Antimicrobial Prophylaxis and Stewardship in Nursing Home: A Narrative Review

The rapid increase in antimicrobial resistance is a great concern in safeguarding the nursing home population. Improving inappropriate prescribing is the main agenda of antimicrobial stewardship. It is complicated to articulate the appropriateness of antimicrobial prescribed in nursing home residents, especially the prophylaxis. It is tricky because most of the residents are often on multiple medications, and there are no guidelines available for prescribers to decide on the appropriateness. Except for urinary tract infections, prescribing instructions rarely exists for other infections in nursing homes. Very few studies discuss prophylactic prescribing, and most of them are prevalence studies. These studies showed the urinary tract, respiratory tract, and skin-related problem as the most common cause of antimicrobial prophylaxis. However, this information is presented as total proportion without disaggregated analysis of conditions and types of the urinary and respiratory tract and skin-related infections. Further, the definition used is vague, and significant risk factors of antimicrobial prophylaxis and precision about the use remain unanswered. Lack of appropriate definition and unanswered questions are potentially challenging for stewardship in nursing homes. This review summarizes the current situation of antimicrobial prophylaxis and discusses gaps in the literature and pertinent areas for moving forward for antimicrobial stewardship in nursing home settings.

Appropriateness of Initiating Antibiotics for Urinary Tract Infection Among Nursing Home Residents

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.637 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s127-s128

Author(s):

Taniece R. Eure ◽

Nicola D. Thompson ◽

Austin Penna ◽

Wendy M. Bamberg ◽

Grant Barney ◽

...

Keyword(s):

Nursing Home ◽

Urinary Tract ◽

Nursing Homes ◽

Treatment Guidelines ◽

Nursing Home Residents ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Emerging Infections ◽

Tract Infections ◽

Uncomplicated Cystitis

Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.Funding: NoneDisclosures: None

The role of nurse (practitioner) to improve the diagnosis of urinary tract infections in nursing home residents

Journal of Nursing and Health Studies ◽

10.21767/2574-2825-c3-008 ◽

2018 ◽

Vol 03 ◽

Author(s):

J Haaijman ◽

E Stobberingh

Keyword(s):

Nursing Home ◽

Urinary Tract ◽

Nurse Practitioner ◽

Nursing Home Residents ◽

Measuring Antibiotic Appropriateness for Urinary Tract Infections in Nursing Home Residents

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2017.96 ◽

2017 ◽

Vol 38 (8) ◽

pp. 998-1001 ◽

Cited By ~ 10

Author(s):

Taniece Eure ◽

Lisa L. LaPlace ◽

Richard Melchreit ◽

Meghan Maloney ◽

Ruth Lynfield ◽

...

Keyword(s):

Urinary Tract Infection ◽

Nursing Home ◽

Urinary Tract ◽

Tract Infection ◽

Nursing Home Residents ◽

Infect Control Hosp ◽

Antibiotic Prescribing ◽

Appropriate Use ◽

We assessed the appropriateness of initiating antibiotics in 49 nursing home (NH) residents receiving antibiotics for urinary tract infection (UTI) using 3 published algorithms. Overall, 16 residents (32%) received prophylaxis, and among the 33 receiving treatment, the percentage of appropriate use ranged from 15% to 45%. Opportunities exist for improving UTI antibiotic prescribing in NH.Infect Control Hosp Epidemiol 2017;38:998–1001

Challenges in Assessing Nursing Home Residents with Advanced Dementia for Suspected Urinary Tract Infections

Journal of the American Geriatrics Society ◽

10.1111/jgs.12070 ◽

2013 ◽

Vol 61 (1) ◽

pp. 62-66 ◽

Cited By ~ 91

Author(s):

Erika D' Agata ◽

Mark B. Loeb ◽

Susan L. Mitchell

Keyword(s):

Nursing Home ◽

Urinary Tract ◽

Nursing Home Residents ◽

Advanced Dementia ◽

Risk Factors for Methicillin-Resistant Staphylococcus Aureus Carriage in Residents of German Nursing Homes

Infection Control and Hospital Epidemiology ◽

10.1086/502098 ◽

2002 ◽

Vol 23 (9) ◽

pp. 511-515 ◽

Cited By ~ 79

Author(s):

H. von Baum ◽

C. Schmidt ◽

D. Svoboda ◽

O. Bock-Hensley ◽

Constanze Wendt

Keyword(s):

Risk Factors ◽

Staphylococcus Aureus ◽

Nursing Home ◽

Nursing Homes ◽

Methicillin Resistant Staphylococcus Aureus ◽

Significant Risk ◽

Nursing Home Residents ◽

Medium Size ◽

Prevalence Survey ◽

Methicillin Resistant

Objectives:To determine the prevalence of and the risk factors for methicillin-resistant Staphylococcus aureus (MRSA) carriage in nursing home residents in the Rhine-Neckar region of southern Germany.Design:Point-prevalence survey.Setting:Forty-seven nursing homes in the region.Participants:All residents of the approached nursing homes who agreed to participate.Methods:After informed consent was obtained, all participants had their nares swabbed, some personal data collected, or both. All swabs were examined for growth of MRSA All S. aureus isolates underwent oxacillin susceptibility testing and polymerase chain reaction for demonstration of the meek gene. All MRSA isolates were typed using pulsed-field gel electrophoresis after digestion with SmaI.Results:Swabs from 3,236 nursing home residents yielded 36 MRSA strains, contributing to a prevalence rate of 1.1%. Significant risk factors for MRSA carriage in the multivariate analysis were the presence of wounds or urinary catheters, limited mobility, admission to a hospital during the preceding 3 months, or stay in a medium-size nursing home. One predominant MRSA strain could be detected in 30 of the 36 MRSA carriers.Conclusions:The prevalence of MRSA in German nursing homes is still low. These residents seemed to acquire their MRSA in the hospital and transfer it to their nursing home. Apart from well-known risk factors for the acquisition of MRSA we identified the size of the nursing home as an independent risk factor. This might be due to an increased use of antimicrobials in nursing homes of a certain size.

Determinants of Urinary Incontinence and Subtypes Among the Elderly in Nursing Homes

Frontiers in Public Health ◽

10.3389/fpubh.2021.788642 ◽

2021 ◽

Vol 9 ◽

Author(s):

Hongyan Tai ◽

Shunying Liu ◽

Haiqin Wang ◽

Hongzhuan Tan

Keyword(s):

Risk Factors ◽

Urinary Incontinence ◽

Nursing Home ◽

Nursing Homes ◽

Spinal Surgery ◽

Short Form ◽

Significant Risk ◽

Nursing Home Residents ◽

International Consultation ◽

History Of

Urinary incontinence (UI) is a common problem among older adults. This study investigated the prevalence of UI in nursing home residents aged ≥75 years in China and examined potential risk factors associated with UI and its subtypes. Data were collected during face-to-face interviews using a general questionnaire, the International Consultation Incontinence Questionnaire Short-Form, and the Barthel Index. A total of 551 participants aged ≥75 years residing in Changsha city were enrolled from June to December 2018. The UI prevalence rate among nursing home residents aged ≥75 years was 24.3%. The most frequent subtype was mixed (M) UI (38.1%), followed by urge (U) UI (35.1%), stress (S) UI (11.9%), and other types (14.9%). In terms of severity, 57.5% had moderate UI, while 35.1% had mild and 7.5% had severe UI. Constipation, immobility, wheelchair use, cardiovascular disease (CVD), and pelvic or spinal surgery were significant risk factors for UI. Participants with a history of surgery had higher risks of SUI (odds ratio [OR] = 4.87, 95% confidence interval [CI]: 1.55–15.30) and UUI (OR = 1.97, 95% CI: 1.05–3.71), those who were immobile or used a wheelchair had higher rates of MUI (OR = 11.07, 95% CI: 4.19–29.28; OR = 3.36, 95% CI: 1.16–9.78) and other UI types (OR = 7.89, 95% CI: 1.99–31.30; OR = 14.90, 95% CI: 4.88–45.50), those with CVD had a higher rate of UUI (OR = 2.25, 95% CI: 1.17–4.34), and those with diabetes had a higher risk of UUI (OR = 2.250, 95% CI: 1.14–4.44). Use of oral antithrombotic agents increased UUI risk (OR = 4.98, 95% CI: 2.10–11.85) whereas sedative hypnotic drug use was associated with a higher risk of MUI (OR = 3.62, 95% CI: 1.25–10.45). Each UI subtype has distinct risk factors, and elderly residents of nursing homes with a history of CVD and pelvic or spinal surgery who experience constipation should be closely monitored. Reducing time spent in bed and engaging in active rehabilitation including walking and muscle strengthening may aid in UI prevention and treatment.

Do Volunteers Make a Difference on Nursing Home Quality Measures?

Innovation in Aging ◽

10.1093/geroni/igaa057.1229 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 382-382

Author(s):

Paul Falkowski ◽

Christopher Kelly ◽

Nancy Kelley

Keyword(s):

Nursing Home ◽

Urinary Tract ◽

Nursing Homes ◽

Quality Measures ◽

Bivariate Analysis ◽

Volunteer Program ◽

Hypnotic Drugs ◽

Feeding Assistance ◽

Abstract The purpose of this study was to explore the relationship between nursing home volunteer programming and quality measures and increase the knowledge base of nursing home volunteer programming in various settings. Fifty-two nursing homes were surveyed using electronic surveys and personal interviews. Questions focused on the organization of the nursing home, characteristics of the volunteer program and volunteer activities. Of the 52 facilities surveyed, 19 were not part of a chain, 37 were in urban settings, and 24 were for-profit entities. Volunteers were used in 46 nursing homes with a mean number of volunteers of 51.7 onsite an average of 4.9 days per week. Bivariate analysis revealed statistically significant correlations (p<.05) between organizational and volunteer programming characteristics and six quality measures (pressure sores, urinary tract infections, depression, use of restraints, falls, use of antipsychotic and hypnotic drugs). Statistically significant (p<.05) inverse relationships were found between volunteers providing individualized activities (e.g., feeding assistance, combing hair, doing nails, and letter writing) and the incidence of urinary tract infections and the use of psychotropic drugs. Multiple regression analysis revealed a statistically significant (p<.05) inverse relationship between personal volunteer services such as combing hair and doing nails and the use of hypnotic drugs and antipsychotic drugs. This study indicates a significant correlation between volunteer programming and quality measure scores. A larger study of these relationships is indicated.