Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis

Abstract

BackgroundThe pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate. The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation.MethodsThis was a retrospective, cross-sectional multi-center study that occurred in five NHs in southern Wisconsin between January 2013 and September 2014. All NH residents with an antibiotic prescribing events for suspected lower respiratory tract infections (LRTI), skin and soft tissue infections (SSTI), and urinary tract infections (UTI), initiated in-facility, from an emergency department (ED), or an outpatient clinic were included in this sample. We assessed appropriateness of antibiotic prescribing using the Loeb criteria based on documentation available in the NH medical record or transfer documents. We compared appropriateness by setting and infection type using the Chi-square test and estimated associations of demographic and clinical variables with inappropriate antibiotic prescribing using logistic regression.ResultsAmong 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the ED. Inappropriate antibiotic prescribing for urinary tract infections differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 (95% CI: 1.64–5.44, P < .001) times increased odds of inappropriate use.ConclusionsAntibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings. Further research is needed to characterize antibiotic prescribing patterns for patients managed in these settings as this likely represents an important, yet under recognized, area of consideration in attempts to improve antibiotic stewardship in NHs.

Combining Procalcitonin and Rapid Multiplex Respiratory Virus Testing for Antibiotic Stewardship in Older Adult Patients With Severe Acute Respiratory Infection

“…NHs become the reservoirs for resistant bacteria within a community. 31 Although the present protocol cannot be implemented in NHs, it can be used among severe NH patients who are transferred to the ED. In a less severe outbreak, the nasopharyngeal samples of NH residents can be collected and sent to contracted laboratories for respiratory panel testing.…”

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey

“…Studies, however, have found that as many as 75% of those antibiotics were prescribed inappropriately, without adequate documentation or evidence of infection. [8][9][10][11][12][13][14][15] Inappropriate use and overuse of antibiotics can lead to increased risk of infections from Clostridium difficile and multidrug-resistant organisms as well as antibiotic resistance. [16][17][18][19] NH residents are also at higher risk of adverse drug reactions, polypharmacy, and decreased antibiotic efficacy owing to altered pharmacokinetics.…”

Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes

“…Administrative fragmentation is characterized by lack of adequate hospital records, frequent staff and leadership turnover, and frequent changes in regulations that inhibit the uptake, dissemination, and reinforcement of changes in antibiotic prescribing policies . Sloane et al used a pragmatic trial to compare the effect of an intervention bundle to reduce systemic antibiotic prescribing in 27 North Carolina nursing homes .…”

“…Administrative fragmentation is characterized by lack of adequate hospital records, frequent staff and leadership turnover, and frequent changes in regulations that inhibit the uptake, dissemination, and reinforcement of changes in antibiotic prescribing policies. 11 Sloane et al used a pragmatic trial to compare the effect of an intervention bundle to reduce systemic antibiotic prescribing in 27 North Carolina nursing homes. 12 Two administrative structures were considered: (1) chain nursing homes, in which the intervention was disseminated by a corporate leader; and (2) nonchain facilities, in which the medical director and other providers disseminated the intervention.…”