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

Antibiotic prescribing for care-home residents: a population-based, cross-classified multilevel analysis in Scotland, UK

BACKGROUND

There is wide variation in antibiotic prescribing across care-homes for older people, with implications for resident outcomes and antimicrobial resistance.

OBJECTIVE

To quantify variation in antibiotic prescribing and associations with resident, care-home and general practice characteristics.

DESIGN

Population-based analyses using administrative data.

SETTING AND SUBJECTS

148 care-homes in two Scottish regions, with 6633 residents registered with 139 general practices.

METHODS

Prescriptions for any antibiotic and for broad-spectrum antibiotics between 1 April 2016 and 31 March 2017 were analysed using cross-classified multilevel negative binomial regression.

RESULTS

For any antibiotics, the mean prescription rate was 6.61 (SD 3.06) per 1000 resident bed-days (RBD). In multivariate analysis, prescribing was associated with resident age [incidence rate ratio (IRR) 1.30 [95% confidence interval 1.19 to 1.41] for 90+ versus <80 years old] and comorbidity (1.88 [1.71 to 2.06] for Charlson Comorbidity Index 3+ versus 0), and the care-home's sampling rate for microbiological culture (1.53 [1.28 to 1.84] for >7 versus <3.5 samples per 1000 RBD), with residual unexplained variation between care-homes (median IRR 1.29 [1.23 to 1.36]) and general practices (1.11 [1.05 to 1.18]). For broad-spectrum antibiotics, the mean rate was 0.98 (0.92) per 1000 RBD. Broad-spectrum prescribing was also associated with resident age, sex, comorbidity and sampling rate, with larger residual unexplained variation between care-homes (1.56 [1.36 to 1.77]) and general practices (1.51 [1.31 to 1.72]).

CONCLUSION

Variation in prescribing was influenced by resident case-mix, but there is significant unexplained variation between care-homes and between general practices, indicating a need for antibiotic stewardship to target both.

Antimicrobial prescribing in French nursing homes and interventions for antimicrobial stewardship: a qualitative study

BACKGROUND

Overuse of antibiotics is frequent in nursing homes (NHs) leading to adverse events and selection of resistant bacteria. Antimicrobial stewardship interventions showed heterogeneous effects on reducing inappropriate use of antimicrobials in NHs.

OBJECTIVES

This study aimed (1) to analyze antimicrobial prescribing determinants in NHs; (2) to identify which resources for antimicrobial prescribing are used by NHs' physicians (3) understand which antimicrobial stewardship interventions are required and how they should be implemented in NHs.

METHODS

We conducted individual semi-directed interviews with NHs' prescribing physicians in Ile-de-France, France. A thematic content analysis was conducted iteratively.

RESULTS

Thirteen interviews were conducted. Participants were mostly women, with a median age of 48 years and a median professional experience in NHs of three years. Participants included medical coordinators, general practitioners and salaried physicians. Main determinants of antimicrobial prescribing in NHs were the perceived risk of infectious complications and discomfort in residents, the difficulty in obtaining microbiological samples and the lack of healthcare professionals to monitor patients. Most participants reported using national guidelines and electronic decision support systems to guide their antimicrobial prescribing. Institutional constraints accentuate situations of doubt and prompt physicians to prescribe antimicrobials "just in case" despite the will to follow guidelines and the known risks of antimicrobial misuse. Physicians stated that proper antimicrobial use in NHs would require a major effort but was not judged a priority as compared to other medical issues. Producing guidelines tailored to the NH's context, performing good practice audits with feedback on antimicrobial prescribing, and reinforcing multidisciplinary relationships and discussions between city and hospital professionals were cited as potential interventions. The role of the medical coordinator was described as central. According to physicians, collaboration among stakeholders, providing support and training during the process might prove effective strategies to ensure successful implementation.

CONCLUSION

Antimicrobial prescribing is a complex decision-making process involving different factors and actors in NHs. Tailored guidelines, good practice audits, strengthened multidisciplinary collaboration were proposed as key AMS interventions. Physicians emphasized the central role of the medical coordinator supported by stakeholder engagement, collaboration, training and ongoing support for successful implementation.

Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies

BACKGROUND

Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes.

METHOD

We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings.

RESULTS

Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1).

CONCLUSIONS

Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.

Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents

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.

Prevalence of indwelling urinary catheters in nursing home residents: Systematic review

BACKGROUND

This systematic review examines the prevalence of indwelling urinary catheters in nursing home residents.

METHODS

MEDLINE via PubMed, CINAHL, and EMBASE were searched from inception to 9 August 2022. Cross-sectional studies and longitudinal studies with cross-sectional analyses reporting catheter prevalence in nursing home residents were identified and summarized descriptively. Study quality was assessed using the Joanna Briggs Institute's tool.

RESULTS

Sixty-seven studies (92.5 % cross-sectional) were included. The reported number of included residents ranged from 73 to 110,656. The median catheter prevalence was 7.3 % (interquartile range 4.3-10.1 %; n = 65 studies). It was higher in Germany (10.2 % [9.7-12.8 %]; n = 15) than in the United States of America (9.3 % [6.3-11.9 %]; n = 9), United Kingdom (6.9 % [4.8-8.5 %]; n = 7), and Sweden (7.3 % [6.4-7.9 %]; n = 6). Furthermore, it was higher among men (17.0 % [16.0-26.0 %]) than among women (5.3 % [4.0-9.5 %]) (n = 9). Only one study investigated differences by age. The prevalence was higher for transurethral (5.7 % [5.6-7.2 %]; n = 12) than for suprapubic (1.2 % [0.6-2.5 %]; n = 13) catheters. Most catheterized residents were long-term catheterized (n = 6) and had their catheter changed within 3 months (n = 2). Symptomatic urinary tract infections were more common among catheterized than among non-catheterized residents (n = 4).

DISCUSSION

Catheter prevalence in nursing home residents varies between studies and countries. Prevalence differences by sex, age, and catheter type as well as duration of catheterization, catheter change intervals, and catheter-associated urinary tract infections are rarely reported because most studies do not primarily focus on catheters. Future studies should focus on the circumstances of urinary catheter use and care in nursing home residents.

REGISTRATION AND FUNDING

PROSPERO (29 August 2022; CRD42022354358); no funding.

Prevalence of Antimicrobial Prescribing in Long-Term Care Facilities in a Local Health Authority of Northern Italy

BACKGROUND

Almost half of antimicrobial prescriptions in long-term care facilities (LTCFs) is inappropriate. This broad use might represent a strong contributor to antimicrobial resistance in these facilities. This study aimed to assess antibiotic use patterns and potential associated factors with a survey of LTCFs in the local health authority (LHA) of Novara.

METHODS

A cross-sectional study was conducted in 25 LTCFs in the LHA of Novara following the healthcare-associated infection in LCTFs (HALT) protocol. Information on residents and facilities was assessed. Antibiotic usage and potential determinants were also estimated.

RESULTS

In total, 1137 patients were screened for antibiotic usage. Mean age was 84.58 years (SD 9.77), and the majority were female (76.52%). Twenty-six were antibiotic users (prevalence rate 2.29%, 95%CI 1.50-3.33). Antimicrobials were mainly prescribed orally (84.62%). Potential risk factors for antibiotic prescription were catheter use (central and peripheral venous, p-values 0.0475 and 0.0034, respectively, and urinary, p-value 0.0008), immobilization (p-value < 0.0001), and sex (p-value 0.0486).

CONCLUSIONS

This study identified a low prevalence of antimicrobic consumption in LTCFs. Further surveillance studies are warranted to identify trends and changes in pathogen incidence and antimicrobial resistance and to inform public health authorities on the necessity of prudent use of antimicrobials in LCTFs.

[Healthcare-associated infections and antimicrobial use in long-term care facilities. German results of the third European point prevalence survey HALT-3]

BACKGROUND AND OBJECTIVE

The essential role of infection prevention in long-term care facilities has become evident during the current SARS-CoV‑2 pandemic. In order to obtain a reliable database on nosocomial infections and antibiotic use, the European Centre for Disease Prevention and Control (ECDC) initiated the third point prevalence survey in European long-term care facilities from 2016 to 2017 (HALT-3).

MATERIAL AND METHODS

In Germany, 131 facilities with 10,565 residents participated voluntarily. On a single day in 2016, the number of nosocomial infections and/or uses of antibiotics as well as care characteristics and risk factors of the residents were recorded. Infections were documented based on symptoms using an algorithm in accordance with the McGeer surveillance criteria for long-term care facilities.

RESULTS

A nosocomial infection was documented in 177 residents, which corresponds to a prevalence of 1.7% (95% CI: 1.3-2.1), still low in comparison with the European prevalence (mean value 3.9%). Urinary tract infections were the most common infections at almost 50%, followed by respiratory, skin, and soft-tissue infections. The type of infection was consistent with the most common indications for antibiotic use. Antibiotic use was documented in 143 residents (prevalence of 1.4%, 95% CI: 1.1-1.7). The frequent use of fluoroquinolones with over 20% of all prescriptions was noticeable.

CONCLUSIONS

The establishment of facility-based surveillance of the most common infections and antibiotic consumption, together with the creation of guidelines specifically tailored to the geriatric population, could contribute to improving infection prevention and control as well as a more rational use of antibiotics, thus increasing the quality and safety of care.

Healthcare-associated infections and antibiotic use in long-term care residents from two geographical regions in Switzerland

BACKGROUND

The burden of healthcare-associated infections (HAIs) and antimicrobial use in Swiss long-term care facilities (LTCFs) is currently unknown. This study assessed the prevalence of HAIs and antibiotic use among LTCF residents in Switzerland.

METHODS

A point-prevalence study was undertaken in LTCFs in eastern and western Switzerland from August to October 2019 according to the 'Healthcare-associated infections in long-term care facilities' (HALT) protocol. Characteristics of residents (age, sex, wounds, dementia, indwelling catheters) and institutions (specific factors, geographic region) were assessed. LTCF residents were screened for HAIs and current antibiotic treatment. Personal and institutional factors associated with HAIs were assessed.

RESULTS

In total, 1185 residents from 16 LTCFs (eight per geographic region) were screened for HAIs and antibiotic treatment. Median age was 87 years (interquartile range 79-91) and 71% were female. The prevalence of HAIs was 4.2% (west 4.3% vs east 4.2%; P=0.93), with mucocutaneous skin infections (36%) and respiratory tract infections (30%) being the most common. Independent risk factors for the presence of HAIs were presence of a chronic wound [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1-5.0; P=0.02] and being immobile (OR 1.8, 95% CI 1.0-3.3; P=0.04). Antibiotics were given to 2.9% of residents (west 3.9% vs east 1.8%; P=0.05) on the day of the survey. The most commonly prescribed antibiotics were amoxicillin-clavulanic acid and quinolones.

CONCLUSIONS

The prevalence of HAIs in Swiss LTCFs is similar to that in other European countries, whereas antibiotic consumption is lower. Further point-prevalence surveys on a broader scale are recommended to improve understanding of the burden of HAIs and antibiotic consumption in this setting.

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.

Case-based audit and feedback around a decision aid improved antibiotic choice and duration for uncomplicated cystitis in primary care clinics

OBJECTIVES

The objective of our study was to evaluate the impact of a multifaceted stewardship intervention on adherence to the evidence-based practice guidelines on treatment of uncomplicated cystitis in primary care. We hypothesised that our intervention would increase guideline adherence in terms of antibiotic choice and duration of treatment.

DESIGN

A preintervention and postintervention comparison with a contemporaneous control group was performed. During the first two study periods, we obtained baseline data and performed interviews exploring provider prescribing decisions for cystitis at both clinics. During the third period in the intervention clinic only, the intervention included a didactic lecture, a decision algorithm and audit and feedback. We used a difference-in-differences analysis to determine the effects of our intervention on the outcome and guideline adherence to antibiotic choice and duration.

SETTING

Two family medicine clinics (one intervention and one control) were included.

PARTICIPANTS

All female patients with uncomplicated cystitis attending the study clinics between 2016 and 2019.

RESULTS

Our sample included 932 visits representing 812 unique patients with uncomplicated cystitis. The proportion of guideline-adherent antibiotic regimens increased during the intervention period (from 33.2% (95% CI 26.9 to 39.9) to 66.9% (95% CI 58.4 to 74.6) in the intervention site and from 5.3% (95% CI 2.3 to 10.1) to 17.0% (95% CI 9.9 to 26.6) in the control site). The increase in guideline adherence was greater in the intervention site compared with the control site with a difference-in-differences of 22 percentage points, p=0.001.

CONCLUSION

A multifaceted intervention increased guideline adherence for antibiotic choice and duration in greater magnitude than similar trends at the control site. Future research is needed to facilitate scale-up and sustainability of case-based audit and feedback interventions in primary care.

Oral and parenteral antibiotic use in Norwegian nursing homes: are primary care institutions becoming our new local hospitals?

Background

Norwegian nursing homes (NHs) have over the last 10 years increasingly applied the use of parenteral treatment, which in turn allows more broad-spectrum use of antibiotics. Previous studies from Norwegian NHs have for the most part not described parenteral formulations.

Objectives

To describe systemic antibiotic use in Norwegian NHs.

Methods

Thirty-seven NHs in the county of Østfold, Norway, were invited to participate in this retrospective cross-sectional study. Associated pharmacies provided sales data for systemic antibiotic use for the participating NHs for 1 year (October 2015 to October 2016). General institutional characteristics were collected through a questionnaire.

Results

Thirty-four NHs participated in the study. Mean use of antibiotics was 9.5 DDD/100 bed days (range 0.6–30.9 DDD/100 bed days). Oral antibiotics accounted for 83% and parenteral antibiotics for 17% of the total antibiotic use. Of parenteral antibiotics, ampicillin was most used (31.1%) followed by cefotaxime (17.7%) and penicillin G (16.6%). The proportion of antibiotics compliant with guideline recommendations was 60%. Being a short-term NH was associated with increased antibiotic use, with an unstandardized coefficient of 13.1 (95% CI 4.2–21.9; P = 0.005).

Conclusions

We found a high level of total and parenteral antibiotic use compared with previous studies from Norwegian NHs. Data showed wide variations in total antibiotic use and that only a moderate proportion of the antibiotic use was considered guideline compliant. This highlights the necessity of further implementation strategies regarding the national guidelines for antibiotic use in NHs.

The situation of infection in the elderly in Spain: a multidisciplinary opinion document

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.

A comparative analysis of prophylactic antimicrobial use in long-term care facilities in Ireland, 2013 and 2016

Background

Long-term care facilities (LTCFs) are important locations of antimicrobial consumption. Of particular concern is inappropriate prescribing of prophylactic antimicrobials.

Aim

We aimed to explore factors related to antimicrobial prophylaxis in LTCFs in Ireland.

Methods

The point prevalence surveys of Healthcare-Associated Infections in Long-Term Care Facilities (HALT) were performed in Ireland in May 2013 and 2016. Data were collected on facility (type and stewardship initiatives) and resident characteristics (age, sex, antimicrobial and indication) for those meeting the surveillance definition for a HAI and/or prescribed an antimicrobial.

Results

In 2013, 9,318 residents (in 190 LTCFs) and in 2016, 10,044 residents (in 224 LTCFs) were included. Of the 10% of residents prescribed antimicrobials, 40% were on prophylaxis, most of which was to prevent urinary tract infection. The main prophylactic agents were: nitrofurantoin (39%) and trimethoprim (41%) for urinary tract (UT); macrolides (47%) for respiratory tract and macrolides and tetracycline (56%) for skin or wounds. More than 50% of the prophylaxis was prescribed in intellectual disability facilities and around 40% in nursing homes. Prophylaxis was recorded more often for females, residents living in LTCFs for more than 1 year and residents with a urinary catheter. No difference in prophylactic prescribing was observed when comparing LTCFs participating and not participating in both years.

Conclusions

Forty per cent of antimicrobial prescriptions in Irish LTCFs were prophylactic. This practice is not consistent with national antimicrobial prescribing guidelines. Addressing inappropriate prophylaxis prescribing in Irish LTCFs should be a key objective of antimicrobial stewardship initiatives.

Antibiotic prescribing in UK care homes 2016-2017: retrospective cohort study of linked data

BACKGROUND

Older people living in care homes are particularly susceptible to infections and antibiotics are therefore used frequently for this population. However, there is limited information on antibiotic prescribing in this setting. This study aimed to investigate the frequency, patterns and risk factors for antibiotic prescribing in a large chain of UK care homes.

METHODS

Retrospective cohort study of administrative data from a large chain of UK care homes (resident and care home-level) linked to individual-level pharmacy data. Residents aged 65 years or older between 1 January 2016 and 31 December 2017 were included. Antibiotics were classified by type and as new or repeated prescriptions. Rates of antibiotic prescribing were calculated and modelled using multilevel negative binomial regression.

RESULTS

13,487 residents of 135 homes were included. The median age was 85; 63% residents were female. 28,689 antibiotic prescriptions were dispensed, the majority were penicillins (11,327, 39%), sulfonamides and trimethoprim (5818, 20%), or other antibacterials (4665, 16%). 8433 (30%) were repeat prescriptions. The crude rate of antibiotic prescriptions was 2.68 per resident year (95% confidence interval (CI) 2.64-2.71). Increased antibiotic prescribing was associated with residents requiring more medical assistance (adjusted incidence rate ratio for nursing opposed to residential care 1.21, 95% CI 1.13-1.30). Prescribing rates varied widely by care home but there were no significant associations with the care home-level characteristics available in routine data.

CONCLUSIONS

Rates of antibiotic prescribing in care homes are high and there is substantial variation between homes. Further research is needed to understand the drivers of this variation to enable development of effective stewardship approaches that target the influences of prescribing.

Impact of an Antimicrobial Stewardship Program on Resistance to Fluoroquinolones of Urinary Enterobacteriaceae Isolated From Nursing Home Residents: A Retrospective Cohort Study

OBJECTIVES

This study investigated the impact of an antimicrobial stewardship program on fluoroquinolone (FLQ) resistance in urinary Enterobacteriaceae isolated from residents of 3 French nursing homes.

DESIGN

A multicentric retrospective before-and-after study was conducted.

SETTING AND PARTICIPANTS

All the first urinary Enterobacteriaceae isolates obtained from nursing home residents were included. Two time frames were analyzed: 2013-2015 and 2016-2017.

METHODS

The antimicrobial stewardship program started in 2015 and was based on (1) 1-day training for use of an "antimicrobial stewardship kit for nursing homes;" and (2) daily support and training of the coordinating physician by an antibiotic mobile team (AMT) in 2 of 3 nursing homes.

RESULTS

Overall, 338 urinary isolates were analyzed. Escherichia coli was the most frequent species (212/338, 63%). A significant reduction of resistance to ofloxacin was observed between 2013-2015 and 2016-2017 in general (Δ = -16%, P = .004) and among isolates obtained from patients hospitalized in the county nursing home with AMT support (Δ = -28%, P < .01). A nonstatistically significant reduction in ofloxacin resistance was also observed in the hospital nursing home with AMT support (Δ = -18%, P = .06).

CONCLUSIONS AND IMPLICATIONS

Our antimicrobial stewardship program resulted in a decrease in resistance to FLQ among urinary Enterobacteriaceae isolated from nursing home residents. The support of an AMT along with continuous training of the coordinating physician seems to be an important component to ensure efficacy of the intervention.

Surveillance of infections in long-term care facilities (LTCFs): The impact of participation during multiple years on health care-associated infection incidence

We studied trends in the incidence of health care-associated infections (HAIs) in LTCFs between 2009 and 2015 and determined the effect of participation in our network. Elder-care physicians reported weekly the number of cases of influenza-like illness, gastroenteritis, (probable) pneumonia, urinary tract infections (UTIs) and all-cause mortality. Trends in the incidence of infection and mortality in relation to LTCF characteristics were calculated using multilevel univariate and multivariate logistic regression. Thirty LTCF participated for 3 years or more, 16 for 2 years and the remaining 12 LTCF for 1 year. During the study period, the median number of beds decreased from 158 to 139, whereas the percentage of residents with private bedrooms increased from 14% to 87%. UTIs were the most frequently reported infections, followed by (probable) pneumonia and gastroenteritis. Adjusted for calendar year and season, we observed a statistically significant decrease in the incidence of influenza-like illness (odds ratio (OR) = 0.8, P < 0.01) and (probable) pneumonia (OR = 0.8, P < 0.01) for each extra year an LTCF participated. Although there are other likely contributors, such as more private rooms and enhanced infection control measures, the decreasing trend of HAI in LTCFs participating in surveillance implies that surveillance is a valuable addition to current strategies to optimise infection control.

Improving Antimicrobial Prescribing: A Multinomial Model Identifying Factors Associated With First- and Second-Line Prescribing

BACKGROUND/OBJECTIVES

Broad-spectrum, second-line antimicrobials may be prescribed when initial first-line options prove ineffective. This study compares prescribing practices and identifies potential influencing factors for first- and second-line antimicrobials in long-term care facilities.

DESIGN

Point prevalence survey of health care-associated infections and antimicrobial use in long-term care facilities (HALT), expanded by additional data collection.

SETTING

Long-term care facilities in Ireland.

PARTICIPANTS

Of long-term care facilities that participated in the HALT study 2016, additional data provided by 77 facilities with a record of 3677 residents.

MEASUREMENT

On the survey date, an institutional questionnaire was completed by each participating long-term care facility, and resident questionnaires were completed only for those residents who met a health care-associated infection surveillance definition and/or were prescribed a systemic antimicrobial. All participating long-term care facilities were contacted at a later time point to provide limited anonymized data (age, sex, urinary catheterization, and disorientation) on all current residents. These additional data were matched to the original data set, facilitating multilevel multinominal logistic regression (first-line/second-line/no antimicrobial).

RESULTS

Of 3677 residents in 77 long-term care facilities, 381 (10%) were prescribed systemic antimicrobials on the survey day. Of those, 46% were categorized as second-line choices, with substantial interfacility variation observed with regard to prescription of first- versus second-line antimicrobials. The odds of a second-line antimicrobial prescription for a resident doubled when comparing the highest with the lowest prescribing long-term care facilities (median odds ratio = 2.0, credibility interval = 1.5-2.9). Male residents were less often prescribed first-line antimicrobials [odds ratio (OR) = 0.6, 95% confidence interval (CI) = 0.4-0.9, P = .02]. Long-term care facilities that reported the provision of education on antimicrobial prescribing use significantly less second-line antimicrobials (OR = 0.2, 95% CI = 0.1-0.7, P = .02). Females and residents with a urinary catheter were more likely to receive first-line antimicrobials.

CONCLUSION/IMPLICATIONS

The use of second-line antimicrobials is common practice in long-term care facilities, but education and training on appropriate antimicrobial use has the potential to reduce second-line antimicrobial prescribing, improve patients' outcomes, and reduce antimicrobial resistance.