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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: ■■ Advanced age ■■ Multiple chronic conditions ■■ Functional disability ■■ Immunosuppression ■■ Increased antibiotic exposure which affects resistance to infection ■■ Use of urinary tract catheters ■■ Multiple hospital admissions ■■ 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: ■■ Acute respiratory infections ■■ Acute otitis media ■■ Acute sore throat/pharyngitis ■■ 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 ■■ ■■ ■■ 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: ■■ improving the appropriateness of antimicrobial use ■■ reducing antimicrobial resistance rates, morbidity and mortality ■■ 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.