outcomes (eg, hospitalisations, mortality) and impact of the existing National Immunization Program (NIP) funded vaccines in preventing VPDs in this vulnerable population. CQ Public Health Unit (CQPHU) will implement the active surveillance by collecting demographic, clinical, pathological, diagnostic, therapeutic and clinical outcome data from the RACFs based on predefined selection criteria and case report forms as per routine public health practices. Descriptive statistics, univariate and multivariate regression analysis will be conducted to identify the predictors of morbidity and clinical outcomes following infection. ETHICS AND DISSEMINATION The study has been approved by the CQHHS Human Research Ethics Committee (HREC) (reference number HREC/2021/QCQ/74305). This study involves data that is routinely collected as part of the surveillance of notifiable conditions under the Public Health Act 2005. The CQHHS HREC approved a request to waive consent requirements of study participants as researchers will be provided non-identifiable data. The findings from the study will be actively disseminated through publication in peer-reviewed journals, conference presentations, social and print media, federal, state, and local authorities to reflect on the results that may facilitate revision of policy and highlight the stakeholders, funding bodies both locally and internationally.
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Affiliation(s)
- Mohammad Rashidul Hashan
- School of Business and Law, Central Queensland University, Rockhampton North, Queensland, Australia
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Gwenda Chapman
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Jacina Walker
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Sonya Jayne Davidson
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Jill Auriac
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Nicolas Smoll
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Michael Kirk
- Rockhampton Business Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Delwar Akbar
- School of Business and Law, Central Queensland University, Rockhampton North, Queensland, Australia
| | - Robert Booy
- National Centre for Immunisation Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gulam Khandaker
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
- Research Division, Central Queensland University, Rockhampton North, Queensland, Australia
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10
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Falconer N, Paterson DL, Peel N, Welch A, Freeman C, Burkett E, Hubbard R, Comans T, Hanjani LS, Pascoe E, Hawley C, Gray L. A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial. Trials 2022; 23:427. [PMID: 35597993 PMCID: PMC9123829 DOI: 10.1186/s13063-022-06323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Nazanin Falconer
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia.
- Department of Pharmacy, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, 4102, Australia.
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia.
| | - David L Paterson
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
- Royal Brisbane and Women's Hospital, Metro North Health, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Nancye Peel
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Alyssa Welch
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Christopher Freeman
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Ruth Hubbard
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Tracy Comans
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Leila Shafiee Hanjani
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Elaine Pascoe
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Carmel Hawley
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Leonard Gray
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
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11
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Rutten JJS, van Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, Sloane PD, van der Wouden JC, Twisk JWR, Hertogh CMPM. An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc 2021; 23:387-393. [PMID: 34896069 DOI: 10.1016/j.jamda.2021.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents. DESIGN Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual. SETTING AND PARTICIPANTS 212 residents with suspected UTI, from 16 NHs in the Netherlands. METHODS Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level. RESULTS 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02). CONCLUSION AND IMPLICATIONS Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Radboud Institute for Health Sciences, Radboudumc Alzheimer Center, Department of Primary and Community care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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12
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Presumed Urinary Tract Infection in Patients Admitted with COVID-19: Are We Treating Too Much? Antibiotics (Basel) 2021; 10:antibiotics10121493. [PMID: 34943705 PMCID: PMC8698875 DOI: 10.3390/antibiotics10121493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/26/2021] [Accepted: 12/03/2021] [Indexed: 01/02/2023] Open
Abstract
Despite the low rates of bacterial co-/superinfections in COVID-19 patients, antimicrobial drug use has been liberal since the start of the COVID-19 pandemic. Due to the low specificity of markers of bacterial co-/superinfection in the COVID-19 setting, overdiagnosis and antimicrobial overprescription have become widespread. A quantitative and qualitative evaluation of urinary tract infection (UTI) diagnoses and antimicrobial drug prescriptions for UTI diagnoses was performed in patients admitted to the COVID-19 ward of a university hospital between 17 March and 2 November 2020. A team of infectious disease specialists performed an appropriateness evaluation for every diagnosis of UTI and every antimicrobial drug prescription covering a UTI. A driver analysis was performed to identify factors increasing the odds of UTI (over)diagnosis. A total of 622 patients were included. UTI was present in 13% of included admissions, and in 12%, antimicrobials were initiated for a UTI diagnosis (0.71 daily defined doses (DDDs)/admission; 22% were scored as ‘appropriate’). An evaluation of UTI diagnoses by ID specialists revealed that of the 79 UTI diagnoses, 61% were classified as probable overdiagnosis related to the COVID-19 hospitalization. The following factors were associated with UTI overdiagnosis: physicians who are unfamiliar working in an internal medicine ward, urinary incontinence, mechanical ventilation and female sex. Antimicrobial stewardship teams should focus on diagnostic stewardship of UTIs, as UTI overdiagnosis seems to be highly prevalent in admitted COVID-19 patients.
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13
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Implementation and Use of Point-of-Care C-Reactive Protein Testing in Nursing Homes. J Am Med Dir Assoc 2021; 23:968-975.e3. [PMID: 34626578 DOI: 10.1016/j.jamda.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents. DESIGN This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents. SETTING AND PARTICIPANTS Eleven NHs in the Netherlands. METHODS Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs. RESULTS Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice. CONCLUSIONS AND IMPLICATIONS This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.
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14
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Boere TM, van Buul LW, Hopstaken RM, van Tulder MW, Twisk JWMR, Verheij TJM, Hertogh CMPM. Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: cluster randomised controlled trial. BMJ 2021; 374:n2198. [PMID: 34548288 PMCID: PMC8453309 DOI: 10.1136/bmj.n2198] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents. DESIGN Pragmatic, cluster randomised controlled trial. SETTING The UPCARE study included 11 nursing home organisations in the Netherlands. PARTICIPANTS 84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020. INTERVENTIONS Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections. MAIN OUTCOME MEASURES The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks). RESULTS Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups. CONCLUSIONS CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance. TRIAL REGISTRATION Netherlands Trial Register NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Rogier M Hopstaken
- Primary Health Care Center, Hapert en Hoogeloon, Hapert, Netherlands
- Star-shl Diagnostic Centers, Etten-Leur, Netherlands
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jos W M R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Theo J M Verheij
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
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15
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Caughey GE, Jorissen RN, Lang C, Wesselingh SL, Inacio MC. Hospitalisation for lower respiratory viral infections in older people in residential aged care facilities. Australas J Ageing 2021; 41:e58-e66. [PMID: 34192408 DOI: 10.1111/ajag.12976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To quantify incidence, trends and outcomes associated with lower respiratory viral infection (LRVI) hospitalisations in Australian residential aged care facilities (RACFs). METHODS A population-based cohort study of residents in RACFs aged ≥65 years from New South Wales (NSW), South Australia (SA) and Victoria (VIC) using data from the Registry of Senior Australians (2013-2016) was conducted. Age- and sex-standardised monthly and yearly LRVI hospitalisation incidences were calculated, and time trends and risk factors were assessed. RESULTS Of 268 657 residents included over the study period, 12% had ≥1 LRVI hospitalisation. Average annual incidence/1000 residents was 7.1 [6.9-7.2] in 2013, increasing to 7.8 [7.7-8.1] in 2016. Males, increasing co-morbidity, presence of CHF, respiratory disease and hypertension had a higher incidence of LRVI hospitalisation. In-hospital mortality was 14%. Within 30 days following discharge, 15% died and 8% were readmitted. CONCLUSION Prior to COVID-19, incidence of hospitalisation for LRVI in Australia's residential aged care population was increasing and was associated with significant morbidity and mortality.
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Affiliation(s)
- Gillian E Caughey
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia.,Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Robert N Jorissen
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,Department of Rehabilitation, Aged and Extended Care, Flinders University, Bedford Park, SA, Australia
| | - Catherine Lang
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Steve L Wesselingh
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Maria C Inacio
- Registry of Senior Australians (ROSA), South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,UniSA Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
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16
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Sluggett JK, Moldovan M, Lynn DJ, Papanicolas LE, Crotty M, Whitehead C, Wesselingh SL, Rogers GB, Inacio MC. National Trends in Antibiotic Use in Australian Residential Aged Care Facilities, 2005-2016. Clin Infect Dis 2021; 72:2167-2174. [PMID: 32460321 DOI: 10.1093/cid/ciaa436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding current patterns of antibiotic use in residential aged care facilities (RACFs) is essential to inform stewardship activities, but limited utilization data exist. This study examined changes in prevalence and consumption of antibiotics in Australian RACFs between 2005-2006 and 2015-2016. METHODS This population-based, repeated cross-sectional analysis included all long-term permanent residents of Australian RACFs between July 2005 and June 2016 who were aged ≥ 65 years. The yearly prevalence rate of antibiotic use and number of defined daily doses (DDDs) of systemic antibiotics per 1000 resident-days were determined annually from linked pharmaceutical claims data. Trends were assessed using ordinary least squares regression. RESULTS This study included 502 752 residents from 3218 RACFs, with 424.9 million resident-days analyzed. Antibiotics were dispensed on 5 608 126 occasions during the study period, of which 88% were for oral use. Cefalexin, amoxicillin-clavulanic acid, and trimethoprim were the most commonly dispensed antibiotics. The annual prevalence of antibiotic use increased from 63.8% (95% confidence interval [CI], 63.3%-64.4%) to 70.3% (95% CI, 69.9%-70.7%) between 2005-2006 and 2015-2016 (0.8% average annual increase, P < .001). There was a 39% relative increase in total consumption of systemic antibiotics, with utilization increasing from 67.6 to 93.8 DDDs/1000 resident-days during the study period (average annual increase of 2.8 DDDs/1000 resident-days, P < .001). CONCLUSIONS This nationwide study showed substantial increases in both prevalence of use and total consumption of antibiotics in Australian RACFs between 2005 and 2016. The increasingly widespread use of antibiotics in Australian RACFs is concerning and points to a need for enhanced efforts to optimize antibiotic use in this setting.
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Affiliation(s)
- Janet K Sluggett
- Registry of Senior Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,University of South Australia, Allied Health and Human Performance, Adelaide, South Australia, Australia
| | - Max Moldovan
- Registry of Senior Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - David J Lynn
- Precision Medicine Theme, South Australian Medical and Health Research Institute, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Lito E Papanicolas
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute Microbiome Research Laboratory, School of Medicine, Flinders University, Bedford Park, South Australia, Australia.,Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Maria Crotty
- Department of Rehabilitation, Aged and Extended Care, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Craig Whitehead
- Department of Rehabilitation, Aged and Extended Care, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Steve L Wesselingh
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute Microbiome Research Laboratory, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Geraint B Rogers
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute Microbiome Research Laboratory, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Maria C Inacio
- Registry of Senior Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,University of South Australia, Allied Health and Human Performance, Adelaide, South Australia, Australia
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17
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Jiao P, Jiang Y, Jiao J, Zhang L. The pathogenic characteristics and influencing factors of health care-associated infection in elderly care center under the mode of integration of medical care and elderly care service: A cross-sectional study. Medicine (Baltimore) 2021; 100:e26158. [PMID: 34032774 PMCID: PMC8154447 DOI: 10.1097/md.0000000000026158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to analyze the distribution of pathogenic bacteria in hospitalized patients in elderly care centers under the mode of integration of medical care and elderly care service, and explore the influencing factors to reduce the health care-associated infection rate of hospitalized patients.A total of 2597 inpatients admitted to elderly care centers from April 2018 to December 2019 were included in the study. The etiology characteristics of health care-associated infections (HCAI) was statistically analyzed, univariate analysis, and multivariate logistic regression analysis method were used to analyze the influencing factors of HCAI.A total of 98 of 2597 inpatients in the elderly care centers had HCAI, and the infection rate was 3.77%. The infection sites were mainly in the lower respiratory tract and urinary tract, accounting for 53.92% and 18.63%, respectively. A total of 53 pathogenic bacteria were isolated, 43 of which (81.13%) were Gram-negative, mainly Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, which respectively accounted for 24.53, 16.98, and 13.21%. 9 (16.98%) strains were Gram-positive, mainly Staphylococcus aureus and Enterococcus faecium, respectively accounting for 7.55 and 5.66%. Only 1 patient (1.89%) had a fungal infection. Multivariate logistic regression analysis indicated that total hospitalization days, antibiotic agents used, days of central line catheter, use of urinary catheter and diabetes were independent risk factors of nosocomial infection in elderly care centers (P < .05).Many factors can lead to nosocomial infections in elderly care centers. Medical staff should take effective intervention measures according to the influencing factors to reduce the risk of infection in elderly care facilities.
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Affiliation(s)
- Panpan Jiao
- Hospital Infection Management Office, Binzhou People's Hospital, Binzhou Shandong
| | - Yufen Jiang
- Department of Gastroenterology, Kezhou People's Hospital, Atushi Xinjiang
| | - Jianhong Jiao
- Department of Department of Cardiology, Yangxin County Hospital of Traditional Chinese Medicine of Shandong Province, Binzhou Shandong
| | - Long Zhang
- Department of Hepatopancreatobiliary Surgery, Ganzhou People's Hospital of Jiangxi Province (Ganzhou Hospital Affiliated to Nanchang University), Ganzhou, Jiangxi, P.R. China
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18
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Jokanovic N, Haines T, Cheng AC, Holt KE, Hilmer SN, Jeon YH, Stewardson AJ, Stuart RL, Spelman T, Peel TN, Peleg AY. Multicentre stepped-wedge cluster randomised controlled trial of an antimicrobial stewardship programme in residential aged care: protocol for the START trial. BMJ Open 2021; 11:e046142. [PMID: 33653766 PMCID: PMC7929827 DOI: 10.1136/bmjopen-2020-046142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/04/2021] [Accepted: 01/22/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance is a growing global health threat, driven by increasing inappropriate use of antimicrobials. High prevalence of unnecessary use of antimicrobials in residential aged care facilities (RACFs) has driven demand for the development and implementation of antimicrobial stewardship (AMS) programmes. The Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance (START) will implement and evaluate the impact of a nurse-led AMS programme on antimicrobial use in 12 RACFs. METHODS AND ANALYSIS The START trial will implement and evaluate a nurse-led AMS programme via a stepped-wedge cluster randomised controlled trial design in 12 RACFs over 16 months. The AMS programme will incorporate education, aged care-specific treatment guidelines, documentation forms, and audit and feedback strategies that will target aged care staff, general practitioners, pharmacists, and residents and their families. The intervention will primarily focus on urinary tract infections, lower respiratory tract infections, and skin and soft tissue infections. RACFs will transition from control to intervention phases in random order, two at a time, every 2 months, with a 2-month transition, wash-in period. The primary outcome is the cumulative proportion of residents within each facility prescribed an antibiotic during each month and total days of antibiotic use per 1000 occupied bed days. Secondary outcomes include the number of courses of systemic antimicrobial therapy, antimicrobial appropriateness, antimicrobial resistant organisms, Clostridioides difficile infection, change in antimicrobial susceptibility profiles, hospitalisations and all-cause mortality. Analyses will be conducted according to the intention-to-treat principle. ETHICS AND DISSEMINATION Ethics approval has been granted by the Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/591). Research findings will be disseminated through peer-reviewed publications, conferences and summarised reports provided to participating RACFs. TRIAL REGISTRATION NUMBER NCT03941509.
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Affiliation(s)
- Natali Jokanovic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn E Holt
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Yun-Hee Jeon
- Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rhonda L Stuart
- Monash Infectious Diseases, Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Tim Spelman
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Monash Biomedicine Discovery Institute, Infection and Immunity Theme, Department of Microbiology, Monash University, Clayton, Victoria, Australia
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19
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Bouza E, Brenes FJ, Díez Domingo J, Eiros Bouza JM, González J, Gracia D, Juárez González R, Muñoz P, Petidier Torregrossa R, Ribera Casado JM, Ramos Cordero P, Rodríguez Rovira E, Sáez Torralba ME, Serra Rexach JA, Tovar García J, Verdejo Bravo C, Palomo E. The situation of infection in the elderly in Spain: a multidisciplinary opinion document. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:327-349. [PMID: 32896115 PMCID: PMC7528417 DOI: 10.37201/req/057.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 11/10/2022]
Abstract
Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed.
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Affiliation(s)
- E Bouza
- Emilio Bouza, Instituto de Investigación Sanitaria Gregorio Marañón. C/ Dr. Esquerdo, 46 28007 Madrid, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - E Palomo
- Esteban Palomo, Director. Health Sciences Foundation. C/ Severo Ochoa 2 - 28760 Tres Cantos. Madrid. Phone +34 91 3530150
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20
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Shaban RZ, Sotomayor-Castillo C, Macbeth D, Russo PL, Mitchell BG. Scope of practice and educational needs of infection prevention and control professionals in Australian residential aged care facilities. Infect Dis Health 2020; 25:286-293. [PMID: 32711966 DOI: 10.1016/j.idh.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/04/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Healthcare-associated infections are serious and significant complications present across healthcare services, including residential aged care facilities. Although ensuring high quality personal and clinical care delivered to older people residing in these facilities is a high national priority, there is a paucity of evidence published about outbreaks, governance and education programs held for healthcare workers within Australian residential aged care facilities. The aim of this study is to examine the scope of practice of Infection Prevention and Control professionals within Australian residential aged care facilities and the types of infection prevention and control education and training delivered. METHODS A cross-sectional study was conducted inviting all Australian residential aged care facilities to participate in an online survey. RESULTS A total of 134 residential aged care facilities completed the survey. The majority (88.1%) reported having a designated Infection Prevention and Control professional responsible for surveillance and educational activities. Hand hygiene (94%), personal protective equipment (PPE) (79.9%) and environmental cleaning (70.1%) were some of the available Infection Prevention and Control programs. The lack of access to Infection Prevention and Control education (69.5%) and lack of Infection Prevention and Control expert advice (67.2%) were also reported by some Residential aged care facilities. CONCLUSION Australian residential aged care facilities recognise the importance of Infection Prevention and Control training programs to manage infection surveillance and outbreaks. Considerable activities are carried out to increase knowledge on breaking the chain of infection. Yet, more support and resources are needed to assist these efforts.
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Affiliation(s)
- Ramon Z Shaban
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, University of Sydney, Camperdown, NSW, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Camperdown, NSW, Australia; Department of Infection Prevention and Control, Division of Infectious Diseases and Sexual Health, Westmead Hospital and the Directorate of Nursing, Midwifery and Clinical Governance, Western Sydney Local Health District, Westmead, NSW, Australia.
| | - Cristina Sotomayor-Castillo
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, University of Sydney, Camperdown, NSW, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Camperdown, NSW, Australia; Department of Infection Prevention and Control, Division of Infectious Diseases and Sexual Health, Westmead Hospital and the Directorate of Nursing, Midwifery and Clinical Governance, Western Sydney Local Health District, Westmead, NSW, Australia
| | - Deborough Macbeth
- Infection Control Department, Infectious Diseases and Immunology, Gold Coast Hospital and Health Service, Southport, QLD, Australia
| | - Philip L Russo
- Department of Nursing Research, Cabrini Institute, Malvern, VIC, Australia; Nursing and Midwifery, Monash University, Clayton, Frankston, VIC, Australia
| | - Brett G Mitchell
- School of Nursing and Midwifery, Faculty of Health and Medicine, Newcastle University, NSW, Australia; School of Nursing, Avondale University College, Wahroonga, NSW, Australia
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21
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. 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. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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22
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Chaaban T, Ahouah M, Lombrail P, Febvre HL, Mourad A, Morvillers JM, Rothan-Tondeur M. Decisional issues in antibiotic prescribing in French nursing homes: An ethnographic study. J Public Health Res 2019; 8:1533. [PMID: 31819866 PMCID: PMC6886007 DOI: 10.4081/jphr.2019.1533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 08/30/2019] [Indexed: 11/22/2022] Open
Abstract
Background:Medication prescription is generally the responsibility of doctors. In nursing homes, the nursing staff is often the first to suspect an infection. Today, physicians are more confident with nursing assessment, relying primarily on nursing staff information. Very few studies have investigated the nurses' influence on decision of medical prescription. This study investigates the role of nurses in antibiotic prescribing for the treatment of suspected infections in nursing home residents. Design and methods:An ethnographic study based on semi-structured interviews and participant observations was conducted. Sixteen nurses and five doctors working in five nursing homes in Paris, France participated between October 2015 and January 2016. Results:Given their proximity to elderly residents, registered nurses at the nursing homes occasionally assisted doctors in their medical diagnostic. However, nurses who are theoretically incompetent have met difficulties in their ability to participate in their decisions to prescribe antibiotics when managing residents' infections. Conclusion: if proximity and nursing skills reinforce the relevance of the clinical judgment of nurses, the effective and collaborative communication between the nurse and the doctor may help the nurse to enhance their role in the antibiotic prescribing in nursing homes, which would enhance antimicrobial stewardship efficiency.
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Affiliation(s)
| | - Mathieu Ahouah
- Nursing Sciences Research, LEPS, University Paris 13, Sorbonne, Paris, France
| | - Pierre Lombrail
- Nursing Sciences Research, LEPS, University Paris 13, Sorbonne, Paris, France
| | - Héléne Le Febvre
- Faculty of Nursing Sciences, Montréal University, Centre-Ville, Montréal, Canada
| | - Adnan Mourad
- Islamic University of Lebanon (IUL), Faculty of Public Health, Beirut, Lebanon
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23
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Mitchell BG, Shaban RZ, MacBeth D, Russo P. Organisation and governance of infection prevention and control in Australian residential aged care facilities: A national survey. Infect Dis Health 2019; 24:187-193. [PMID: 31279705 DOI: 10.1016/j.idh.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Individuals in residential and aged care facilities (RACFs) are at risk of developing health care-associated infections (HAIs) due to factors such as age-related changes in physiology, immunity, comorbid illness and functional disability. The recent establishment of an Australian Royal Commission into the Quality of Residential and Aged Care Services highlights the challenges of providing care in this sector. This national study identified infection prevention and control (IPC) services, practice and priorities in Australian RACFs. METHODS A cross-sectional study of 158 Australian RACFs comprising a 42-question survey incorporating five key domains relating to IPC namely governance, education, practice, surveillance, competency and capability was undertaken in 2018. RESULTS Of the 131 respondents, the majority 92.4% of respondents reported having a documented IPC program, 22.9% (n = 30) operated with a dedicated infection control committee The majority of RACFs reported lacking specialist and qualified experienced IPC professionals (n = 67). The majority of RACFs (90.1%, n = 118) reported the existence of a designated employee with IPC responsibilities. Of these 118 staff members with IPC responsibilities, 42.5% had a qualification in IPC. The reported average funded hours per month for IPC professional or an external provider of IPC activities was 14 (95% CI 9.6-18.9 h). CONCLUSION The overwhelming majority of RACFs deliver IPC services and report doing so in ways that meet the needs of their own specific contexts in the absence of the lack of formal guidelines when compared to the hospital sector. Quality residential and aged care free from HAIs requires formal structure and organization strategies.
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Affiliation(s)
- Brett G Mitchell
- Discipline of Nursing, Avondale College of Higher Education, Wahroonga, NSW, Australia; School of Nursing and Midwifery, University of Newcastle, Newcastle, NSW, Australia.
| | - Ramon Z Shaban
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, University of Sydney, Camperdown. NSW, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Camperdown, NSW, Australia; Directorate of Nursing, Midwifery and Clinical Governance, Western Sydney Local Health District, Westmead, NSW, Australia
| | - Deborough MacBeth
- Department of Infection Prevent and Control, Gold Coast Hospital and Health Service, Gold Coast, QLD, Australia
| | - Philp Russo
- Department of Nursing Research, Cabrini Institute, Malvern, Victoria, Australia; Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; Lifestyle Research Centre, Avondale College of Higher Education, Cooranbong, NSW, Australia
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24
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Individual and community predictors of urinary ceftriaxone-resistant Escherichia coli isolates, Victoria, Australia. Antimicrob Resist Infect Control 2019; 8:36. [PMID: 30805183 PMCID: PMC6373108 DOI: 10.1186/s13756-019-0492-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 02/03/2019] [Indexed: 12/25/2022] Open
Abstract
Background Ceftriaxone-resistant Enterobacteriaceae are priority pathogens of critical importance. Escherichia coli is the most commonly isolated Enterobacteriaceae. There are few data regarding non-invasive ceftriaxone-resistant E. coli (CR-EC) isolates in the Australian community. We aimed to describe the prevalence, phenotype, geographic variation, and sociodemographic predictors of ceftriaxone-resistance among E. coli isolates recovered from urine specimens. Methods In August 2017, we prospectively analysed E. coli isolates recovered from urine specimens submitted to Dorevitch Pathology (Victoria, Australia), a laboratory that services patients in the community and hospitals. In addition to patient-level predictors of ceftriaxone resistance, we mapped patient postcodes to community-level indicators including Index of Relative Socioeconomic Deprivation, remoteness, and proportion of residents born overseas. We used Poisson regression with log link and robust standard errors to quantify the association between ceftriaxone resistance and patient- and community-level factors. Results We included 6732 non-duplicate E. coli isolates. Most (89.2%, 6008/6732) were obtained from female patients. Median age was 56 years (IQR, 32–74). Most patients (90.5%, 5789/6732) were neither referred from a hospital nor residing in a residential aged care facility (RACF). Among the 6732 isolates, 5.7% (382) were CR-EC, ranging from 3.5% (44/1268) in inner regional areas to 6.3% (330/5267) in major cities. Extended spectrum ß–lactamase (ESBL) -production was the most common mechanism for ceftriaxone resistance (89%, 341/382). Nitrofurantoin was the most active oral agent against CR-EC. Eight CR-EC isolates (2.4%) were susceptible only to amikacin, meropenem and nitrofurantoin. None were resistant to meropenem. On multivariable analysis, ceftriaxone resistance was associated with age, residence in a RACF (adjusted relative risk [aRR] 2.94, 95% confidence interval [CI] 2.10–4.13), specimen referral from hospital (aRR 2.05, 95% CI 1.45–2.9), and the proportion of residents born in North Africa and the Middle East (aRR 1.30 for each 5% absolute increase, 95% CI 1.09–1.54), South-East Asia (aRR 1.14, 95% CI 1.02–1.27), and Southern and Central Asia (aRR 1.16, 95% CI 1.04–1.28). Conclusions These results provide insights into sociodemographic variation in CR-EC in the community. A better understanding of this variation may inform empiric treatment guidelines and strategies to reduce community dissemination of CR-EC.
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25
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van Buul LW, Vreeken HL, Bradley SF, Crnich CJ, Drinka PJ, Geerlings SE, Jump RLP, Mody L, Mylotte JJ, Loeb M, Nace DA, Nicolle LE, Sloane PD, Stuart RL, Sundvall PD, Ulleryd P, Veenhuizen RB, Hertogh CMPM. The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure. J Am Med Dir Assoc 2018; 19:757-764. [PMID: 29910137 DOI: 10.1016/j.jamda.2018.05.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/11/2018] [Accepted: 05/01/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population. DESIGN A Delphi consensus procedure. SETTING AND PARTICIPANTS An international panel of practitioners recognized as experts in the field of UTI in frail older patients. MEASURES In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool. RESULTS Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter. CONCLUSIONS A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.
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Affiliation(s)
- Laura W van Buul
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.
| | - Hilde L Vreeken
- Dutch Association of Elderly Care Physicians, Utrecht, The Netherlands
| | - Suzanne F Bradley
- Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Medical School, Ann Arbor, MI
| | - Christopher J Crnich
- University of Wisconsin School of Medicine and Public Health, Madison, WI; Medical Service, William S. Middleton VA Hospital, Madison, WI
| | - Paul J Drinka
- Department of Internal Medicine, Geriatrics University of Wisconsin, Madison, WI
| | - Suzanne E Geerlings
- Division Infectious Diseases, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Robin L P Jump
- Geriatric Research, Education and Clinical Center and Specialty Care Center of Innovation at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC), Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Epidemiology and Biostatistics at Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lona Mody
- University of Michigan and Geriatrics Research Education and Clinical Care, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Joseph J Mylotte
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY
| | - Mark Loeb
- Department of Pathology and Molecular Medicine and Institute for Infectious Diseases Research, McMaster University, Hamilton, Canada
| | - David A Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Philip D Sloane
- Department of Family Medicine and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rhonda L Stuart
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia; Monash University, Victoria, Australia; National Centre for Antimicrobial Stewardship, Victoria, Australia
| | - Pär-Daniel Sundvall
- Närhälsan, Research and Development Primary Health Care Region Västra Götaland, R&D Center Södra Älvsborg, Sweden; The Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Peter Ulleryd
- Department of Communicable Disease Control, Region Västra Götaland, Sweden
| | - Ruth B Veenhuizen
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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Mayne S, Sundvall PD, Gunnarsson R. Confusion Strongly Associated with Antibiotic Prescribing Due to Suspected Urinary Tract Infections in Nursing Homes. J Am Geriatr Soc 2018; 66:274-281. [DOI: 10.1111/jgs.15179] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Sean Mayne
- Cairns Clinical School; College of Medicine and Dentistry; James Cook University; Cairns Queensland Australia
| | - Pär-Daniel Sundvall
- Närhälsan Research and Development Unit; Primary Health Care and Dental Care; Southern Alvsborg County Region Vastra Gotaland Sweden
- Department of Public Health and Community Medicine; Institute of Medicine; The Sahlgrenska Academy; Goteborg University; Gothenburg Sweden
| | - Ronny Gunnarsson
- Cairns Clinical School; College of Medicine and Dentistry; James Cook University; Cairns Queensland Australia
- Närhälsan Research and Development Unit; Primary Health Care and Dental Care; Southern Alvsborg County Region Vastra Gotaland Sweden
- Department of Public Health and Community Medicine; Institute of Medicine; The Sahlgrenska Academy; Goteborg University; Gothenburg Sweden
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Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf 2017; 8:31-46. [PMID: 28203365 PMCID: PMC5298466 DOI: 10.1177/2042098616670798] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.
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Affiliation(s)
- Carole Parsons
- Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK
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Stuart RL, Marshall C, Orr E, Bennett N, Athan E, Friedman D, Reilly M. Survey of infection control and antimicrobial stewardship practices in Australian residential aged-care facilities. Intern Med J 2016; 45:576-80. [PMID: 25955463 DOI: 10.1111/imj.12740] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 01/29/2015] [Indexed: 11/27/2022]
Abstract
This study assessed infection prevention and antimicrobial stewardship (AMS) practices in Australian residential aged-care facilities (RACF). Two hundred and sixty-five surveys (15.6%) were completed with all states represented and the majority (177 (67.3%)) privately run. Only 30.6% RACF had infection control trained staff on site. Few facilities had AMS policies, only 14% had antimicrobial prescribing restrictions. Most facilities offered vaccination to residents (influenza vaccination rates >75% in 73% of facilities), but pneumococcal vaccination was poor.
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Affiliation(s)
- R L Stuart
- Department of Infectious Diseases, Monash Health, Melbourne, Australia.,Department Medicine, Monash University, Melbourne, Australia
| | - C Marshall
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Australia.,Department Medicine, University of Melbourne, Melbourne, Australia
| | - E Orr
- Department of Infectious Diseases, Monash Health, Melbourne, Australia
| | - N Bennett
- VICNISS Coordinating Centre, Melbourne, Australia
| | - E Athan
- Department Infectious Disease, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine, Deakin University, Geelong, Victoria, Australia
| | - D Friedman
- Department Infectious Disease, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine, Deakin University, Geelong, Victoria, Australia
| | - M Reilly
- Hands-On Infection Control, Perth, Western Australia, Australia
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Giannella M, Tedeschi S, Bartoletti M, Viale P. Prevention of infections in nursing homes: antibiotic prophylaxis versus infection control and antimicrobial stewardship measures. Expert Rev Anti Infect Ther 2016; 14:219-30. [PMID: 26655286 DOI: 10.1586/14787210.2016.1132161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Because of the lack of structural and human resources for implementing more effective and safe preventive procedures, antimicrobial prophylaxis is often used to prevent infections in nursing homes. However, if data on the efficacy of antibiotic prophylaxis in nursing homes are null, there is a plenty of evidence that the inappropriate use of antimicrobials in this setting is associated with a high rate of colonization and infection with multi-drug-resistant organisms (MDROs), and of Clostridium difficile infection (CDI). Here, we have reviewed the infection epidemiology, the burden of MDROs and CDI, the antibiotic use and some potential infection preventive measures in nursing homes, pointing up the peculiarities of this setting and the absolute need of a more prudential use of antimicrobials.
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Affiliation(s)
- Maddalena Giannella
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
| | - Sara Tedeschi
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
| | - Michele Bartoletti
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
| | - Pierluigi Viale
- a Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna , Bologna , Italy
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Cairns KA, Roberts JA, Cotta MO, Cheng AC. Antimicrobial Stewardship in Australian Hospitals and Other Settings. Infect Dis Ther 2015; 4:27-38. [PMID: 26362294 PMCID: PMC4569646 DOI: 10.1007/s40121-015-0083-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Indexed: 11/25/2022] Open
Abstract
Australia’s model of antimicrobial stewardship (AMS) has evolved significantly over recent years, from a long-standing national approach of antimicrobial prescribing guidelines and antimicrobial prescribing restrictions to recent advances including the first National Antimicrobial Resistance Strategy and incorporating mandatory AMS as part of hospital accreditation standards. AMS programs are most commonly found in the hospital setting. Various models are used throughout the country based on the local context and resources available. Programs implemented at Alfred Health and the Royal Brisbane and Women’s Hospital represent two successful models in tertiary referral settings that accommodate a general ward setting as well as specialized areas with a high infection burden. Measurement of outcomes related to AMS activities remains poorly standardized, with process indicators such as antimicrobial utilization forming a large proportion of outcome measurement. Presently there is no requirement for any AMS outcome measurements to be reported externally. Point prevalence surveys of appropriateness of prescribing and compliance with prescribing guidelines are widely used at a national level. Despite this, there is still a paucity of published Australian data to support the effect of AMS on patient clinical outcomes. Private hospitals, the community, veterinary medicine and aged care sectors represent an important area for future AMS expansion within Australia. The AMS focus has traditionally been on prescribing restrictions (through the Commonwealth funding agencies); however, recent work has described other areas for improvement and development in both settings. AMS in Australia continues to evolve. The recent development of an Australian strategic plan to link antimicrobial utilization and resistance surveillance with policy represents an important step forward for the future of AMS in Australia.
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Affiliation(s)
- Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia.
| | - Jason A Roberts
- Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.,School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Menino O Cotta
- Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.,School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, VIC, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Girard R, Gaujard S, Pergay V, Pornon P, Martin Gaujard G, Vieux C, Bourguignon L. Controlling urinary tract infections associated with intermittent bladder catheterization in geriatric hospitals. J Hosp Infect 2015; 90:240-7. [DOI: 10.1016/j.jhin.2015.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/09/2015] [Indexed: 11/26/2022]
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van Buul LW, van der Steen JT, Achterberg WP, Schellevis FG, Essink RTGM, de Greeff SC, Natsch S, Sloane PD, Zimmerman S, Twisk JWR, Veenhuizen RB, Hertogh CMPM. Effect of tailored antibiotic stewardship programmes on the appropriateness of antibiotic prescribing in nursing homes. J Antimicrob Chemother 2015; 70:2153-62. [PMID: 25745104 DOI: 10.1093/jac/dkv051] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/04/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the effect of tailored interventions on the appropriateness of decisions to prescribe or withhold antibiotics, antibiotic use and guideline-adherent antibiotic selection in nursing homes (NHs). METHODS We conducted a quasi-experimental study in 10 NHs in the Netherlands. A participatory action research (PAR) approach was applied, with local stakeholders in charge of selecting tailored interventions based on opportunities for improved antibiotic prescribing that they derived from provided baseline data. An algorithm was used to evaluate the appropriateness of prescribing decisions, based on infections recorded by physicians. Effects of the interventions on the appropriateness of prescribing decisions were analysed with a multilevel logistic regression model. Pharmacy data were used to calculate differences in antibiotic use and recorded infections were used to calculate differences in guideline-adherent antibiotic selection. RESULTS The appropriateness of 1059 prescribing decisions was assessed. Adjusting for pre-test differences in the proportion of appropriate prescribing decisions (intervention, 82%; control, 70%), post-test appropriateness did not differ between groups (crude: P = 0.26; adjusted for covariates: P = 0.35). We observed more appropriate prescribing decisions at the start of data collection and before receiving feedback on prescribing behaviour. No changes in antibiotic use or guideline-adherent antibiotic selection were observed in intervention NHs. CONCLUSIONS The PAR approach, or the way PAR was applied in the study, was not effective in improving antibiotic prescribing behaviour. The study findings suggest that drawing prescribers' attention to prescribing behaviour and monitoring activities, and increasing use of diagnostic resources may be promising interventions to improve antibiotic prescribing in NHs.
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Affiliation(s)
- Laura W van Buul
- EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Department of General Practice & Elderly Care Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Jenny T van der Steen
- EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Department of General Practice & Elderly Care Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2300 RC Leiden, The Netherlands
| | - François G Schellevis
- EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Department of General Practice & Elderly Care Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Netherlands Institute for Health Services Research, Otterstraat 118-124, 3513 CR Utrecht, The Netherlands
| | - Rob T G M Essink
- Dutch Institute for Rational Use of Medicine, Churchilllaan 11, 3527 GV Utrecht, The Netherlands
| | - Sabine C de Greeff
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, Chapel Hill, NC 27599-7590, USA Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, 590 Manning Drive, Chapel Hill, NC 27599, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, Chapel Hill, NC 27599-7590, USA School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro St, Chapel Hill, NC 27599-3550, USA
| | - Jos W R Twisk
- EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Department of Epidemiology and Biostatistics, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Ruth B Veenhuizen
- EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Department of General Practice & Elderly Care Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Department of General Practice & Elderly Care Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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Antibiotic prescribing in Dutch nursing homes: how appropriate is it? J Am Med Dir Assoc 2014; 16:229-37. [PMID: 25458444 DOI: 10.1016/j.jamda.2014.10.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/29/2014] [Accepted: 10/03/2014] [Indexed: 11/22/2022]
Abstract
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.
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Lim CJ, Kwong M, Stuart RL, Buising KL, Friedman ND, Bennett N, Cheng AC, Peleg AY, Marshall C, Kong DCM. Antimicrobial stewardship in residential aged care facilities: need and readiness assessment. BMC Infect Dis 2014; 14:410. [PMID: 25055957 PMCID: PMC4117949 DOI: 10.1186/1471-2334-14-410] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/15/2014] [Indexed: 11/10/2022] Open
Abstract
Background Information about the feasibility, barriers and facilitators of antimicrobial stewardship (AMS) in residential aged care facilities (RACFs) has been scant. Exploring the prevailing perceptions and attitudes of key healthcare providers towards antibiotic prescribing behaviour, antibiotic resistance and AMS in the RACF setting is imperative to guide AMS interventions. Methods Semi-structured interviews and focus groups were conducted with key RACF healthcare providers until saturation of themes occurred. Participants were recruited using purposive and snowball sampling. The framework approach was applied for data analysis. Results A total of 40 nurses, 15 general practitioners (GPs) and 6 pharmacists from 12 RACFs were recruited. Five major themes emerged; perceptions of current antibiotic prescribing behaviour, perceptions of antibiotic resistance, attitude towards and understanding of AMS, perceived barriers to and facilitators of AMS implementation, and feasible AMS interventions. A higher proportion of GPs and pharmacists compared with nurses felt there was over-prescribing of antibiotics in the RACF setting. Antibiotic resistance was generally perceived as an issue for infection control rather than impacting clinical decisions. All key stakeholders were supportive of AMS implementation in RACFs; however, they recognized barriers related to workload and logistical issues. A range of practical AMS interventions were identified, with nursing-based education, aged-care specific antibiotic guidelines and regular antibiotic surveillance deemed most useful and feasible. Conclusions Areas of antibiotic over-prescribing have been identified from different healthcare providers’ perspectives. However, concern about the clinical impact of antibiotic resistance was generally lacking. Importantly, information gathered about feasibility, barriers and facilitators of various AMS interventions will provide important insights to guide development of AMS programs in the RACF setting. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-410) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Caroline Marshall
- Department of Medicine, University of Melbourne, Royal Melbourne Hospital, 4th Floor, Clinical Sciences Building, Royal Parade, Parkville, VIC 3050, Australia.
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Lim CJ, Kwong MW, Stuart RL, Buising KL, Friedman ND, Bennett NJ, Cheng AC, Peleg AY, Marshall C, Kong DC. Antibiotic prescribing practice in residential aged care facilities ‐ health care providers' perspectives. Med J Aust 2014. [DOI: 10.5694/j.1326-5377.2014.tb04232.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Megan W‐L Kwong
- Department of Medicine, University of Melbourne, Melbourne, VIC
| | - Rhonda L Stuart
- Monash University, Melbourne, VIC
- Monash Health, Melbourne, VIC
| | - Kirsty L Buising
- St Vincent's Hospital, Melbourne, VIC
- Royal Melbourne Hospital, Melbourne, VIC
| | | | - Noleen J Bennett
- Victorian Nosocomial Infection Surveillance System Coordinating Centre, Melbourne Health, Melbourne, VIC
| | - Allen C Cheng
- Monash University, Melbourne, VIC
- Alfred Hospital, Melbourne, VIC
| | - Anton Y Peleg
- Monash University, Melbourne, VIC
- Alfred Hospital, Melbourne, VIC
| | - Caroline Marshall
- Department of Medicine, University of Melbourne, Melbourne, VIC
- Royal Melbourne Hospital, Melbourne, VIC
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36
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Fleet E, Gopal Rao G, Patel B, Cookson B, Charlett A, Bowman C, Davey P. Impact of implementation of a novel antimicrobial stewardship tool on antibiotic use in nursing homes: a prospective cluster randomized control pilot study. J Antimicrob Chemother 2014; 69:2265-73. [PMID: 24777901 DOI: 10.1093/jac/dku115] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Elizabeth Fleet
- Centre for Ethnicity and Infection and Microbiology Department, North West London Hospitals NHS Trust, Watford Road, Harrow HA1 3UJ, UK
| | - G Gopal Rao
- Centre for Ethnicity and Infection and Microbiology Department, North West London Hospitals NHS Trust, Watford Road, Harrow HA1 3UJ, UK
| | - Bharat Patel
- Public Health England, Public Health Laboratory London, Division of Infection, Barts Health NHS Trust, Whitechapel, London E1 2ES, UK
| | - Barry Cookson
- Division of Infection and Immunity, University College London, Gower Street, London WC1E 6BT, UK
| | - Andre Charlett
- Public Health England Colindale, 61 Colindale Avenue, London NW9 5HT, UK
| | - Clive Bowman
- School of Health Sciences, City University London, Northampton Square, London EC1V 0HB, UK
| | - Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
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Lim CJ, Cheng AC, Kennon J, Spelman D, Hale D, Melican G, Sidjabat HE, Paterson DL, Kong DCM, Peleg AY. Prevalence of multidrug-resistant organisms and risk factors for carriage in long-term care facilities: a nested case-control study. J Antimicrob Chemother 2014; 69:1972-80. [PMID: 24710025 DOI: 10.1093/jac/dku077] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) are a potentially important reservoir of multidrug-resistant (MDR) organisms; however, limited data exist. METHODS A point-prevalence study was conducted in four co-located LTCFs in Australia. Nasal and rectal swabs were cultured for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and MDR Gram-negative bacilli (GNB). Molecular typing and resistance detection were performed. Risk factors for colonization with an MDR organism were determined using a nested case-control study. RESULTS Consent was obtained from 115 (85%) of 136 eligible participants. Forty-one (36%) residents carried at least one type of MDR organism. The prevalence was 16% MRSA (n = 18), 6% VRE (n = 7) and 21% MDR GNB [n = 24; including extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (n = 12) and Acinetobacter baumannii (n = 6)]. The majority of ESBL-producing E. coli and A. baumannii were clonal. Current wound management [adjusted OR (AOR) 8.81 (95% CI 2.78-27.94), P < 0.001], medical device in situ [AOR 5.58 (95% CI 1.34-23.32), P = 0.018] and pressure ulcer [AOR 3.69 (95% CI 1.06-12.86), P = 0.04] were independent risk factors for MDR organism colonization. Advanced dementia [AOR 3.54 (95% CI 1.23-10.23), P = 0.02] and prolonged antibiotic use [AOR 2.95 (95% CI 1.01-8.60), P = 0.047] were independently associated with MRSA colonization, whilst current wound management [AOR 15.59 (95% CI 4.85-50.10), P < 0.001] and fluoroquinolone use [AOR 4.27 (95% CI 1.20-15.25), P = 0.025] were risk factors for MDR GNB colonization. CONCLUSIONS LTCFs are an important reservoir of MDR organisms, with person-to-person transmissions being a potential issue. We have identified several predictors of colonization with MDR organisms, allowing a more targeted management of high-risk residents.
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Affiliation(s)
- Ching Jou Lim
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Jacqueline Kennon
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Denis Spelman
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia Microbiology Department, Alfred Health, Melbourne, Victoria, Australia
| | - Dayna Hale
- Microbiology Department, Alfred Health, Melbourne, Victoria, Australia
| | - Gabrielle Melican
- Nursing Service, Caulfield Hospital, Alfred Health, Melbourne, Victoria, Australia
| | - Hanna E Sidjabat
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia Department of Microbiology, Monash University, Melbourne, Victoria, Australia
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Lim CJ, Kong DCM, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives. Clin Interv Aging 2014; 9:165-77. [PMID: 24477218 PMCID: PMC3894957 DOI: 10.2147/cia.s46058] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Ching Jou Lim
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Rhonda L Stuart
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia ; Department of Medicine, Monash University, Clayton, VIC, Australia
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Friedman ND. Antimicrobial Stewardship: The Need to Cover All Bases. Antibiotics (Basel) 2013; 2:400-18. [PMID: 27029310 PMCID: PMC4790271 DOI: 10.3390/antibiotics2030400] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/18/2013] [Accepted: 08/21/2013] [Indexed: 12/18/2022] Open
Abstract
Increasing antimicrobial resistance has necessitated an approach to guide the use of antibiotics. The necessity to guide antimicrobial use via stewardship has never been more urgent. The decline in anti-infective innovation and the failure of currently available antimicrobials to treat some serious infections forces clinicians to change those behaviors that drive antimicrobial resistance. The majority of antimicrobial stewardship (AMS) programs function in acute-care hospitals, however, hospitals are only one setting where antibiotics are prescribed. Antimicrobial use is also high in residential aged care facilities and in the community. Prescribing in aged care is influenced by the fact that elderly residents have lowered immunity, are susceptible to infection and are frequently colonized with multi-resistant organisms. While in the community, prescribers are faced with public misconceptions about the effectiveness of antibiotics for many upper respiratory tract illnesses. AMS programs in all of these locations must be sustainable over a long period of time in order to be effective. A future with effective antimicrobials to treat bacterial infection will depend on AMS covering all of these bases. This review discusses AMS in acute care hospitals, aged care and the community and emphasizes that AMS is critical to patient safety and relies on government, clinician and community engagement.
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Affiliation(s)
- N Deborah Friedman
- Barwon Health, Bellerine St, Geelong, VIC 3220, Australia.
- Deakin University, Geelong, VIC 3216, Australia .
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