Antimicrobial prescribing in European nursing homes

Healthcare-Associated Infections and Prevention Programs in General Nursing versus Residential Homes-Results of the Point Prevalence Survey in Polish Long-Term Care Facilities

Background and Objectives: The number of residents of long-term care facilities (LTCFs) is expected to increase. Determining the epidemiological situation in the context of organizational conditions is therefore extremely important for planning the necessary future activities in the field of infection prevention. The aim of this study was to analyze the prevalence rates in Polish nursing vs. residential homes, in the context of the medical and functional burdens of residents and the organizational conditions of both types of units. Material and Methods: the data that were analyzed came from a point prevalence survey of infections and antibiotic consumption in LTCFs, conducted in accordance with the HALT-3 protocol in Poland in 2017, between April and June. Results: This study included a total of 2313 residents in 24 LTCFs. The most common risk factors for infections in the study population were urinary and fecal incontinence (77.0%), impaired mobility (the patient was in a wheelchair or lying down) (68.7%), and impaired spatial and temporal orientation (52.5%). The median prevalence in nursing homes (NHs) was 3.2% and that in residential homes (RHs) was 0.7%, but without statistical significance. The median for the entire group was 2.6%. A total of 93 healthcare-related infections were detected in 91 residents. The most frequently reported forms of infections were urinary tract infections, lower respiratory tract infections, and skin infections. A statistically significant positive correlation was found only between the percentage of residents with pressure ulcers and other wounds and the incidence of gastrointestinal infections (correlation coefficient = 0.413, p < 0.05). Infection prevention and control measures were implemented mainly in nursing homes, and in residential homes, only hand hygiene procedures were commonly available. Conclusions: For the two types of LTCFs, the epidemiological situation in terms of nosocomial infections is diverse. Consequently, both types of facilities require different approaches to infection control and prevention and outcomes analysis.

Real-World Data about Commonly Used Antibiotics in Long-Term Care Homes in Australia from 2016 to 2019

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.

Risk factors for colonization with multidrug-resistant Gram-negative bacteria and Clostridioides difficile in Long Term Care Facilities (LTCFs) residents: the evidence from 27 facilities in a high endemic setting

Introduction

Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for C. difficile colonization.

Methods

A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of C. difficile was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models.

Results

In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (E. coli 65%, K. pneumoniae 14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant K. pneumoniae, and 3% in a carbapenem-resistant E. coli. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by C. difficile was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with C. difficile colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%).

Conclusion

Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.

The global prevalence of methicillin-resistant Staphylococcus aureus colonization in residents of elderly care centers: a systematic review and meta-analysis

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a difficult to treat infection, particularly in residents of elderly care centers (ECCs). Despite the substantial burden of MRSA, an inadequate number of studies have analyzed MRSA prevalence in ECCs.

OBJECTIVES

We conducted a worldwide systematic review and meta-analysis on the prevalence and risk factors of MRSA in ECCs.

METHODS

We searched MEDLINE/PubMed, EMBASE, Web of Science, and Scopus databases and the gray literature sources for all studies published between January 1980 and December 2022 on the prevalence of MRSA in ECCs. A random-effects model was utilized to estimate pooled prevalence rates at 95% confidence intervals (CI). Moreover, the data were analyzed based on World Health Organization-defined regions, income, and human development index levels.

RESULTS

In total, 119 studies, including 164,717 participants from 29 countries, were found eligible for meta-analysis. The pooled global prevalence of MRSA was 14.69% (95% CI 12.39-17.15%; 16,793/164,717). Male gender [prevalence ratio (PR) = 1.55; 95% CI 1.47-1.64], previous MRSA infection (PR = 3.71; 95% CI 3.44-4.01), prior use of antibiotics (PR = 1.97; 95% CI 1.83-2.12), hospitalized within the previous year (PR = 1.32; 95% CI 1.20-1.45), have had any wound (PR = 2.38; 95% CI 2.23-2.55), have used urinary catheter (PR = 2.24; 95% CI 2.06-2.43), have used any medical device (PR = 1.78; 95% CI 1.66-1.91), and those with diabetes (PR = 1.55; CI 1.43-1.67) were more likely to be colonized by MRSA than other patients.

CONCLUSION

Screening programs and preventive measures should target MRSA in ECCs due to the high global prevalence rates.

Increased prescription rate of anti-infective agents after diagnosis of myelodysplastic syndromes

The a priori risk for infections in patients with myelodysplastic syndromes (MDS) is unknown. This study examines prescription rates of anti-infective agents in MDS patients before and after diagnosis, in both in- and outpatient settings, to provide information on infection management in clinical practice. We performed a population-based study using the HemoBase registry, containing data of all MDS patients diagnosed since 2005 in Friesland, the Netherlands. Community and hospital pharmacies provided prescription data from 1995 to 2020. Data were obtained for 203 of 292 patients (70%). Patients received significantly more anti-infective agents, predominantly antibacterials (70%), after diagnosis compared to before: 148.7 defined daily dose/1000 days (DID) (95% CI: 146.9-150.5) and 55.1 DID (95% CI: 54.5-55.8, p < 0.01), respectively, corresponding to median 23.5 and 7.6 treatment days/year. Higher-risk (449.9 DID) and lower-risk patients (129.1 DID) both received significantly more anti-infective agents after diagnosis; comorbidities, neutropenia, and age did not show significant differences relative to prescription rates. Before diagnosis, 10% of patients had infection-related hospital admissions versus 38% after diagnosis. In conclusion, MDS patients received significantly more anti-infective agents compared to before diagnosis. This is the first study that has quantified the prescription rate of anti-infective agents within and beyond the clinical setting in MDS.

Temporal and regional trends of antibiotic use in long-term aged care facilities across 39 countries, 1985-2019: Systematic review and meta-analysis

BACKGROUND

Antibiotic misuse is a key contributor to antimicrobial resistance and a concern in long-term aged care facilities (LTCFs). Our objectives were to: i) summarise key indicators of systemic antibiotic use and appropriateness of use, and ii) examine temporal and regional variations in antibiotic use, in LTCFs (PROSPERO registration CRD42018107125).

METHODS & FINDINGS

Medline and EMBASE were searched for studies published between 1990-2021 reporting antibiotic use rates in LTCFs. Random effects meta-analysis provided pooled estimates of antibiotic use rates (percentage of residents on an antibiotic on a single day [point prevalence] and over 12 months [period prevalence]; percentage of appropriate prescriptions). Meta-regression examined associations between antibiotic use, year of measurement and region. A total of 90 articles representing 78 studies from 39 countries with data between 1985-2019 were included. Pooled estimates of point prevalence and 12-month period prevalence were 5.2% (95% CI: 3.3-7.9; n = 523,171) and 62.0% (95% CI: 54.0-69.3; n = 946,127), respectively. Point prevalence varied significantly between regions (Q = 224.1, df = 7, p<0.001), and ranged from 2.4% (95% CI: 1.9-2.7) in Eastern Europe to 9.0% in the British Isles (95% CI: 7.6-10.5) and Northern Europe (95% CI: 7.7-10.5). Twelve-month period prevalence varied significantly between regions (Q = 15.1, df = 3, p = 0.002) and ranged from 53.9% (95% CI: 48.3-59.4) in the British Isles to 68.3% (95% CI: 63.6-72.7) in Australia. Meta-regression found no association between year of measurement and antibiotic use prevalence. The pooled estimate of the percentage of appropriate antibiotic prescriptions was 28.5% (95% CI: 10.3-58.0; n = 17,245) as assessed by the McGeer criteria. Year of measurement was associated with decreasing appropriateness of antibiotic use over time (OR:0.78, 95% CI: 0.67-0.91). The most frequently used antibiotic classes were penicillins (n = 44 studies), cephalosporins (n = 36), sulphonamides/trimethoprim (n = 31), and quinolones (n = 28).

CONCLUSIONS

Coordinated efforts focusing on LTCFs are required to address antibiotic misuse in LTCFs. Our analysis provides overall baseline and regional estimates for future monitoring of antibiotic use in LTCFs.

Interventions to optimize medication use in nursing homes: a narrative review

PURPOSE

Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes.

METHODS

We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting.

RESULTS

Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels.

CONCLUSION

Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

Predictors of potentially suboptimal treatment of urinary tract infections in long-term care facilities

BACKGROUND

Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted.

AIM

To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities.

METHODS

This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities.

FINDINGS

The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37.

CONCLUSION

Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs.

The Urine-culturing Cascade: Variation in Nursing Home Urine Culturing and Association With Antibiotic Use and Clostridiodes difficile Infection

BACKGROUND

Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use.

METHODS

We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates.

RESULTS

A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18-1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28-1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07-1.31).

CONCLUSIONS

Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection.

Prevalence of Multi-Resistant Microorganisms and Antibiotic Stewardship among Hospitalized Patients Living in Residential Care Homes in Spain: A Cross-Sectional Study

Antimicrobial resistance is a growing global health problem. Patients living in care homes are a vulnerable high-risk population colonized by multidrug-resistant organisms (MDRO). We identified a case series of 116 residents of care homes from a cohort of 540 consecutive patients admitted to the internal medicine service of our hospital. We performed early diagnostic tests of MDRO through anal exudates in our sample. The prevalence of MDRO colonization was 34.5% of residents and 70% of them had not been previously identified in the clinical records. Previous hospitalizations and in-hospital antibiotic administration were significantly associated with the presence of MDRO. Our results emphasize the need to consider care homes in the planning of regional and national infection control measures and for implementing surveillance systems that monitor the spread of antimicrobial resistance in Spain. Systematic early testing upon admission to hospital services with a high prevalence of patients with MDRO colonization (e.g., internal medicine) could contribute to the adoption of adequate prevention measures. Specific educational programs for care home staff should also be implemented to address this increasing problem.

Point-of-care tests for urinary tract infections: protocol for a systematic review and meta-analysis of diagnostic test accuracy

INTRODUCTION

Urinary tract infections (UTIs) are the second most common type of infection worldwide, accounting for a large number of primary care consultations and antibiotic prescribing. Current diagnosis is based on an empirical approach, relying on symptoms and occasional use of urine dipsticks. The diagnostic reference standard is still urine culture, although it is not routinely recommended for uncomplicated UTIs in the community, due to time to diagnosis (48 hours). Faster point-of-care tests have been developed, but their diagnostic accuracy has not been compared. Our objective is to systematically review and meta-analyse the diagnostic accuracy of currently available point-of-care tests for UTIs.

METHODS AND ANALYSIS

Studies evaluating the diagnostic accuracy of point-of-care tests for UTIs will be included. PubMed, Web of Science, Embase and Cochrane Database of Systematic Reviews were searched from inception to 1 June 2019. Data extraction and risk-of-bias assessment will be assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. Meta-analysis will be performed depending on data availability and heterogeneity.

ETHICS AND DISSEMINATION

This is a systematic review protocol and therefore formal ethical approval is not required, as no primary, identifiable, personal data will be collected. Patients or the public were not involved in the design of our research. However, the findings from this review will be shared with key stakeholders, including patient groups, clinicians and guideline developers, and will also be presented and national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42018112019.

Developing evidence-based guidance for assessment of suspected infections in care home residents

BACKGROUND

The aim of this study was to update and refine an algorithm, originally developed in Canada, to assist care home staff to manage residents with suspected infection in the United Kingdom care home setting. The infections of interest were urinary tract infections, respiratory tract infections and skin and soft tissue infection.

METHOD

We used a multi-faceted process involving a literature review, consensus meeting [nominal group technique involving general practitioners (GPs) and specialists in geriatric medicine and clinical microbiology], focus groups (care home staff and resident family members) and interviews (GPs), alongside continual iterative internal review and analysis within the research team.

RESULTS

Six publications were identified in the literature which met inclusion criteria. These were used to update the algorithm which was presented to a consensus meeting (four participants all with a medical background) which discussed and agreed to inclusion of signs and symptoms, and the algorithm format. Focus groups and interview participants could see the value in the algorithm, and staff often reported that it reflected their usual practice. There were also interesting contrasts between evidence and usual practice informed by experience. Through continual iterative review and analysis, the final algorithm was finally presented in a format which described management of the three infections in terms of initial assessment of the resident, observation of the resident and action by the care home staff.

CONCLUSIONS

This study has resulted in an updated algorithm targeting key infections in care home residents which should be considered for implementation into everyday practice.

A multifaceted intervention to reduce antimicrobial prescribing in care homes: a non-randomised feasibility study and process evaluation

Background

The most frequent acute health-care intervention that care home residents receive is the prescribing of medications. There are serious concerns about prescribing generally, and about antimicrobial prescribing in particular, with facilities such as care homes being described as an important ‘reservoir’ of antimicrobial resistance.

Objectives

To evaluate the feasibility and acceptability of a multifaceted intervention on the prescribing of antimicrobials for the treatment of infections.

Design

This was a non-randomised feasibility study, using a mixed-methods design with normalization process theory as the underpinning theoretical framework and consisting of a number of interlinked strands: (1) recruitment of care homes; (2) adaptation of a Canadian intervention (a decision-making algorithm and an associated training programme) for implementation in UK care homes through rapid reviews of the literature, focus groups/interviews with care home staff, family members of residents and general practitioners (GPs), a consensus group with health-care professionals and development of a training programme; (3) implementation of the intervention; (4) a process evaluation consisting of observations of practice and focus groups with staff post implementation; and (5) a survey of a sample of care homes to ascertain interest in a larger study.

Setting

Six care homes – three in Northern Ireland and three in the West Midlands.

Participants

Care home staff, GPs associated with the care homes and family members of residents.

Interventions

A training programme for care home staff in the use of the decision-making algorithm, and implementation of the decision-making algorithm over a 6-month period in the six participating care homes. REACH (REduce Antimicrobial prescribing in Care Homes) Champions were appointed in each care home to support intervention implementation and the training of staff.

Main outcome measures

The acceptability of the intervention in terms of recruitment, delivery of training, feasibility of data collection from a variety of sources, implementation, practicality of use and the feasibility of measuring the appropriateness of prescribing.

Results

Six care homes from two jurisdictions were recruited, and the intervention was adapted and implemented. The intervention appeared to be broadly acceptable and was implemented largely as intended, although staff were concerned about the workload associated with study documentation. It was feasible to collect data from community pharmacies and care homes, but hospitalisation data from administrative sources could not be obtained. The survey indicated that there was interest in participating in a larger study.

Conclusions

The adapted and implemented intervention was largely acceptable to care home staff. Approaches to minimising the data-collection burden on staff will be examined, together with access to a range of data sources, with a view to conducting a larger randomised study.

Trial registration

Current Controlled Trials ISRCTN10441831.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 8. See the NIHR Journals Library website for further project information. Queen’s University Belfast acted as sponsor.

Antibiotic Stewardship in European Nursing Homes: Experiences From the Netherlands, Norway, Poland, and Sweden

Antibiotics are among the most widely prescribed drugs in long-term care facilities, which highlights the importance of antibiotic stewardship (ABS) in this setting. In this article, we describe the experiences with ABS in nursing homes (NHs) from the perspective of 4 European countries: the Netherlands, Norway, Poland, and Sweden. In these countries, a large variety of initiatives to develop and implement ABS in NHs have been introduced in recent years. Among these initiatives are national antibiotic prescribing surveillance systems, NH-specific prescribing guidelines, and national networks of healthcare institutions that exchange information and develop ABS policy. Several initiatives evolved as a result of political prioritization of antibiotic resistance, translated into national action plans. Experiences of the 4 countries with the presented initiatives may inspire other countries that aim to develop or improve ABS in the long-term care setting.

Antimicrobial prescribing and infections in long-term care facilities (LTCF): a multilevel analysis of the HALT 2016 study, Ireland, 2017

Background

The 2016 point prevalence survey (PPS) of healthcare-associated infections (HAI) and antimicrobial use (AMU) in Irish long-term care facilities (LTCF) (HALT) showed a 9.8% AMU and 4.4% HAI prevalence, based on aggregated data analysis.

Aim

Our aim was to identify institutional and resident risk factors of AMU and HAI.

Methods

HALT 2016 gathered information using institutional and resident questionnaires, for residents who met the surveillance definition of active HAI and/or AMU, limiting analysis to the aggregated institutional level. In January 2017, we requested additional data on age, sex, urinary catheter use and disorientation of current residents from HALT 2016 LTCF and matched to 2016 HALT data.

Results

Of 224 HALT 2016 LTCF, 80 provided additional information on 3,816 residents; prevalence of AMU was 10.6% and HAI was 4.7%. Presence of a coordinating physician (Odds ratio (OR): 0.3; 95% confidence interval (CI): 0.2–0.6), antimicrobial stewardship committee (OR: 0.2; 95%; CI: 0.1–0.6), healthcare assistants (OR: 0.9; 95% CI: 0.9–1.0), antimicrobial consumption feedback (OR: 0.3; 95% CI: 0.1–0.6) and medical care by personal general practitioner (OR: 0.6; 95% CI: 0.7–1.0) were associated with less AMU and feedback on surveillance of infection prevention and control (IPC) practices (OR: 0.6; 95% CI: 0.3–1.0) with less HAI. AMU and HAI varied significantly between LTCF.

Conclusions

Multilevel modelling identified significant inter-facility variation, as well as institutional factors associated with AMU and HAI. An antimicrobial stewardship committee linked with feedback on IPC and prescribing was associated with reduced AMU and HAI.

Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017

Antimicrobials are commonly prescribed and contribute to the development of antimicrobial resistance in long-term care facilities (LTCFs). In 2010, the European Centre for Disease Prevention and Control initiated point prevalence surveys (PPS) of healthcare-associated infections and antimicrobial use in European LTCFs, performed by external contractors as the Healthcare-Associated infections in Long-Term care facilities (HALT) projects. Here, we investigated prevalence and characteristics of antimicrobial use and antimicrobial stewardship indicators in European LTCFs in 2016–17. Twenty-four European Union/European Economic Area (EU/EEA) countries, the former Yugoslav Republic of Macedonia and Serbia participated in the third PPS in European LTCFs. Overall, 4.9% (95% confidence interval: 4.8–5.1) of LTCF residents in the EU/EEA participating countries received at least one antimicrobial. The most commonly reported Anatomical Therapeutic Chemical (ATC) groups were beta-lactam antibacterials/penicillins (J01C), other antibacterials (J01X) (e.g. glycopeptide antibacterials, polymyxins), quinolones (J01M), sulfonamides and trimethoprim (J01E), and other beta-lactams (J01D). Urinary tract infections and respiratory tract infections were the main indications for antimicrobial prescription. This PPS provides updated and detailed information on antimicrobial use in LTCFs across the EU/EEA that can be used to identify targets for future interventions, follow-up of these interventions and promote prudent use of antimicrobials in European LTCFs.

Antimicrobial prescribing in long-term care facilities: a nationwide point-prevalence study, Slovenia, 2016

Residents in long-term care are at high risk of infections because of their old age and many related health problems that lead to frequent antibiotic prescribing. The aim of the study was to assess antibiotic use in Slovenian long-term care facilities (LTCFs). The point-prevalence study was conducted between April and June 2016. Online questionnaires were sent to all Slovenian LTCFs. Eighty (68.4%) of the 117 LTCFs contacted, caring for 13,032 residents (70.6% of all Slovenian LTCF residents), responded to the survey. On the day of the study, the mean antibiotic prevalence per LTCF was 2.4% (95% confidence interval: 1.94-2.66). Most (70.2%) of the residents taking antibiotics were female. Most residents were being treated for respiratory tract (42.7%) or urinary tract (33.3%) infections. Co-amoxiclav and fluoroquinolones were the most frequently prescribed antibiotics (41.0% and 22.3% respectively). Microbiological tests were performed for 5.2% of residents receiving antibiotics. Forty nine (19.8%) residents receiving antibiotics were colonised with multidrug-resistant bacteria (MDR). Antibiotic use in Slovenian LTCFs is not very high, but most prescribed antibiotics are broad-spectrum. Together with low use of microbiological testing and high prevalence of colonisation with MDR bacteria the situation is worrisome and warrants the introduction of antimicrobial stewardship interventions.

Interventions to Improve Antimicrobial Stewardship for Older People in Care Homes: A Systematic Review

BACKGROUND

Inappropriate antimicrobial prescribing has been reported in care homes. This may result in serious drug-related adverse events, Clostridium difficile colonization, and the development of antimicrobial resistance among care home residents. Interventions to improve antibiotic prescribing in nursing homes have been reported through clinical trials, but whether antifungal and antiviral prescribing and residential homes have been considered, or how outcomes were measured and reported in such interventions, remains unclear.

OBJECTIVES

Our aims were to evaluate the effect of interventions to improve antimicrobial stewardship in care homes and to report the outcomes used in these trials.

METHODS

We searched 11 electronic databases and five trial registries for studies published until 30 November 2018. Inclusion criteria for the review were randomized controlled trials, targeting care home residents and healthcare professionals, providing interventions to improve antimicrobial prescribing compared with usual care or other interventions. The Cochrane tools for assessing risk of bias were used for quality assessment. A narrative approach was taken because of heterogeneity across the studies.

RESULTS

Five studies met the inclusion criteria. The studies varied in terms of types of infection, key targets, delivery of interventions, and reported outcomes. In total, 27 outcomes were reported across the studies, with seven not prespecified in the methods. The interventions had little impact on adherence to guidelines and prevalence of antimicrobial prescribing; they appeared to decrease total antimicrobial consumption but were unlikely to have affected overall hospital admissions and mortality. The overall quality of evidence was low because the risk of bias was high across the studies.

CONCLUSION

The interventions had limited effect on improving antimicrobial prescribing but did not appear to cause harm to care home residents. The low quality of evidence and heterogeneity in outcome measurement suggest the need for future well-designed studies and the development of a core outcome set to best evaluate the effectiveness of antimicrobial stewardship in care homes.

Choice of Empirical Antibiotic Therapy and Adverse Outcomes in Older Adults With Suspected Urinary Tract Infection: Cohort Study

Background

Nitrofurantoin is widely recommended for empirical treatment of urinary tract infection (UTI), but primary care clinicians may prescribe alternative antibiotics to improve prognosis in older, sicker patients. We assessed whether prescribing alternative antibiotics was associated with reduced risk of adverse outcomes in older patients.

Methods

This retrospective cohort study included patients aged ≥65 years empirically treated for a UTI with nitrofurantoin, cefalexin, ciprofloxacin, or co-amoxiclav. We matched patients on their propensity to receive a nitrofurantoin prescription and used mixed-effects logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for reconsultation and represcription (proxy for treatment failure), hospitalization for UTI, sepsis, or acute kidney injury, and death.

Results

We identified 42 298 patients aged ≥65 years prescribed empirical nitrofurantoin, cefalexin, ciprofloxacin, or co-amoxiclav for a UTI. Compared with nitrofurantoin, patients prescribed cefalexin, ciprofloxacin, or co-amoxiclav had lower odds of reconsultation and represcription (OR for cefalexin = 0.85, 95% CI = 0.75–0.98; OR for ciprofloxacin = 0.48, 95% CI = 0.38–0.61, OR for co-amoxiclav = 0.77, 95% CI = 0.64–0.93). Patients prescribed cefalexin or ciprofloxacin had greater odds of hospitalization for sepsis (OR for cefalexin = 1.89, 95% CI = 1.03–3.47; OR for ciprofloxacin = 3.21, 95% CI = 1.59–6.50), and patients prescribed cefalexin had greater odds of death (OR = 1.44, 95% CI = 1.12–1.85).

Conclusions

Compared with nitrofurantoin, prescribing of alternative antibiotics for UTI in older people may be associated with lower rates of treatment failure but was not associated with reduced risk of UTI-related hospitalization or death.

Antibiotic consumption and resistance of gram-negative pathogens (collateral damage)

Antibiotics are commonly prescribed in community and hospital care. Overuse and misuse favors emergence and spread of resistant bacteria. The ATC/DDD methodology is commonly used for presenting the drug utilization data. In primary care, the consumption is usually expressed in DDD per 1,000 inhabitants per day, in hospital, preferably in DDD per 100 bed days and DDD per 100 admissions. The alternative metric is days of therapy (DOT), which needs IT support. Antibiotics have ecological adverse effects at individual and population level. Antibiotics select resistant bacteria among pathogens and normal flora. Broad-spectrum antibiotics, low dosage and prolonged antibiotic therapy favor the development of resistance. Although total use of antibiotics in hospital is much less than in the community, the intensity of use magnified by cross infection ensures a multitude of resistant bacteria in today's hospitals. Reversal of resistance is complex and might persist for many years despite the introduction of antimicrobial containment and stewardship programs.

Utilization of Antibiotics in Long-Term Care Facilities in British Columbia, Canada

BACKGROUND

Antibiotic use is highly prevalent in long-term care facilities (LTCFs); a resident's annual exposure to at least 1 course of antibiotic is approximately 50% to 80%. The objective of this study was to understand the extent of antibiotic use in the population of residents in British Columbia's (BC) LTCFs from 2007 to 2014.

METHODS

Antibiotic prescription data for LTCF residents was extracted from the central prescription database and linked to the physician billing plan to obtain antibiotic indication. Total defined daily dose (DDD) per 1000 residents per day was calculated.

RESULTS

Our database had 381 LTCFs with an average of nearly 24,694 residents annually and 419,036 antibiotic prescriptions. Antibiotic utilization did not change dramatically between 2007 and 2014, ranging from 39.2 in 2007 to 35.2 DDD per 1000 residents per day in 2014. Although usage of most antibiotics declined, use of moxifloxacin, amoxicillin-clavulanate, doxycycline, and amoxicillin increased significantly. The indication most frequently linked to prescription was urinary tract infection (6.58 DDD per 1000 residents per day), with nitrofurantoin, ciprofloxacin, and trimethoprim/sulfamethoxazole being the most commonly prescribed agents. This was followed closely by prescriptions for respiratory infections (5.34 DDD per 1000 residents per day), with moxifloxacin being the most commonly prescribed antibiotic, primarily for upper respiratory tract infection (URTI), whereas doxycycline is used commonly for lower respiratory tract infection. Duration of antibiotic therapy in LTCF residents has decreased significantly from 9.29 days to 7.3 days per prescription in 2014.

CONCLUSION

Antibiotic use in LTCFs is high relative to the general population. Our study underscores that stewardship in LTCFs should continue to focus on length of treatment, appropriate detection of urinary tract infections, and avoidance of treating URTIs with antibiotics.

Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities

BACKGROUND

Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting.

OBJECTIVES

This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting.

SOURCE

PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively.

CONTENT

Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions.

IMPLICATIONS

There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.

Variation in antibiotic use among and within different settings: a systematic review

Objectives

Variation in antibiotic use may reflect inappropriate use. We aimed to systematically describe the variation in measures for antibiotic use among settings or providers. This study was conducted as part of the innovative medicines initiative (IMI)-funded international project DRIVE-AB.

Methods

We searched for studies published in MEDLINE from January 2004 to January 2015 reporting variation in measures for systemic antibiotic use (e.g. DDDs) in inpatient and outpatient settings. The ratio between a study's reported maximum and minimum values of a given measure [maximum:minimum ratio (MMR)] was calculated as a measure of variation. Similar measures were grouped into categories and when possible the overall median ratio and IQR were calculated.

Results

One hundred and forty-three studies were included, of which 85 (59.4%) were conducted in Europe and 12 (8.4%) in low- to middle-income countries. Most studies described the variation in the quantity of antibiotic use in the inpatient setting (81/143, 56.6%), especially among hospitals (41/81, 50.6%). The most frequent measure was DDDs with different denominators, reported in 23/81 (28.4%) inpatient studies and in 28/62 (45.2%) outpatient studies. For this measure, we found a median MMR of 3.7 (IQR 2.6-5.0) in 4 studies reporting antibiotic use in ICUs in DDDs/1000 patient-days and a median MMR of 2.3 (IQR 1.5-3.2) in 18 studies reporting outpatient antibiotic use in DDDs/1000 inhabitant-days. Substantial variation was also identified in other measures.

Conclusions

Our review confirms the large variation in antibiotic use even across similar settings and providers. Data from low- and middle-income countries are under-represented. Further studies should try to better elucidate reasons for the observed variation to facilitate interventions that reduce unwarranted practice variation. In addition, the heterogeneity of reported measures clearly shows that there is need for standardization.

Surveillance of antimicrobial use in Dutch long-term care facilities

Objectives

: Residents living in a long-term care facility (LTCF) are more susceptible to infections. Treatment with antimicrobials is sometimes necessary; however, antibiotic use is considered one of the most important drivers of the development of antibiotic resistance. Surveillance data on antibiotic use in these LTCFs are necessary to get more insight into these patterns. The objective of this study was to describe antibiotic use in LTCFs in the Netherlands.

Methods

: One hundred and seventy-seven LTCFs in the Netherlands were contacted and asked to participate in a study concerning antibiotic resistance and antibiotic use. Associated pharmacies were asked to provide data about systemic antibiotic use for each participating LTCF location over 1 year. Results on antibiotic use are reported here.

Results

: Antibiotic use data from 96 LTCFs were collected from the pharmacies, and 68 of these LTCFs completed additional questionnaires on general characteristics of their location. Mean total use of systemic antimicrobials was 73 DDDs/1000 residents per day (range 2-197 DDDs/1000 residents per day). Co-amoxiclav (23 DDDs/1000 residents/day, range 0-70) was used the most, followed by nitrofurantoin derivatives (12 DDDs/1000 residents/day, range 0-38) and fluoroquinolones (12 DDDs/1000 residents/day, range 0-52). Statistical analysis revealed no significant correlations between the LTCF characteristics and the level of antibiotic use.

Conclusions

There was a high use of broad-spectrum antimicrobials, with a large variation in total antibiotic use between individual locations. Further analysis of more in-depth data and possible influencing factors is needed.

Time trends in antibiotic consumption in the elderly: Ten-year follow-up of the Spanish National Health Survey and the European Health Interview Survey for Spain (2003-2014)

Background

The purposes of this study were: firstly, to estimate time trends in the prevalence of prescription antibiotic consumption between 2003 and 2014; secondly, to identify the factors associated with the probability of consuming antibiotics during this period in elderly persons in Spain.

Methods

We analyzed data collected from the Spanish National Health Survey in 2003 (n = 21,650), 2006 (n = 29,478), and 2012 (n = 20,007) and from the European Health Interview Survey for Spain in 2009 (n = 22,188) and 2014 (n = 22,842). Antibiotic consumption was the dependent variable. We also analyzed sociodemographic features, self-perceived health status, lifestyle habits, comorbid diseases, and disabilities using logistic regression models.

Results

The prevalence of antibiotic consumption increased from 2003 to 2014 in both sexes. The variables that predicted antibiotic consumption (men; women) were secondary education (OR 1.38; OR 1.31), visits to a general practitioner (OR 2.05; OR 2.15), hospitalization (OR 1.91; OR 1.83), therapy with > 4 non-antibiotic drugs (OR 3.36; OR 5.84), instrumental activities of daily living (OR 1.50; OR 1.24), and activities of daily living (OR 1.39; OR 1.35). In contrast, age > 85 years was associated with low antibiotic consumption in both men (OR 0.81) and women (OR 0.88).

Conclusions

The prevalence of antibiotic prescription has increased in Spain in the last decade. Our study identified several factors that appear to affect antibiotic consumption in elderly persons, with potential implications for healthcare providers.

Cross-national comparison of medication use in Australian and Dutch nursing homes

Background

cross-national comparisons can be used to explore therapeutic areas and identify potential medication issues.

Methods

we used cross-sectional pharmacy supply data to explore medication use for nursing home residents in Australia (AU n = 26 homes, 1,560 residents) and the Netherlands (NL n = 6 homes, 2,037 residents). Binary logistic regression analysis was used to calculate the sex and aged adjusted odds ratios (OR) and associated 95% confidence intervals with a flexible Bonferroni-Holm procedure used to adjust for multiple hypothesis testing.

Results

total use of antipsychotics (AU: 37.7%, NL: 40.3%; OR 0.91 (0.79-1.04, P = 0.16) and antibacterials (66.8% AU, 62.4% NL, OR 1.08 (0.93-1.24, P = 0.31) was similar, but choice of individual agents differed between the two countries. Differences were observed in the use of antithrombotics (46.7% AU, 64.7% NL, OR 0.48 (0.42-0.56, P > 0.01), ophthalmologicals (44.3% AU, 22.1% NL, OR 2.80 (2.42-3.24, P < 0.001), laxatives (77.1% AU, 65.8% NL, OR 1.65 (1.41-1.92, P < 0.001).

Conclusion

while the general prevalence of medication use in nursing home residents was similar across the two countries, distinct differences existed in the choice of agent among therapeutic groups. Comparing use between countries identified a number of potential medication related problem areas that need further exploration.

Registro do uso de antimicrobianos em Instituições de Longa Permanência para Idosos

Resumo Objetivo: Verificar o registro da prescrição e da utilização de antimicrobianos em Instituições de Longa Permanência para Idosos (ILPI), em municípios do Centro-Oeste de Minas Gerais. Método: Tratou-se de uma coorte retrospectiva, realizada em seis ILPIs filantrópicas. Utilizou-se um questionário contendo variáveis relacionadas aos dados sociodemográficos e de saúde, e registros de antimicrobianos. Empregou-se o teste Qui-quadrado de Pearson ou teste Exato de Fisher para avaliar a associação entre as variáveis. Resultados: Avaliaram-se os registros de 250 idosos. Dentre estes, 110 idosos fizeram uso de antimicrobianos. Houve associação entre tempo de permanência na instituição, o uso de antimicrobiano e o diagnóstico de infecção (p<0,05). Conclusão: A escassez e/ou inadequações quanto aos registros/prescrições de antimicrobianos e de infecções representa um problema para a saúde dos idosos podendo também comprometer a assistência por outros profissionais.

Antimicrobial stewardship in long-term care facilities in Belgium: a questionnaire-based survey of nursing homes to evaluate initiatives and future developments

Background

The use of antimicrobials is intense and often inappropriate in long-term care facilities. Antimicrobial resistance has increased in acute and chronic care facilities, including those in Belgium. Evidence is lacking concerning antimicrobial stewardship programmes in chronic care settings. The medical coordinator practicing in Belgian nursing homes is a general practitioner designated to coordinate medical activity. He is likely to be the key position for effective implementation of such programmes. The aim of this study was to evaluate past, present, and future developments of antimicrobial stewardship programmes by surveying medical coordinators working in long-term care facilities in Belgium.

Methods

We conducted an online questionnaire-based survey of 327 Belgian medical coordinators.

The questionnaire was composed of 33 questions divided into four sections: characteristics of the respondents, organisational frameworks for implementation of the antimicrobial stewardship programme, tools to promote appropriate antimicrobial use and priorities of action. Questions were multiple choice, rating scale, or free text.

Results

A total of 39 medical coordinators (12 %) completed the questionnaire. Past or present antimicrobial stewardship initiatives were reported by 23 % of respondents. The possibility of future developments was rated 2.7/5. The proposed key role of medical coordinators was rated <3/5 by 36 % of respondents. General practitioners, nursing staff, and hospital specialists are accepted as important roles. The use of antimicrobial guidelines was reported by only 19 % of respondents. Education was considered the cornerstone for any future developments. Specific diagnostic recommendations were considered useful, but chest x-rays were judged difficult to undertake. The top priority identified was to reduce unnecessary treatment of asymptomatic urinary infections.

Conclusions

Our study shows that the implementation of an antimicrobial stewardship programme is reported only in a minority of nursing homes. The possibility of future developments is uncertain. Nevertheless, the self-selected medical coordinators who responded to the survey reported a good knowledge of this complex problem. Despite a lack of optimism, medical coordinators seem to have the appropriate competencies to play a key role in antimicrobial stewardship in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0106-7) contains supplementary material, which is available to authorized users.

Prevention of infections in nursing homes: antibiotic prophylaxis versus infection control and antimicrobial stewardship measures

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.

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

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

National point prevalence survey of healthcare-associated infections and antimicrobial use in French home care settings, May to June 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Antibiotic use in the care home setting: a retrospective cohort study analysing routine data

Background

Point prevalence studies in care homes show a high use of antibiotics, especially to treat urinary tract infections (UTI). There is a lack of large studies presenting annual antibiotic prescription data in care homes compared to those not in care homes. This study aimed to describe the pattern of antibiotic prescribing in those 75 years and over, with a focus on UTI.

Methods

In this retrospective longitudinal cohort study we used the Hampshire Health Record (HHR) containing routine data from general practices in Hampshire area, UK covering 1.24 million residents. Data were extracted throughout 2011 from the Hampshire Health Record on age, gender, care home status, antibiotic prescriptions, urinary catheters and comorbidity. Prescription pattern expressed as rate per 100 people. Nursing home residence defined by postcode. Logistic regression was used to assess independent risk of one or more antibiotic prescriptions in care home residents adjusting for age, sex and comorbidity, separately by catheter use.

Results

102,020 of 1,244,313 residents in the Hampshire Health Record (8.2 %) were aged ≥75 years of whom 7481 (7.3 %) were resident in care home settings. The annual antibiotic prescriptions increased from 53/100 inhabitants among those <75 years, to 142/100 among those ≥75 years not in a care home and to 199/100 among those ≥75 years in a care home. Care home residents with urinary catheters (4.4 %) had even higher use at 440/100 versus 188/100 if no catheter. UTI antibiotics showed a similar but more rapidly increasing pattern. For those in care homes without a urinary catheter, the odds ratio was 2.2 (2.1–2.3) higher for prescriptions of UTI antibiotics compared to those not in care homes after adjusting for age, gender and comorbidity. For those with a urinary catheter the odds ratio was 1.4 (1.1–1.8) for UTI antibiotics compared to those not in care homes. For all antibiotics the odds ratio was 1.2 (1.2–1.3).

Conclusions

Residence in a care home setting is associated with high antibiotic consumption; this is especially evident for UTI antibiotics where the odds of prescription is doubled.

Three years of antibiotic consumption evaluation in French nursing homes

OBJECTIVES

We had for aim to assess antibiotic consumption and to better understand their use in nursing homes so as to target messages on relevant practice procedures sent to prescribers.

DESIGN

The MedQual network asked nursing homes with in-house pharmacies to participate in a retrospective collection of yearly antibiotic consumption data with an Excel(®) spread sheet according to the Health Ministry recommendations.

RESULTS

Fifty-two nursing homes participated in 2011, 2012, and 74 in 2013, accounting for 10% of the Pays de la Loire region's nursing homes and 15% of beds. The medians of total antibiotic consumption in daily-defined dose for 1000 patient-days were respectively 39 (32.4-49.0), 39.3 (34.4-52.9), and 44.8 (33.6-55.4). There was no significant difference between 2011 and 2013. Penicillins (J01C) were the most commonly used class with a median of 25.7 [IQ 18.8; 33.8] in 2011 and 30.4 [IQ 23.6; 41.3] in 2013. Quinolones (J01M) were the second most commonly used class with a median of 4.6 [IQ 2.9; 5.9] in 2011 and 3.8 [IQ 2.3; 6.5] in 2013, followed by the other beta-lactams (J01D) with a median of 2.5 [IQ 1.7; 4.5] in 2011 and 2,8 [IQ 1.7; 3.8] in 2013.

CONCLUSION

The monitoring of antibiotic consumption in nursing homes in the Pays de la Loire Region since 2011 has allowed identifying inappropriate use and helped improve practices. No increase of overall consumption was observed in nursing homes but the distribution according to antibiotic class changed. The current objective is to extend this monitoring and to send personalized messages to prescribers.

Colonisation with ESBL-producing and carbapenemase-producing Enterobacteriaceae, vancomycin-resistant enterococci, and meticillin-resistant Staphylococcus aureus in a long-term care facility over one year

Background

This study examined colonisation with and characteristics of antimicrobial-resistant organisms among residents of a long-term care facility (LTCF) over one year, including strain persistence and molecular diversity among isolates of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae.

Methods

Sixty-four residents of a LTCF were recruited (51 at baseline, 13 during the year). Data on dependency levels, hospitalisations, and antimicrobial prescribing were collected. Nasal and rectal swabs and catheter urine specimens were examined quarterly, using chromogenic agars, for ESBL-producing Enterobacteriaceae, carbapenemase-producing Enterobacteriaceae (CPE), vancomycin-resistant enterococci (VRE), and meticillin-resistant S. aureus (MRSA). All ESBL-producing E. coli (ESBL-EC) were characterised by pulsed-field gel electrophoresis (PFGE) and PCR to assess for sequence type (ST) ST131, its resistance-associated H30 and H30-Rx subclones, and bla_CTX-M,bla_TEM,bla_SHV, and bla_OXA-1.

Results

The overall number of residents colonised, by organism, was as follows: ESBL-EC, 35 (55%); MRSA, 17 (27%); ESBL-producing K. pneumoniae (ESBL-KP), 5 (8%); VRE, 2 (3%) and CPE, 0 (0%). All 98 ESBL-EC isolates were H30-Rx ST131, with bla_{CTX-M-group 1.} By PFGE, a group of 91 ESBL-EC (from 33 participants) had ≥ 85% similar profiles and resembled UK epidemic strain A/ international pulsotype PFGE812. Sequential ESBL-EC from individual residents were closely related. Six ESBL-KP isolates, from five participants, had bla_{CTX-M-group 1} and by PFGE were closely related. Colonisation with ESBL and MRSA was associated with location within the LTCF and previous exposure to antimicrobials.

Conclusions

Among LTCF residents, colonisation with ESBL-EC and MRSA was common. All ESBL-EC were H30-Rx ST131, consistent with clonal dissemination.

Influence of a non-hospital medical care facility on antimicrobial resistance in wastewater

The global widespread use of antimicrobials and accompanying increase in resistant bacterial strains is of major public health concern. Wastewater systems and wastewater treatment plants are considered a niche for antibiotic resistance genes (ARGs), with diverse microbial communities facilitating ARG transfer via mobile genetic element (MGE). In contrast to hospital sewage, wastewater from other health care facilities is still poorly investigated. At the instance of a nursing home located in south-west Germany, in the present study, shotgun metagenomics was used to investigate the impact on wastewater of samples collected up- and down-stream in different seasons. Microbial composition, ARGs and MGEs were analyzed using different annotation approaches with various databases, including Antibiotic Resistance Ontologies (ARO), integrons and plasmids. Our analysis identified seasonal differences in microbial communities and abundance of ARG and MGE between samples from different seasons. However, no obvious differences were detected between up- and downstream samples. The results suggest that, in contrast to hospitals, sewage from the nursing home does not have a major impact on ARG or MGE in wastewater, presumably due to much less intense antimicrobial usage. Possible limitations of metagenomic studies using high-throughput sequencing for detection of genes that seemingly confer antibiotic resistance are discussed.

Infections and antimicrobial use among institutionalized residents in Hungary: increasing need of microbiological surveillance

As a result of the age-related changes, more elders live in long-term care facilities (LTCFs). Due to their susceptibility, infections and excess use of antimicrobials are common. The aim was to estimate the burden of infections and antimicrobial use in Hungarian LTCFs in order to increase the attention given to the prevention. European-wide point prevalence survey was conducted between April and May 2013. For each resident who had a signs and symptoms of an infection and/or treated with an antibacterial for systemic use a resident questionnaire was completed. Descriptive statistics were used to present the data. In total, 91 LTCFs with 11,823 residents were selected in this survey. The 252 residents had a sign/symptom of an infection (2.1%) and 156 received antimicrobial (1.3%). Skin and soft tissues (36.5%) was the most frequent infection. However, antimicrobials were mostly prescribed for respiratory tract infections (40.4%). The most common therapeutic antimicrobial agent (97.5%) belonged to the quinolone antibacterials (34.2%). Our results emphasise the need for targeted improvement of antimicrobial use including: reducing the use of quinolone antibacterials in order to prevent the spread of Clostridium difficile and other antimicrobial resistant microorganisms among institutionalized residents.

Compositional dynamics of the human intestinal microbiota with aging: implications for health

The human gut contains trillions of microbes which form an essential part of the complex ecosystem of the host. This microbiota is relatively stable throughout adult life, but may fluctuate over time with aging and disease. The gut microbiota serves a number of functions including roles in energy provision, nutrition and also in the maintenance of host health such as protection against pathogens. This review summarizes the age-related changes in the microbiota of the gastrointestinal tract (GIT) and the link between the gut microbiota in health and disease. Understanding the composition and function of the gut microbiota along with the changes it undergoes overtime should aid the design of novel therapeutic strategies to counteract such alterations. These strategies include probiotic and prebiotic preparations as well as targeted nutrients, designed to enrich the gut microbiota of the aging population.

Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus strains isolated in a multicenter study of nursing home residents in Croatia

BACKGROUND

Residents of nursing homes (NHs) are often hospitalized and could present a potential reservoir for methicillin-resistant Staphylococcus aureus (MRSA). The aim of the study was to determine the prevalence for MRSA carriage in residents and staff in Croatian NHs and to characterize MRSA strains using genotyping techniques.

METHODS

A cross-sectional study was performed among 877 residents and staff of 7 NHs representing 3 major Croatian regions. Nasal swabs from residents and staff and other samples from residents with invasive devices were obtained. Identified isolates were submitted to susceptibility testing and genotyping with SCCmec typing, S aureus protein A (spa) locus typing, and pulsed-field gel electrophoresis (PFGE).

RESULTS

The overall prevalence of MRSA colonization was 7.1% (95 confidence interval, 5.4%-8.8%), ranging from 0% to 28.8%. Four MRSA isolates were found in NH staff. All MRSA isolates were negative for Panton-Valentine leukocidin-encoding genes. SCCmec type II was found in 32 MRSA strains; SCCmec IV, in 27 strains; SCCmec I, in 3 strains. The predominant spa type was t008, found in 49 strains; PFGE analysis revealed 2 major clonal groups.

CONCLUSIONS

MRSA strains were found to be colonizing residents and staff of 7 NHs in Croatia. Our study demonstrates the spread of 2 clones within and among Croatian NHs. The data presented here provide an important baseline for future surveillance of MRSA in NH.

Compositional dynamics of the human intestinal microbiota with aging: implications for health

The human gut contains trillions of microbes which form an essential part of the complex ecosystem of the host. This microbiota is relatively stable throughout adult life, but may fluctuate over time with aging and disease. The gut microbiota serves a number of functions including roles in energy provision, nutrition and also in the maintenance of host health such as protection against pathogens. This review summarizes the age-related changes in the microbiota of the gastrointestinal tract (GIT) and the link between the gut microbiota in health and disease. Understanding the composition and function of the gut microbiota along with the changes it undergoes overtime should aid the design of novel therapeutic strategies to counteract such alterations. These strategies include probiotic and prebiotic preparations as well as targeted nutrients, designed to enrich the gut microbiota of the aging population.

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

As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes.

Point prevalence survey of antimicrobial utilization in a Canadian tertiary-care teaching hospital

Objectives: Inappropriate antimicrobial use can promote antimicrobial resistance, which is associated with increased patient morbidity and mortality. Identifying the pattern of antimicrobial use can provide data from which targeted antimicrobial stewardship interventions can be made. The primary objective was to identify the prevalence of antimicrobial use at a tertiary care teaching hospital with both acute and long-term care patients.

Methods: A point prevalence study was conducted on July 19th, 2012. Data on antimicrobial utilization, indication for prescribing, duration of therapy, and frequency of infectious disease or antimicrobial stewardship consultations were collected using a customized integrated stewardship database (SPIRIT) and prospective chart review.

Results: One or more antimicrobial agents were ordered in 31% and 4% of acute care and long-term care patients, respectively. Respiratory and urinary tract infections were the most common indication for antimicrobial therapy in both acute and long-term care. About 25% of surgical prophylaxis orders were prescribed for greater than 24 h.

Conclusion: This prospective point prevalence survey provided important baseline information on antimicrobial use within a large tertiary care teaching hospital and identified potential targets for future antimicrobial stewardship initiatives. A multi-center point prevalence survey should be considered to identify patterns of antimicrobial use in Canada and to establish the first steps toward international antimicrobial surveillance.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from 2003 to 2012

BACKGROUND

There are several risk factors for the colonisation, infection and spreading of antibiotic resistant bacteria among elderly residents of nursing homes. An updated estimate of the native prevalence of antimicrobial resistance in uropathogens among Swedish nursing home residents is needed.

METHODS

Urine specimens were collected for culture and antimicrobial susceptibility testing against mecillinam, ampicillin, cefadroxil, trimethoprim, nitrofurantoin and quinolones from the residents of 32 and 22 nursing homes, respectively. The residents were capable of providing a voided urine sample in 2003 and 2012. In 2012 urine specimens were also collected from residents with urinary catheters. Any antibiotic treatment during the previous month was registered in 2003 as well as hospitalisation and any antibiotic treatment during the previous six months in 2012.

RESULTS

The proportion of positive urine cultures was 32% (207/651) in voided urine specimens in 2003, 35% (147/421) in 2012, and 46% (27/59) in urine samples from catheters in 2012. Escherichia coli (E. coli) was the most commonly occurring bacteria.Resistance rates in E. coli (voided urine specimens) in 2012 were; ampicillin 21%, trimethoprim 12%, mecillinam 7.7%, ciprofloxacin 3.4%, cefadroxil 2.6% and nitrofurantoin 0.85%. There were no significant changes in the average resistance rates in E. coli for antibiotics tested 2003-2012.In 2012, two isolates of E. coli produced extended spectrum beta-lactamase enzymes (ESBL) and one with plasmid mediated AmpC production.Any antibiotic treatment during the previous month increased the risk for resistance in E. coli, adjusted for age and gender; for mecillinam with an odds ratio (OR) of 7.1 (2.4-21; p = 0.00049), ampicillin OR 5.2 (2.4-11; p = 0.000036), nalidixic acid OR 4.6 (1.4-16; p = 0.014) and trimethoprim OR 3.9 (1.6-9.2; p = 0.0023). Hospitalisation during the previous six months increased the risk for antibiotic resistance in E. coli to ampicillin, ciprofloxacin and any antimicrobial tested, adjusted for age, gender and antibiotic treatments during the previous six months.

CONCLUSIONS

The average rates of antimicrobial resistance were low and did not increase between 2003 and 2012 in E. coli urinary isolates among Swedish nursing home residents. Antibiotic treatment during the previous month and hospitalisation during the previous six months predicted higher resistance rates.

Antimicrobial use in Hungarian long-term care facilities: high proportion of quinolone antibacterials

The aim of this survey was to estimate the burden of antimicrobial use and to describe the determinants for antimicrobial use in Hungarian long-term care facilities (LTCFs) in order to increase the attention given to the proper prescription for this vulnerable population. A one-day point-prevalence study was undertaken between April and May 2013. Data on resident treated with an antibacterial, antimycotic or tuberculostatic for systemic use were collected prospectively on a single day in each participating LTCF with over 50 beds. Descriptive statistics were used to present the data. 91 LTCFs with 11,823 residents participated in this survey. 156 residents (1.3%) were given antimicrobials. 96.8% of antimicrobials were mostly prescribed for therapy included urinary tract infections (40.3%), respiratory tract infections (38.4%) and skin and soft tissue infections (13.2%). The most common therapeutic antimicrobials (97.5%) belonged to the ATC J01 class of 'antibacterials for systemic use'. The most important J01 subclasses were J01M quinolone antibacterials (32.7%), J01C beta-lactam antibacterials (25.2%), J01D other beta-lactam antibacterials (11.3%) and J01F macrolides, lincosamides and streptogramins (11.3%). Antimicrobials were mostly prescribed empirically whereas 3.8% was microbiologically documented treatments. 3.2% of all prescribed antimicrobials were prescribed for the prophylaxis of urinary tract infections (60%) and ear, nose, mouth infections (40%). Our results emphasize the need of a national recommendation for good practice in LTCFs in order to avoid inappropriate antimicrobial therapy leading to spread of multidrug resistant pathogens. In addition, continuing education of prescribers on antimicrobial treatment is essential.