Systemic Antibiotic Use in Nursing Homes: A Quality Assessment

Abstract

In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.

Predictors of Aspiration Pneumonia: How Important Is Dysphagia?

“…It accounts for anywhere from 13% to 48% of all infections in nursing home residents [1,2] and is the second most common type of nosocomial infection in hospitalized patients, after urinary tract infections [3]. The overall mortality rate ranges from 20% to 50%, with a rate as high as 80% reported in some studies [4][5][6][7][8].…”

Antibiotic Resistance in Nursing Homes

“…Previous study have found relatively high rates of antimicrobial use and substantial inappropriate use of antimicrobial agents in nursing homes and longterm care facilities (Zimmer JG & Al, 1986;Crossley K & Al 1987;Jones SR & Al, 1987;Katz PR & Al, 1990;Yakabowich MR & Al, 1994;Pickering TD & Al, 1994;Montgomery P & Al, 1995). In addition to increasing the risk of colonization or infection with antimicrobial-resistant organisms, inappropriate antimicrobial use adds cost to resident care and may place the patient at increased risk for drug adverse reactions (Mylotte JM, 1999).…”

“…A substantial proportion of antimicrobial treatment in nursing homes is considered inappropriate: from 30 to 75% of systemic antimicrobial agents (Zimmer JG & Al, 1986;Crossley K & Al 1987;Jones SR & Al, 1987;Katz PR & Al, 1990;Yakabowich MR & Al, 1994;Pickering TD & Al, 1994;Montgomery P & Al, 1995) and up to 60% of topical antimicrobial agents (Montgomery P & Al, 1995) are inappropriately used.…”

“…Reports summarizing antimicrobial agent use consistently identify urinary infection as the most frequent diagnosis for which treatment is prescribed, with respiratory infections second in frequency (Zimmer JG & Al, 1986;Crossley K & Al, 1987;Waine SJ & Al, 1992;Montgomery P & Al, 1995;Bentley DW & Al, 2000).…”

Community acquired pneumonia: Rampant Empiricism or Cautious Overkill?

“…Currently, it is likely that noninstitutionalized community acquired pneumonia is frequently treated with amoxicillin. In addition, amoxicillin is not recommended as a therapy for pneumonia in nursing home patients and yet, in many nursing homes, the majority of pneumonias are currently treated with amoxicillin (1) . Is this inappropriate practice in the absence of clinical outcome data documenting impaired efficacy?…”