Original Study
Antibiotic Prescribing In Dutch Nursing Homes: How Appropriate Is It?

https://doi.org/10.1016/j.jamda.2014.10.003Get rights and content

Abstract

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.

Section snippets

Study Setting

The study was conducted in 10 NHs participating in a research project aimed at rationalizing antibiotic prescribing in LTCFs: the Improving Rational Prescribing of Antibiotics in Long-term Care Facilities (IMPACT) study.18 The current study comprises a baseline measurement, ahead of any intervening to improve antibiotic prescribing. Table 1 summarizes the recruitment of study facilities. Eight NHs were located in urban areas, and 2 were located in rural areas, all in the central-west region of

Demographics

The 10 participating NHs had a mean of 163 beds per facility (range: 67–228) and a mean bed occupancy of 97% (range: 93%–100%). On average, 51% of beds were for psychogeriatric patients (ie, mostly with dementia; range: 0%–78%), 32% for somatic patients (ie, with physical disability; range: 17%–72%), and 17% for rehabilitation patients (range: 0%–35%). In total, 707 consultations for 525 residents were registered by 62 physicians. Of these consultations, 406 (57%) were for UTI, 247 (35%) for

Discussion

We investigated the appropriateness of decisions to prescribe or withhold antibiotics in Dutch NHs and found that 76% of these decisions were appropriate. Treatment decisions were less often appropriate for UTI compared with decisions for RTI and SI. Decisions were more often appropriate when antibiotics were withheld compared with when antibiotics were prescribed, which indicates that overprescribing occurs more frequently than underprescribing. The most common clinical situations in which

Conclusion

Our findings suggest that more appropriate treatment decisions can lead to decreased antibiotic consumption in NHs in the Netherlands, as inappropriate treatment decisions were more often related to overuse than underuse of antibiotics. Appropriateness of treatment decisions can be improved by focusing on reduced antibiotic prescribing for asymptomatic bacteriuria, and to a lesser extent for viral RTI. Interventions directed at these conditions, thereby taking into account the many factors

Acknowledgments

We acknowledge the following persons: Philip D. Sloane and Sheryl Zimmerman (University of North Carolina at Chapel Hill), for their contribution to the conception and design of the IMPACT study; Sarah M.M.M. Doncker, for her contribution to data collection; Giselka Gutschow, for her contribution to data processing; and Jochen W. Cals, Susanne E. Geerlings, Marlies E.J.L. Hulscher, Marianne A.B. van der Sande, Paul B.M. Went, Ellen E. Stobberingh, John E. Degener, Inge C. Gyssens, Theo J.M.

References (36)

  • P. Montgomery et al.

    Antimicrobial use in nursing homes in Manitoba

    J Geriatr Drug Ther

    (1995)
  • R.L. Stuart et al.

    Antibiotic use and misuse in residential aged care facilities

    Intern Med J

    (2012)
  • C.J. Lim et al.

    Surveillance of infection burden in residential aged care facilities

    Med J Aust

    (2012)
  • M. Loeb et al.

    Antibiotic use in Ontario facilities that provide chronic care

    J Gen Intern Med

    (2001)
  • E.P. Peron et al.

    Another setting for stewardship: High rate of unnecessary antimicrobial use in a Veterans Affairs long-term care facility

    J Am Geriatr Soc

    (2013)
  • E. D’Agata et al.

    Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections

    J Am Geriatr Soc

    (2013)
  • P. Rotjanapan et al.

    Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes

    Arch Intern Med

    (2011)
  • P. Vergidis et al.

    Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities

    J Am Geriatr Soc

    (2011)
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    The authors declare no conflicts of interest.

    This study was funded by a grant from The Netherlands Organisation for Health Research and Development (ZonMw, The Hague; grant number 205 100011).

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