Issue 10 / 19 March 2012

EFFORTS to keep multiresistant infections at bay are being hampered by inappropriate use of antibiotics in residential aged care facilities, according to new research. (1)

The study of recorded infectious illness and antimicrobial prescribing in four Melbourne residential aged care facilities (RACFs), published in the latest MJA, found that about 40% of suspected infections treated with antibiotics did not meet the McGeer criteria for clinical infection. (See Appendix, [1])

Inappropriate antimicrobial use was most likely in urinary tract infection (including 28 episodes of prescribing for asymptomatic bacteriuria), upper respiratory tract infection (URTI), and bronchitis.

All episodes of antimicrobial prescribing for URTI and nearly all for bronchitis occurred without further confirmation of bacterial aetiology, contrary to national Antibiotic Therapeutic Guidelines.

Also, in more than 60% of suspected infections treated with antibiotics there was no documentation that clinical specimens were obtained.

“The prescribing of antimicrobials for asymptomatic bacteriuria is of particular concern because the emergence of multiresistant organisms in the RACF setting is often attributable to extensive or inappropriate use of antimicrobials and may result in the RACFs becoming a reservoir for multiresistant organisms”, the authors wrote.

They acknowledged that their findings reflected the difficulties in clinically assessing this patient population.

“Routine ordering of microbiological tests is not always practical in the RACF setting. This reflects difficulties in obtaining specimens, the involvement of multiple laboratories servicing these institutions and the lack of timely results that inform prescribing”, they wrote.

Professor Richard Reed, head of the discipline of general practice at Flinders University, agreed. “Access to chest radiographs for patients with suspected respiratory infections is also very difficult, often requiring calling an ambulance for people with decreased mobility or cognitive impairment”, he told MJA InSight.

“In some cases, infections do not present in the classic way but, instead, by changes in behaviour. Nursing home staff turnover may impede timely observation of these changes as [new staff] do not know baseline behaviour. Delays in communication with GPs may further delay timely treatment”, he said.

Professor Reed said creating dedicated teams to provide primary care services to RACF patients could help reduce the problem. Such teams were used extensively in some parts of the US, as well as in Adelaide through the General Practice Network South.

Adelaide GP and chair of the AMA’s healthy ageing committee, Dr Peter Ford, said the complexity of the patient cohort in RACFs created challenges for treating doctors.

“These patients often have diminished immunity and a gamut of chronic health problems including cardiac failure, dementia and diabetes”, he said.

Doctors working in this setting had only the limited resources contained in their “black bags and prescription pads”, Dr Ford said.

The design and structure of RACFs could be improved to reduce the spread of infection, and better staffing levels and better education of staff were also needed. “One would also want to see an optimal level of vaccinations for things like influenza and pneumococcus”, Dr Ford said.

The MJA researchers said periodic surveillance of antimicrobial resistance patterns might be feasible in the RACF setting.

“Work is required in developing policies to prevent infection among RACF residents, to explore the epidemiology of antimicrobial resistance in clinical infections, and in developing antimicrobial stewardship initiatives appropriate to this primary care setting”, the authors wrote.

An accompanying editorial called for the creation of an antimicrobial resistance management body to coordinate efforts. (2)

The editorial said a further logical extension was to establish an Australian Centre for Disease Control “to deal with the broad range of infectious disease threats … with strong professional leadership to support state and territory activities and coordinate surveillance, preparedness and timely responses to national health crises”.

– Amanda Bryan

1. MJA 2012; 196: 327-331
2. MJA 2012; 196: 292-293

Posted 19 March 2012

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