Antimicrobial Use in Long‐Term–Care Facilities • Author(S): Lindsay E

Antimicrobial Use in Long‐Term–Care Facilities • Author(s): Lindsay E. Nicolle , MD, David W. Bentley , MD, Richard Garibaldi , MD, Ellen G. Neuhaus , MD, Philip W. Smith , MD Source: Infection Control and Hospital Epidemiology, Vol. 21, No. 8 (August 2000), pp. 537-545 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/501798 . Accessed: 06/06/2011 18:37 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at . http://www.jstor.org/action/showPublisher?publisherCode=ucpress. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaborating with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology. http://www.jstor.org Vol. 21 No. 8 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY 537 SHEA Position Paper Antimicrobial Use in Long-Term–Care Facilities Lindsay E. Nicolle, MD; David W. Bentley, MD; Richard Garibaldi, MD; Ellen G. Neuhaus, MD; Philip W. Smith, MD; the SHEA Long-Term–Care Committee ABSTRACT There is intense antimicrobial use in long-term–care facil- absence of relevant clinical trials. This position paper recom- ities (LTCFs), and studies repeatedly document that much of mends approaches to management of common infections in this use is inappropriate. The current crisis in antimicrobial LTCF patients and proposes minimal standards for an anti- resistance, which encompasses the LTCF, heightens concerns of microbial review program. In developing these recommenda- antimicrobial use. Attempts to improve antimicrobial use in the tions, the position paper acknowledges the unique aspects of LTCF are complicated by characteristics of the patient popula- provision of care in the LTCF (Infect Control Hosp Epidemiol tion, limited availability of diagnostic tests, and the virtual 2000;21:537-545). This position paper outlines concerns regarding, and ly. Although inappropriateness of antimicrobial use is a adverse consequences of, inappropriate antimicrobial use in problem in all settings,10 the intensity of antimicrobial use long-term–care facilities (LTCFs) and recommends and the additional concerns noted below warrant careful approaches to promote the rational use and limit the potential attention toward improving prescribing practices in LTCFs. adverse effects of antimicrobials in this high-risk setting. This paper updates the guideline previously published in 1996.1 Adverse Consequences of Inappropriate Antimicrobial Use STATEMENT OF THE PROBLEM Because infections occur frequently in LTCFs,11-15 Intensive Use of Antimicrobials in LTCFs residents often are exposed to antimicrobial agents. These Antimicrobials are among the most frequently pre- agents carry with them a risk of adverse consequences scribed pharmaceutical agents in LTCFs, accounting for even when they are prescribed optimally. Elderly nursing approximately 40% of all systemic drugs prescribed.2,3 The home (NH) residents are at increased risk of drug-related point prevalence of systemic antibiotic use in LTCFs is adverse effects by virtue of the physiological effects of approximately 8%,4,5 with a likelihood of 50% to 70% that a aging on kidney, liver, and cerebral function, the presence resident will receive at least one course of a systemic of comorbid medical illnesses, and the concurrent use of antimicrobial agent during a 1-year period.4,6 In addition, other drugs to treat these diseases. Probably the most topical antimicrobial drugs also are frequently prescribed important adverse outcome of inappropriate antimicrobial in LTCFs, although the extent of use of these agents has use in LTCFs is the promotion of antimicrobial resistance been less well studied.6 in this high-risk population and the increased opportunities for transmission of resistant organisms to other patients in Inappropriate Use of Antimicrobials in LTCFs the LTCF.16 Because residents of LTCFs frequently are A substantial proportion of the antimicrobial use in treated with multiple drugs,2,6 the addition of antimicrobials LTCFs is considered inappropriate. Recent reports indicate increases the potential for harmful drug interactions in that 25% to 75% of systemic antimicrobials4,5,7-9 and up to addition to the adverse drug effects directly associated 60% of topical antimicrobials8 are prescribed inappropriate- with the antimicrobials prescribed. In addition, the From the Department of Medicine (Dr. Nicolle), Health Sciences Center, Winnipeg, Manitoba, Canada; the Veterans Affairs Medical Center (Dr. Bentley), St Louis, Missouri; University of Connecticut Health Center (Dr. Garibaldi), Farmington, Connecticut; Rockville General Hospital (Dr. Neuhaus), Vernon, Connecticut; University of Nebraska Medical Center (Dr. Smith), Omaha, Nebraska. Address reprint requests to Lindsay E. Nicolle, MD, Head, Department of Medicine, Health Sciences Center, 820 Sherbrook St, Room GC430, Winnipeg, Manitoba R3A 1R9, Canada. SHEA Long-Term–Care Committee members include Suzanne Bradley, MD; Sky R. Blue, MD; R. Brooks Gainer, MD; Kent Crossley, MD; Carol V. Freer, MD; Nelson Gantz, MD; Lindsay E. Nicolle, MD (chair), Andrew E. Simor, MD; Philip W. Smith, MD; Larry J. Strausbaugh, MD; Lauri Thrupp, MD. 00-SR-126. Nicolle LE, Bentley DW, Garibaldi R, Neuhaus EG, Smith PW, the SHEA Long-Term–Care Committee. Antimicrobial Use in Long- Term–Care Facilities. Infect Control Hosp Epidemiol 2000;21:537-545. 538 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY August 2000 increased use of antimicrobials contributes substantially and peritoneal dialysis and hemodialysis. All of this increas- to costs. Excess costs associated with inappropriate es the frequency of infection in residents. Many LTCFs antimicrobial use cannot be sustained in the current cli- now offer intravenous antibiotics, making it possible for mate of cost containment and rationing of resources. physicians to prescribe the array of broad-spectrum agents available for hospitalized patients. This may promote the Problems in Optimizing Use of induction of antimicrobial-resistant infections in the LTCF. Antimicrobials in LTCFs Finally, a substantial problem in providing guidelines There are many difficulties in promoting the optimal for the optimal use of antimicrobials in LTCFs is the use of antimicrobials in LTCFs. First, the clinical diagnosis absence of relevant comparative clinical trials to define the of infection frequently is imprecise. Hearing and cognition most effective management of residents with probable or often are impaired in residents of LTCFs, and symptoms documented infections. The difficulties in clinical and may not be expressed or interpreted correctly. Chronic microbiological diagnosis complicate the performance of comorbid clinical conditions may obscure the signs or these trials. Restrictive entry criteria, such as requiring a symptoms of infection. Infectious illnesses may not present sputum specimen, limit the generalizability of studies. with classic clinical findings.17 The febrile response may be Thus, recommendations regarding the use of anti- relatively impaired, and there is an increased frequency of microbials in LTCFs are limited, because they are based on afebrile infection.18,19 Alternatively, fever with no clearly clinical criteria targeted for younger populations with less identified source is frequent.11-14,20 Illness may present with complex medical problems, drug selection must be made vague systemic symptoms such as confusion, diminished with limited assistance from diagnostic tests, and virtually appetite, or low-grade fever rather than localizing findings. no data are available from relevant clinical trials to define There are limitations in resources to support physician (or optimal treatment regimens. other health professional) clinical assessment. Clinical criteria for the diagnosis of infections have been identified pri- Use of Quinolones in LTCFs marily for younger populations with limited comorbidities, Ciprofloxacin initially was introduced to North and in most cases their validity in the LTCF population has America in 1987. Since its release, it has been widely used not been assessed.21 The uncertainties in clinical diagnosis in NHs,7 as have subsequent quinolones. These agents are contribute to inappropriate use of empirical antimicrobials. used because they allow oral therapy with an agent with Limited use of laboratory and radiological tests also good bioavailability, are easily administered by once- or contributes to less than optimal use of

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