Antibiotics Overused in Nursing Homes

By Nancy Walsh, Staff Writer, MedPage Today

Published: March 18, 2013

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

·         This retrospective anlysis looked at antibiotic treatment in residents in long-term-care facilities.

·         Three-quarters of patients received an incident antibiotic treatment course which in almost half exceeded 7 days. One-fifth of prescribers had a higher-than-expected proportion of prescriptions beyond the 7-day threshold.

About one-fifth of clinicians working at long-term-care facilities prescribed most of the antibiotics given to the elderly residents, and almost half of those prescriptions were for longer than a week, Canadian researchers reported.

A total of 21.6% of prescribers wrote 79.6% of the courses of antibiotics for these patients, according to Nick Daneman, MD, and colleagues from the University of Toronto.

And in 43.5% of cases the prescriptions specified treatment for more than 7 days, the researchers reported online in JAMA Internal Medicine.

"High rates of institutional antibiotic use are driving increased rates of antibiotic resistance, Clostridium difficile infection, antibiotic-related adverse events, and healthcare costs, yet up to half of antibiotic use in acute and long-term-care institutions is unnecessary or inappropriate," stated Daneman and colleagues.

Previous studies have shown that, for most common bacterial infections, a week-long course of treatment is adequate.

To determine whether the excessive use of antibiotics in this setting is determined by clinician preference and habit -- and therefore could be modified -- the research team conducted a retrospective analysis of prescribing patterns throughout Ontario.

They found that 74.8% of 66,901 patients were given a prescription for an antibiotic during the course of a year.

Almost three-quarters of the patients were women, their median age was 86, and more than half had dementia.

The most commonly prescribed agents were second-generation fluoroquinolones, penicillins, and third-generation fluoroquinolones, with 35% of all prescriptions being for the fluoroquinolones.

In 41% of cases, the duration of treatment was 7 days, but in 44.9% the treatment course was longer than a week and in the remainder it was for less than 7 days.

The average duration of treatment among clinicians who prescribed antibiotic courses longer than 7 days was for 11.6 days.

The usual duration was 9.1 days among those considered average prescribers, and for short-duration prescribers the average was 7.5 days.

"If long-duration prescribers adopted the prescribing profile of average prescribers, their total antibiotic days prescribed would decrease by 22% and the overall antibiotic days in long-term-care would decrease by 7%," Daneman and colleagues calculated.

Moreover, if all clinicians followed the lead of the short-duration prescribers, there would be a 19% decrease in the number of antibiotic days in the care facilities.

In a logistic model adjusting for patient characteristics, the likelihood of a long course of antibiotics was almost four times higher for physicians in the 75th percentile of prescribers compared with those in the 25th percentile (OR 3.84, P<0.001).

The findings of this study concur with other research suggesting that clinicians tend to adopt consistent patterns of prescribing that may not reflect the individual needs of patients, and particularly in circumstances such as long-term-care facilities where prescriptions are often written empirically.

Therefore, as physician preference appears to be the driver in overuse of antibiotics in these circumstances, "efforts to alter these behaviors may offer a reasonable avenue to reduce antibiotic use in long-term-care facilities," the researchers observed.

Possible interventions could include the implementation of standardized order sets and provision of feedback to clinicians, and future studies should assess the utility of these strategies to limit overuse.

A particular concern voiced by Carmel M. Hughes, PhD, and Michael M. Tunney, PhD, of Queen's University in Belfast, Ireland, in an invited commentary was the high rate of fluoroquinolone use.

"The level of fluoroquinolone prescribing is surprising given the association between the use of these antibiotics and Clostridium difficile infection," they wrote.

"Clearly, greater caution should be exercised in the use of fluoroquinolones in the long-term-care setting," Hughes and Tunney cautioned.

In their commentary, they also noted that prescribing physicians often are under pressure from nursing staff and families to provide antibiotics, and that interventions must target this "nurse-physician-family triad" in order to successfully overcome the problem of overuse in long-term care.

Limitations of the study included its reliance on administrative data and the limited availability of information on specific reasons clinicians might have for prescribing long courses of antibiotics.

The study was supported by the Ontario Ministry of Health and Long-Term Care and the Canadian Institutes of Health Research.

One co-author was an employee of Bayer Canada in 2003-2004.

Primary source: JAMA Internal Medicine
Source reference:
Daneman N, et al "Prolonged antibiotic treatment in long-term care: role of the prescriber" JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.3029.

Additional source: JAMA Internal Medicine
Source reference:
Hughes C, Tunney M "Improving prescribing of antibiotics in long-term care: resistant to change?" JAMA Intern Med 2013; DOI: 10.1001/jamainternmed.2013.4077.