Effect of tailored antibiotic stewardship programmes on the appropriateness of antibiotic prescribing in nursing homes.

OBJECTIVES: To evaluate the effect of tailored interventions on the appropriateness of decisions to prescribe or withhold antibiotics, antibiotic use and guideline-adherent antibiotic selection in nursing homes (NHs). METHODS: We conducted a quasi-experimental study in 10 NHs in the Netherlands. A participatory action research (PAR) approach was applied, with local stakeholders in charge of selecting tailored interventions based on opportunities for improved antibiotic prescribing that they derived from provided baseline data. An algorithm was used to evaluate the appropriateness of prescribing decisions, based on infections recorded by physicians. Effects of the interventions on the appropriateness of prescribing decisions were analysed with a multilevel logistic regression model. Pharmacy data were used to calculate differences in antibiotic use and recorded infections were used to calculate differences in guideline-adherent antibiotic selection. RESULTS: The appropriateness of 1059 prescribing decisions was assessed. Adjusting for pre-test differences in the proportion of appropriate prescribing decisions (intervention, 82%; control, 70%), post-test appropriateness did not differ between groups (crude: P = 0.26; adjusted for covariates: P = 0.35). We observed more appropriate prescribing decisions at the start of data collection and before receiving feedback on prescribing behaviour. No changes in antibiotic use or guideline-adherent antibiotic selection were observed in intervention NHs. CONCLUSIONS: The PAR approach, or the way PAR was applied in the study, was not effective in improving antibiotic prescribing behaviour. The study findings suggest that drawing prescribers' attention to prescribing behaviour and monitoring activities, and increasing use of diagnostic resources may be promising interventions to improve antibiotic prescribing in NHs.

Antibiotic prescribing in Dutch nursing homes: how appropriate is it?

OBJECTIVE: To investigate the appropriateness of decisions to prescribe or withhold antibiotics for nursing home (NH) residents with infections of the urinary tract (UTI), respiratory tract (RTI), and skin (SI). DESIGN: Prospective study. SETTING: Ten NHs in the central-west region of the Netherlands. PARTICIPANTS: Physicians providing medical care to NH residents. MEASUREMENTS: Physicians completed a registration form for any suspected infection over an 8-month period, including patient characteristics, signs and symptoms, and treatment decisions. An algorithm, developed by an expert panel and based on national and international guidelines, was used to evaluate treatment decisions for appropriateness of initiating or withholding antibiotics. RESULTS: Appropriateness of 598 treatment decisions was assessed. Overall, 76% were appropriate, with cases that were prescribed antibiotics judged less frequently "appropriate" (74%) compared with cases in which antibiotics were withheld (90%) (P = .003). Decisions around UTI were least often appropriate (68%, compared with 87% for RTI and 94% for SI [P < .001]). The most common situations in which antibiotic prescribing was considered inappropriate were those indicative of asymptomatic bacteriuria or viral RTI. CONCLUSION: Although the rate of appropriate antibiotic prescribing in Dutch NHs is relatively high compared with previous studies in other countries, our results suggest that antibiotic consumption can be reduced by improving appropriateness of treatment decisions, especially for UTI. Given the current antibiotic resistance developments in long-term care facilities, interventions reducing antibiotic use for asymptomatic bacteriuria and viral RTI are warranted.

Antibiotic use and resistance in long term care facilities.

INTRODUCTION: The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance. METHODS: Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations. RESULTS: A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship. CONCLUSION: The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.