Issue 26 / 21 July 2014

RESIDENTIAL aged care facilities are a “melting pot of everything that leads to poor antimicrobial stewardship” a leading expert has told MJA InSight, as new research exposes systemic failures in antibiotic prescribing in the sector.

Associate Professor Ashley Watson, director of the Infectious Diseases Unit at the Canberra Hospital, said facilities needed resident medical officer (RMO) cover, with supervision by an experienced GP or geriatrician to overcome prescribing problems, suggesting that RMO positions could be part of vocational training programs.

Professor Watson was commenting on new qualitative research published in the MJA examining the processes and culture surrounding antibiotic prescribing at 12 Victorian public aged care facilities. (1)

Interviews with 40 nurses, 15 GPs and six pharmacists revealed that a lack of onsite doctors was a major concern, with infection management driven by nurses.

Some GPs felt confident with nursing assessments, but others raised concerns about rapid staff turnover, lack of experienced nurses and variability of assessment quality, especially from agency or casual nurses.

Reliance on locum doctors was generally thought to be associated with greater use of antibiotics.

One GP told the interviewers it was a “fairly typical situation” for doctors to prescribe antibiotics over the phone for a urinary tract infection, and still not have reviewed the patient 4 months later.

A nurse unit manager told the researchers: “GPs will prescribe something because if they don’t … it could be 3 or 4 days before that resident gets an antibiotic.”

Several GPs expressed a belief that existing therapeutic guidelines were not applicable in aged care, with some saying they believed more aggressive treatment was needed in this population.

Another recurrent theme was the influence of routine dipstick urinalysis on the overprescribing of antibiotics for asymptomatic bacteriuria.

“Despite studies showing that urine dipstick tests are unreliable for identifying older residents with laboratory evidence of UTI [urinary tract infection], half of the participating [facilities] used routine full-ward tests”, the researchers wrote.

One frustrated GP commented: “I have tried to tell every facility … don’t check the urine. You know, of course they are going to have white cell counts, of course they are going to have nitrites … Most of them are incontinent.”

The study found lack of pharmacy support was a problem, with antibiotic prescribing rarely reviewed.

Prescribing decisions were also complicated by fears of lawsuits for undertreatment and by difficulties in assessing patients with behavioural problems and cognitive deficits.

Professor Watson said the study was a “stark expose of the prescribing problems in residential aged care facilities”.

He supported the authors’ call for prescribing algorithms for common problems in residential aged care, and said antimicrobial stewardship programs in area health services should include aged care.

“Telephone prescribing also needs to be better regulated”, he said.

Dr John Ward, a geriatrician and associate professor at the University of Newcastle, said most of the issues could be resolved by nurse practitioners working closely with GPs.

“The problems are the inevitable result of trying to manage very sick people with multiple comorbidities through the visiting general practice system”, he told MJA InSight.

The lack of patient monitoring and information on overall rates of antibiotic prescribing in aged care facilities “is a problem and could probably only be solved by having nurse practitioners who had the time and IT systems to do this”, Dr Ward said.

“Prescribing antibiotics on the basis of urinalysis without considering if the person really has a UTI is a common issue. Again, nurse practitioners are probably the only feasible solution.”

Dr Robert Prowse, director of the department of geriatric and rehabilitation medicine at the Royal Adelaide Hospital, said although the problem of increasing antibiotic resistance was the major concern raised in the study, a significant side issue in aged care facilities was delayed treatment for patients with genuine infections — “a probable contributor to preventable acute hospital admission”.

“Given that these are competing aspects of prescribing, the level of education and training required to solve it is likely to be high”, he said, disagreeing that this could be reflected in a simple treatment algorithm.

1. MJA 2014: 201: 101-105

3 thoughts on “Antibiotic “failures” in aged care

  1. Tacye Todd says:

    In my experience, it is very difficult to avert the prescription of antibiotics for asymptomatic bacteriuria. This problem will only be solved if nursing staff in aged care facilities can be better educated regarding the lack of significance of leukocytes/nitrites, smelly urine, etc in nursing home patients in the absence of other signs/symptoms. Currently, what the nurse wants, the nurse gets, by hook or by crook. If I review a patient in person and conclude that there is no UTI, explaining my reasoning to the staff on duty, the next shift will inevitably express shock and horror that the “UTI” remains untreated, and call out a locum in my absence, who will dutifully prescribe an antibiotic. Having nurse practitioners with prescribing rights would not solve this problem – it might actually make it worse. Education of nursing home staff is the key.

  2. dr samuel bouwer says:

    I  practice medicine as GP visiting nursing homes.The dilemma before my involvement was that nobody maintained the health of patients in aged care facilities. This usually led to “crash and burn”scenarios with the patients ended up in A and E depts, worked up, just to be sent home and deteriorate again. On the other hand was the nursing staff trying to care at best for the patients, and constantly standing in the gap for GP’s when family were concerned about their loved ones. The only solution is for someone to accept responsibility for the patients health- this is best done by the GP. Staff need a mentor and team leader, to set priciples of treatment and bring more insight to staff. We have proven it in our area. The number of prescriptions to patients have reduced, is more justified and a lot more timely, reducing complications and admissions as the GP leads the team and install confidence and provide availabilty, whilst knowing the ins and outs of patients. There is no other model that can provide the same care.The number of patients send to A and E as result of critical illness have reduced significantly.To send junior doctors into nursing homes will just add to more inexperienced prescribing and even more referrals to A and E depts. Nurse practitioners will only be second best to GP’s as aged patients has frail health, mutiple organ failure and prone to lots of complex side effects and complications of diseases and treatment.The numbers of nurse practitioners needed to be trained and willing to be available after hours  will take decades to develop and will never match the existing expertise and availability of the GP workforce.

  3. dr samuel bouwer says:

    GP’s need to take up responsibility of care in AGF’s. Its not an add on when you tired at the end of the day and on your way home. Aged care patients are frail, deserves the same care, dignity and respect  than any other patient. Aged care need to be lifted out of the “Recycle Bin”. It is the fasted growing aged care need! RACGP needs to learn from ACCRM and recognise aged care as a GP specialty, same as rural GP’s, procedural GP’s, cosmetic GP’s etc. The present GP model, superclinic model and corporate GP clinic model does not cater for ACF patients. At present my practice cant be accredited as I am not “mainstream” GP anymore. So I cant employ a registrar, and any other MO gets 1/3 time recognition for time spent in aged care GP work- ridicilous!  I teach medical students gratis as I need to make contact with the next generation. So I get penalised for changing the model from frustrating to a workable and much enjoyable practice and simultaneously improve aged care!! on another note- to look at statistics and prescribing methods in AGF without recognising it as a subgroup of frail and complex patients is unjust. The GP is as usual the only true teamleader and doorkeeper than can justify and take responsibility for a very complex cohort of patients.

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