Download antibiotics in racfs

FEBRUARY 2013
ANTIBIOTICS IN RACFS
A
ntibiotics are among the most frequently
prescribed medicines in residential aged care
facilities (RACFs). Optimising antimicrobial use
is an important issue for general practitioners, pharmacists
and nursing staff. Infections are a common cause of acute
care hospitalisations among RACF residents. Frail older
people may present with atypical infections and symptoms.
Risk factors
Residents in aged care facilities are particularly susceptible
to infections for a variety of reasons:
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Advanced age
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Multiple chronic conditions
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Functional disability
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Immunosuppression
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Increased antibiotic exposure which affects resistance to infection
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Use of urinary tract catheters
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Multiple hospital admissions
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Close contact with infected or colonised residents
and staff
antibiotics also inappropriate.
Another study on the use of antimicrobials in four RACFs
in Melbourne found that 40% of courses of antimicrobials
were prescribed for symptoms that did not fulfil the
criteria for infection. In this study around 11% of all
antimicrobials prescribed for UTIs were broad-spectrum
antibiotics, including norfloxacin (Noroxin), ciprofloxacin
(Ciproxin), ceftriaxone (Rocephin) and gentamicin.
Antibiotics were frequently prescribed for upper respiratory
tract infections (URTIs), bronchitis and asymptomatic
bacteriuria, which is likely to be inappropriate.
Antibiotics are only minimally effective in the following
conditions:
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Acute respiratory infections
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Acute otitis media
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Acute sore throat/pharyngitis
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Acute rhinosinusitis
Antibiotic resistance
Infection types
Common infections in residents in aged care facilities
include urinary tract infections (UTIs), lower respiratory
tract infections (LRTIs), skin and soft tissue infection, and
eye infections. Pneumonia and gastroenteritis also occur
in smaller numbers.
Pneumonia and urinary tract infections are frequent causes
of hospitalisations.
Antibiotic prescribing
International studies have shown that up to 50% of antibiotic
prescribing in aged care facilities is inappropriate. Routine
ordering of microbiological tests is not always practical in
the RACF setting.
A recent study of five Australian RACFs showed a
high rate of antimicrobial prescribing and inappropriate
antibiotic use. Doxycycline, cephalexin and flucloxacillin
were the most commonly prescribed antibiotics. The
most common indications for antibiotics were for urinary
tract and respiratory infections. Cephalexin, doxycycline
and nitrofurantoin were prescribed for prophylactic
use. Overall 40% of the antibiotic prescriptions were
considered inappropriate and one-quarter of prophylactic
© Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2013
The widespread use of antibiotics promotes resistance.
The emergence of multidrug-resistant organisms is a major
health concern at both a population and individual level.
People can carry transmissible antibiotic resistance after
a course of antibiotics. They are twice as likely to carry
resistant bacteria after a course of antibiotics as someone
who has not taken them.
The use of broad spectrum oral antibiotics is associated
with development of resistance. Prescribing of broad
spectrum antibiotics in the residential care setting
often occurs empirically in frail older residents without
microbiological testing.
Quinolones such as ciprofloxacin (Ciproxin), moxifloxacin
(Avelox), and norfloxacin (Noroxin), are strongly
associated with resistance. The Australian Medicines
Handbook (AMH) recommends quinolones should
be reserved for proven or suspected infections where
alternative agents are ineffective or contraindicated, eg.
complicated urinary tract infection (UTIs), bone or joint
infections, epididymo-orchitis, and prostatitis.
The current NPS antibiotic resistance campaign advises
rational use of antibiotics to minimise antibiotic resistance:
Antibiotics in RACFs, continued
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hen benefits to the patient are likely to be
w
substantial;
of the narrowest spectrum to treat the likely
pathogen, as recommended by local guidelines and
pathology providers; and
at the appropriate dose and for the appropriate
duration.
Vancomycin-resistant enterococci
Antibiotic stewardship is an organised program than should
be undertaken in RACFs to improve antimicrobial use and
improve clinical outcomes by:
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improving the appropriateness of antimicrobial
use
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reducing antimicrobial resistance rates, morbidity
and mortality
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reducing healthcare costs
Frequent antibiotic use and multiple hospital visits by
residents in aged care facilities have resulted in an increased
incidence of vancomycin-resistant enterococci (VRE). A
Melbourne study showed that 3% of RACF residents were
colonised with VRE.
Infection control is an important activity in aged care
facilities (Standard 4.7). Facilities should ensure they
are adequately applying infection control guidelines to
minimise the risk of infection, including during an outbreak.
Clostridium difficile
Adopting higher rates of hand washing will help to reduce
person-to-person infection with both acute respiratory
infections and resistant genes.
The rates of infection with Clostridium difficile has
increased significantly in Australia in recent times. This
infection may present with a range of symptoms from mild
diarrhoea to pseudomembranous colitis, toxic megacolon
and death.
EBSL-producing organisms
Residents in aged care facilities are at high risk of infection
with extended-spectrum β-lactamases (ESBL) organisms.
Older age, dementia, diabetes and poor nutritional status
are additional risk factors. Poor infection control practices
may facilitate the spread of this resistant organism.
ESBL-producing organisms are often resistant to
norfloxacin, ciprofloxacin and trimethoprim.
In a recent study of 164 residents in three Australian aged
care facilities ESBL-producing Escherichia coli (E. coli)
was detected in 12% of residents.
Asymptomatic bacteriuria
Asymptomatic bacteriuria occurs frequently in the older
persons and in those with urinary catheters. Cloudy or
malodorous urine in a patient without symptoms or signs
does not require investigation or treatment. Residents with
a catheter are always bacteriuric.
The use of antimicrobials for asymptomatic bacteriuria
is not recommended. The emergence of multi-resistant
organisms in the RACF setting is often due to extensive or
inappropriate use of antimicrobials for UTIs.
Antibiotic stewardship
Antibiotic stewardship has been defined as:
The limitation of inappropriate antimicrobial use while
optimising antimicrobial drug selection, dosing, route
and duration of therapy in order to maximise clinical
cure and to limit unintended consequences, such as
adverse drug reactions and the emergence and selection
of pathogenic organisms.
© Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2013
Summary
Antimicrobial resistance in RACFs is a growing concern.
Judicious, evidence-based use of antibiotics in aged care
facilities will prevent adverse effects and drug resistance.
Antibiotic stewardship is important in RACFs to promote
the rational use of antibiotics and minimise the emergence
of resistant pathogens. QUM services by pharmacists can
identify facility-wide issues through medication audits and
drug use evaluations (DUEs). Feedback can be provided
to visiting general practitioners through individual
Residential Medication Management Reviews (RMMRs)
and Medication Advisory Committees (MACs).
References
Clinical Infectious Diseases 2007;44:159-177.
Australian Family Physician 2012;41:839-840.
Medical Journal of Australia 2011;195:530-533.
Medical Journal of Australia 2012;196:327-331.
Healthcare Infection 2011;16:116-120.
Internal Medicine Journal 2012;42:1145-9.
NPS News 77, 2012.