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Antimicrobial Use in Long-Term–Care Facilities

  • Lindsay E. Nicolle (a1), David W. Bentley (a2), Richard Garibaldi (a3), Ellen G. Neuhaus (a4), Philip W. Smith (a5) and SHEA Long-Term–Care Committee...

There is intense antimicrobial use in long-term-care facilities (LTCFs), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and the virtual absence of relevant clinical trials. This position paper recommends approaches to management of common infections in LTCF patients and proposes minimal standards for an anti-microbial review program. In developing these recommendations, the position paper acknowledges the unique aspects of provision of care in the LTCF.

Corresponding author
Department of Medicine, Health Sciences Center, 820 Sherbrook St, Room GC430, Winnipeg, Manitoba R3A 1R9, Canada
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1.Nicolle, LE, Bentley, D, Garibaldi, R, Neuhaus, E, Smith, P. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 1996;17:119128.
2.Wayne, SJ, Rhyne, RL, Stratton, M. Longitudinal prescribing patterns in a nursing home population. J Am Geriatr Soc 1992;40:5356.
3.Crossley, K, Henry, K, Irvine, P, Willenbring, K. Antibiotic use in nursing homes: prevalence, cost, and utilization review. Bull NY Acad Med 1987;63:510518.
4.Warren, JW, Palumbo, FB, Fitterman, L, Speedie, SM. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr Soc 1991;39:963972.
5.Zimmer, JG, Bentley, DW, Valenti, WM, Watson, NM. Systemic antibiotic use in nursing homes. A quality assessment. J Am Geriatr Soc 1986;34:703710.
6.Yakabowich, MR, Keeley, G, Montgomery, PR. Impact of a formulary on personal care homes in Manitoba. CMAJ 1994;150:16011607.
7.Pickering, TD, Gurwitz, JH, Zaleznik, D, Noonan, JP, Avorn, J. The appropriateness of oral fluoroquinolone prescribing in the long-term care setting. J Am Geriatr Soc 1994;42:2832.
8.Montgomery, P, Semenchuk, M, Nicolle, LE. Antimicrobial use in nursing homes in Manitoba. Journal of Geriatric Drug Therapy 1995;9:5574.
9.Katz, PR, Beam, TR, Brand, F, Boyer, K. Antibiotic use in the nursing home. Physician practice patterns. Arch Intern Med 1990;150:14651468.
10.Kunin, CM. The responsibility of the infectious disease community for the optimal use of antimicrobial agents. J Infect Dis 1985;151:388398.
11.Nicolle, LE, McIntyre, M, Zacharies, H, MacDonell, JA. Twelve-month surveillance of infections in institutionalized elderly men. J Am Geriatr Soc 1984;32:513519.
12.Magaziner, J, Tenney, JH, DeForge, B, Hebel, JR, Muncier, HL Jr, Warren, JW. Prevalence and characteristics of nursing home-acquired infections in the aged. J Am Geriatr Soc 1991;39:10711078.
13.Finnegan, TP, Austin, TW, Cape, RD. A 12-month fever surveillance study in a veterans' long-stay institution. J Am Geriatr Soc 1985;33:590594.
14.Jackson, MM, Fierer, J, Barrett-Connor, E, Fraser, D, Klauber, MR, Hatch, R, et al. Intensive surveillance for infections in a three-year study of nursing home patients. Am J Epidemiol 1992;135:685696.
15.Nicolle, LE, Strausbaugh, LJ, Garibaldi, RA. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev 1996;9:117.
16.John, JF JrRibner, BS. Antibiotic resistance in long-term care facilities. Infect Control Hosp Epidemiol 1991;12:245250.
17.Norman, DC, Toledo, SD. Infections in elderly persons: an altered clinical presentation. Clin Geriatr Med 1992;8:713719.
18.Castle, SC, Norman, DC, Yeh, M, Miller, D, Yoshikawa, TT. Fever response in elderly nursing home residents: are the older truly colder? J Am Geriatr Soc 1991;39:853857.
19.McAlpine, CH, Martin, BJ, Lennox, IM, Roberts, MA. Pyrexia in infection in the elderly. Age Ageing 1986;15:230234.
20.Orr, PH, Nicolle, LE, Duckworth, H, Brunka, J, Kennedy, J, Murray, D, Harding, GK. Febrile urinary infection in the institutionalized elderly. Am J Med 1996;100:7177.
21.McGeer, A, Campbell, B, Emori, TG, Hierholzer, WJ, Jackson, MM, Nicolle, LE, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19:17.
22.Valenti, WM, Trudell, RG, Bentley, DW. Factors predisposing to oropharyngeal colonization with gram-negative bacilli in the aged. N Engl J Med 1978;198:11081111.
23.Nicolle, LE, McLeod, J, McIntyre, M, MacDonell, JA. Significance of pharyngeal colonization with aerobic gram-negative bacilli in elderly institutionalized men. Age Ageing 1986;15:4752.
24.Nicolle, LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 1993;14:220225.
25.Warren, JW, Tenney, JH, Hoopes, JM, Muncie, HL, Anthony, WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;146:719723.
26.Muder, RR, Brennen, C, Goetz, AM, Wagener, MM, Rihs, JD. Association with prior fluoroquinolone therapy of widespread ciprofloxacin resistance among gram-negative isolates in a Veterans' Affairs medical center. Antimicrob Agents Chemother 1991;35:256258.
27.Lee, YL, Cesario, T, McCauley, V, Flionis, L, Pax, A, Thrupp, L. Low-level colonization and infection with ciprofloxacin-resistant gram negative bacilli in a skilled nursing facility. Am J Infect Control 1998;26:552557.
28.Kapp, MB. Legal and ethical standards in geriatric medicine. J Am Geriatr Soc 1985;33:179183.
29.Mott, PD, Barker, WH. Hospital and medical care use by nursing home patients: the effect of patient care plans. J Am Geriatr Soc 1988;36:4753.
30.Freer, JP, Bentley, DW. The role of antibiotics in comfort care. In: Olson, E, Chichiw, ER, Libow, LS, eds. Controversies in Ethics in Long Term Care. New York City, New York: Springer Publishing Co; 1995:91104.
31.Katz, PR. Antibiotics for nursing home residents. When are they appropriate? Postgrad Med 1993;93:173180.
32.Jones, SR, Parker, DF, Liebow, ES, Kimbrough, RC, Freur, RS. Appropriateness of antimicrobial therapy in long-term care facilities. Am J Med 1987;83:499502.
33.Gross, PA, Barrett, TL, Dellinger, EP, Krause, PJ, Martone, WJ, McGowan, JE Jr, et al. Consensus development of quality standards. Infect Control Hosp Epidemiol 1994;15:180181.
34.Muder, RR, Brennen, C, Wagener, MM, Goetz, AM. Bacteremia in a long-term care facility: a five-year prospective study of 163 consecutive episodes. Clin Infect Dis 1992;14:647654.
35.Hirata-Dulas, CA, Stein, DJ, Guay, DR, Gruninger, RP, Peterson, PK. A randomized study of ciprofloxacin versus ceftriaxone in the treatment of nursing home-acquired lower respiratory tract infections. J Am Geriatr Soc 1991;39:979985.
36.Peterson, PK, Stein, D, Guay, DR, Logan, G, Obaid, S, Gruninger, R, et al. Prospective study of lower respiratory tract infections in an extended-care nursing home program: potential role of oral ciprofloxacin. Am JMed 1988;85:164171.
37.Marrie, TJ, Durant, H, Kwan, C. Nursing home-acquired pneumonia. A case-control study. J Am Geriatr Soc 1986;34:697702.
38.Loeb, M, McGeer, A, McArthur, M, Walter, S, Simor, AE. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159:20582064.
39.Garb, JL, Brown, RB, Garb, JR, Tuthill, RW. Differences in etiology of pneumonias in nursing home and community patients. JAMA 1978;240:21692172.
40.Orr, PH, Peeling, RW, Fast, M, Brunka, J, Duckworth, H, Harding, GK, et al. Serologic study of responses to selected pathogens causing respiratory tract infection in the institutionalized elderly. Clin Infect Dis 1996;23:12401245.
41.McFadden, JP, Price, RC, Eastwood, HD, Briggs, RS. Raised respiratory rate in elderly residents: a valuable physical sign. BMJ 1982;284:626627.
42.Van Scoy, RE. Bacterial sputum cultures. A clinician's viewpoint. Mayo Clin Proc 1977;52:3941.
43.Mylotte, JM, Ksiazek, S, Bentley, DW. Rational approach to the antibiotic treatment of pneumonia in the elderly. Drugs Aging 1994;4:2133.
44.Phillips, SL, Branaman-Phillips, J. The use of intramuscular cefoperazone versus intramuscular ceftriaxone in patients with nursing home-acquired pneumonia. J Am Geriatr Soc 1993;41:10711074.
45.Lee, YL, Thrupp, LD, Friis, RH, Fine, M, Maleki, P, Cesario, TC. Nosocomial infection and antibiotic utilization in geriatric patients: a pilot prospective surveillance program in skilled nursing facilities. Gerontology 1992;38:223232.
46.Eberle, CM, Winsemius, D, Garibaldi, RA. Risk factors and consequences of bacteriuria in non-catheterized nursing home residents. J Gerontol 1993;48:M266M271.
47.Nicolle, LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997;11:647662.
48.Nicolle, LE, Mayhew, WJ, Bryan, L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987;83:2733.
49.Bjork, DT, Pelletier, LL, Tight, RR. Urinary tract infections with antibiotic resistant organisms in catheterized nursing home patients. Infect Control 1984;5:173176.
50.Raz, R, Schiller, D, Nicolle, LE. Does replacement of catheter improve the outcome of patients with permanent urinary catheter and symptomatic bacteriuria. Presented at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 25, 1998; San Diego, CA. Abstract K-105.
51.Ouslander, JG, Greengold, BA, Silverblatt, FJ, Garcia, JP. An accurate method to obtain urine for culture in men with external catheters. Arch Intern Med 1987;147:286288.
52.Nicolle, LE, Harding, GK, Kennedy, J, McIntyre, M, Aoki, F, Murray, D. Urine specimen collection with external devices for diagnosis of bacteriuria in elderly incontinent men. J Clin Microbiol 1988;26:11151119.
53.Bryan, CS, Dew, CE, Reynolds, KL. Bacteremia associated with decubitus ulcers. Arch Intern Med 1983;143:20932095.
54.Graham, S, Sim, G, Laughren, R, Chicoine, J, Stephenson, E, Leche, G, et al. Percutaneous feeding tube changes in long-term–care facility patients. Infect Control Hosp Epidemiol 1996;17:732736.
55.Bennett, RG. Diarrhea among residents of long-term care facilities. Infect Control Hosp Epidemiol 1993;14:397404.
56.Walker, KJ, Gilliland, SS, Vance-Bryan, K, Moody, JA, Larsson, AJ, Rotschafer, JC, et al. Clostridium difficile colonization in residents of long-term care facilities: prevalence and risk factors. J Am Geriatr Soc 1993;41:940946.
57.Esposito, AL, Gleckman, RA. Fever of unknown origin in the elderly. J Am Geriatr Soc 1978;27:498505.
58.Smith, PW, Rusnak, PG. Infection prevention and control in the long-term-care facility. SHEA Long-Term–Care Committee and APIC Guidelines Committee. Infect Control Hosp Epidemiol 1997;18:831849.
59.Smith, PW, Seip, CW, Schaefer, SC, Bell-Dixon, C. Microbiologic survey of long-term care facilities. Am J Infect Control 2000;28:813.
60.Marr, JJ, Moffet, HL, Kunin, CM. Guidelines for improving the use of antimicrobial agents in hospitals: a statement by the Infectious Diseases Society of America. J Infect Dis 1988;157:869876.
61.Echols, RM, Kowalsky, SF. The use of an antibiotic order form for antibiotic utilization review: influence of physicians' prescribing patterns. J Infect Dis 1984;150:803807.
62.Manning, PR, Lee, PV, Clintworth, WA, Denson, TA, Oppenheimer, PR, Gilman, NJ. Changing prescribing practices through individual continuing education. JAMA 1986;256:230232.
63.Evans, RS, Classen, DC, Pestotnick, SL, Lundsgaarde, HP, Burke, JP. Improving empiric antibiotic selection using computer decision support. Arch Intern Med 1994;154:878884.
64.DeVito, JM, John, JF Jr. Effect of formulary restriction of cefotaxime usage. Arch Intern Med 1985;145:10531056.
65.D'Eramo, JE, DuPont, HL, Preston, GA, Smolensky, MH, Roht, LH. The short- and long-term effects of a handbook on antimicrobial prescribing patterns of hospital physicians. Infect Control 1983;4:209214.
66.Parrino, TA. The nonvalue of restrictive peer comparison feedback in containing hospital antibiotic costs. Am J Med 1989;86:442448.
67.Schroeder, SA, Myers, LP, McPhee, SJ, Showstack, JA, Simborg, DW, Chapman, SA, et al. The failure of physician education as a cost containment strategy. Report of a prospective controlled trial at a university hospital. JAMA 1984;252:225230.
68.Bamberger, DM, Dahl, SL. The impact of voluntary vs enforced compliance of third-generation cephalosporin use in a teaching hospital. Arch Intern Med 1992;152:554557.
69.Beers, MH, Ouslander, JG, Rollingher, I, Reuben, DB, Brooks, J, Beck, JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991;151:18251832.
70.Roccaforte, JS, Smith, PW. Antibiotics. In: Smith, PW, ed. Infection Control in Long-Term Care Facilities. 2nd ed. Albany, New York: Delmar Publishers, Inc; 1994.
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Infection Control & Hospital Epidemiology
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