Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis

Michael Pulia,Michael Kern,Christopher J Crnich,Emmanuel Sampene,Manish N Shah,Rebecca J Schwei

doi:10.1186/s13756-018-0364-7

Michael Pulia, Michael Kern + Show 4 more

Open Access

https://doi.org/10.1186/s13756-018-0364-7

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Abstract

BackgroundThe pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate. The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation.MethodsThis was a retrospective, cross-sectional multi-center study that occurred in five NHs in southern Wisconsin between January 2013 and September 2014. All NH residents with an antibiotic prescribing events for suspected lower respiratory tract infections (LRTI), skin and soft tissue infections (SSTI), and urinary tract infections (UTI), initiated in-facility, from an emergency department (ED), or an outpatient clinic were included in this sample. We assessed appropriateness of antibiotic prescribing using the Loeb criteria based on documentation available in the NH medical record or transfer documents. We compared appropriateness by setting and infection type using the Chi-square test and estimated associations of demographic and clinical variables with inappropriate antibiotic prescribing using logistic regression.ResultsAmong 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the ED. Inappropriate antibiotic prescribing for urinary tract infections differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 (95% CI: 1.64–5.44, P < .001) times increased odds of inappropriate use.ConclusionsAntibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings. Further research is needed to characterize antibiotic prescribing patterns for patients managed in these settings as this likely represents an important, yet under recognized, area of consideration in attempts to improve antibiotic stewardship in NHs.

Highlights

The pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria
Commensurate attention has been given to improving antibiotic stewardship within nursing homes (NH) [7,8,9,10], little is known about the antibiotic prescribing for NH residents initiated in outpatient clinics or the emergency department (ED)
Through this cross sectional study of antibiotic prescribing events for NH residents, we have identified important differences in prescribing patterns between those initiated in-facility and other outpatient settings (clinic, Table 2 Inappropriate antibiotic use stratified by location of antibiotic initiation and infection type (n = 735)

Summary

Introduction

The pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate [2, 3]. This inappropriate use is in spite of existing guidelines released by the Infectious Disease Society of America that provide specific recommendations on how to evaluate and treat infection in NHs [4]. The aims of this study were to characterize the initiation of antibiotic therapy for NH residents by setting, infection type, and antibiotic class and compare prescribing patterns and appropriateness between settings from the NH perspective

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