Another Setting for Stewardship: High Rate of Unnecessary Antimicrobial Use in a Veterans Affairs Long‐Term Care Facility

Abstract

BACKGROUND/OBJECTIVE Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). In order to develop effective stewardship interventions, there is a need for data on current patterns of unnecessary antimicrobial prescribing among LTCF residents. The objective of this study was to examine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in our Veterans Affairs (VA) LTCF. DESIGN Retrospective chart review. SETTING Cleveland VA Medical Center LTCF. PARTICIPANTS Randomly selected patients receiving antimicrobial therapy from October 1, 2008 to March 31, 2009. MEASUREMENTS Days of necessary and unnecessary antimicrobial therapy determined using Infectious Diseases Society of America guidelines, syndromes treated with unnecessary antimicrobials, and the frequency of development of Clostridium difficile infection (CDI), colonization or infection with antimicrobial resistant pathogens, and other adverse effects. RESULTS Of 1351 days of therapy prescribed in 100 regimens, 575 days (42.5%) were deemed unnecessary. Of the 575 unnecessary days of therapy, 334 (58%) were for antimicrobial regimens that were entirely unnecessary (n=42). Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n=21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer than recommended treatment duration accounting for 226 (94%) unnecessary days of therapy. Within 30 days of completing the antimicrobial regimens, 5 patients developed CDI, 5 had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse drug events. CONCLUSIONS In our VA LTCF, 43% of all days of antimicrobial therapy were unnecessary. Our findings suggest that antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria.

Strategies and challenges of antimicrobial stewardship in long-term care facilities

“…Longer-thanneeded durations are one of the most frequent causes of unnecessary antibiotic prescriptions [14]. Several authors have shown that around half of systemic antibiotic courses in LTCFs are longer than 7 days [8,10,30], and this appeared to be influenced by prescriber preference more than patient characteristics, even though 7 days of therapy is sufficient for the most common bacterial infections encountered in LTCF residents [62][63][64].…”

“…Antibiotics prescribed for asymptomatic bacteriuria are nonetheless one of the leading cause of unnecessary antibiotic prescriptions [2,7,14,59]. Colonized wounds should also not be treated with antibiotics, unless clinical signs of infections are present [4].…”

“…Samples are sometimes sent to the microbiology laboratory systematically by nurses [29,32], and positive samples representing only colonization might be mistaken for infections, and lead to unnecessary antibiotic prescriptions [2,7,14,29,32].…”

“…Estimates suggest that around half of antimicrobial use is either unnecessary or inappropriate in LTCFs [4,7,9,[12][13][14]. As a consequence, prevalence of resistant bacteria is higher in LTCFs than in the community [15,16].…”

Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel

“…4,5 Asymptomatic bacteriuria (ASB) is pervasive, and treatment of ASB is a leading cause of unnecessary antibiotic use. 6 Thus, preventing and controlling the spread of infections in nursing homes is an important public health issue.…”