Transcript Slide 1

Antibiotic Use in Care Homes
An audit completed in 2009 by the
Quality, Standards and Effectiveness Directorate
Presented by Rosalind Way
Infection Prevention and the Safe Environment
Nursing Home Conference
16th March 2010
The Crofters Hotel, Garstang
Antibiotic Use in Care Homes
This audit has been designed and carried out by the
Infection Control team, the Medicines Management
department, and with help from the whole of the
Quality, Standards and Effectiveness Directorate at
NHS North Lancashire.
The Issues:
The prevention and control of healthcare-associated infections
(HCAIs) continues to remain a major challenge for the NHS
Guidance suggests that inappropriate use of antibiotics within the care
home environment can have an impact on the levels of Clostridium
difficile (C.diff) and other healthcare-associated infections (HCAIs)
It is recognised that C.diff is the most increasingly common HCAI
which affects primarily the frail and elderly and it is now subject to
mandatory surveillance in the UK
The rise in this HCAI is considered to be a consequence of the
escalating use of ‘broad-spectrum’ antibiotics, especially
cephalosporins and amoxicillin
With C.diff and other HCAIs being considered as antibiotic-resistant they
are therefore more difficult to treat resulting in the likelihood of an
increased use of healthcare resources and ‘excess morbidity and mortality’
The Issues Continued:
It is of particular importance to consider the appropriate use of antibiotics
given that all antibiotics used have an impact on the ‘bacterial flora in the
community where individuals live’, which is of specific significance in
care homes and institutionalised patients
It is widely thought that prudent appropriate prescribing of broad
spectrum antibiotics will reduce the incidence of C.diff. There is strong
evidence that ‘the use of broad-spectrum antibiotics has been strongly
associated with C.diff, especially the third generation cephalosporins
given to the elderly
Antibiotics are increasingly used in the elderly ‘as death approaches’, significantly
the number of patients treated, the antibiotic used and the number of days the
antibiotics are prescribed for, and this is considered to ‘further the spread of
resistant organisms’ which can be transmitted to neighbouring patients resulting in
‘severe infections with adverse outcomes’
Impacts on Patients and Staff
Due to the number of medications that older people tend to prescribed,
particularly those within care homes, it is becoming increasingly
important to monitor and audit this use to determine whether appropriate
prescribing is taking place.
Whilst it is acknowledged that elderly patients may require multiple
prescriptions (polypharmacy) the effects of these need to be closely
monitored.
In addition ‘the harmful consequence of inappropriate prescribing for older people
unnecessarily add to overall health care expenditure and the work load on staff’
Whilst there have been many efforts to reduce the inappropriate use
of antibiotics across the health care community it is still widely
believed that practitioners are continuing to prescribe inappropriately
despite evidence that more care needs to be taken in the
prescription of antibiotics and the length of treatment
Guidance for use of Antibiotics
NHS North Lancashire is committed to the
continued reduction in the incidences of HCAIs and
has produced guidance for prescribers around the
treatment of infections in primary care
By using the lowest effective dose of the most
appropriate antibiotic for the shortest possible time,
patients’ exposure to adverse effects will be
minimised
It is therefore important that antibiotic guidelines
are followed as closely as possible for the majority
of patients
NLTPCT Guidelines aim to limit the use of broad
spectrum antibiotics and restrict treatment course
lengths. Following the guidelines may therefore
help prevent patients being put at risk of HCAIs
Purpose of the Audit
General Aims
•To understand the current use of antibiotics in the elderly
• Whether prescribed antibiotics follow the current Medicines Management
formulary for antibiotic use in certain conditions
• To offer future guidance on antibiotic use within care homes
Detailed Aims
To identify the number of patients within each local nursing and residential
homes who where taking antibiotics 25th February 2009, as a percentage of
overall residency.
To identify who prescribed the antibiotic and if the patient was seen within 3
days prior to commencement of treatment.
To identify the specific antibiotic drug, along with indication for usage and
duration of treatment.
To identify if any swabs for samples where obtained for culture and sensitivity
prior to commencing antibiotic therapy.
Methodology: Making the Audit Effective!
Experiences of Pilot Study in 2008
QS&E Involvement
Easy to use
Meeting to discuss audit
Collate appropriate information
Changes to the audit tool
Good return rate
Changes to audit process
The whole directorate agreed to assist in the
collection of the audits by personally visiting each
care home to ensure the audit results were
collected in as complete a state as possible.
Letters sent to all Care Homes across North Lancashire with Audit Tool
Audit sent to all Care Homes across North Lancashire
Total Questionnaires Sent: 174
Results: Response rates
• 126 Residential and Nursing homes participated (out of
possible 174). Overall Response rate of 72.4%
• 90 Residents in total were being prescribed antibiotics at the
time of the audit
• This translates to around 3-4% of all residents residing at the
Homes at the time of the audit
Results: Antibiotic Split
Over 50% of prescriptions were for Penicillin
Results: Diagnosis/ Complaint Type
Over 90% of prescription reasons were for UTI’s, Chest
Infections or Cellulitis.
Results: Prior Appointments
Almost a quarter of all patients had been seen by a Health
Professional in the three days prior to their actual prescription.
Results: Antibiotic prescribing for chest infections
NHS North Lancashire guidelines offer advice on which antibiotic to use first line and the
duration of treatment.
30
25
20
Telephone
15
Face to face
10
5
0
Penicillin
Cephalosporin
Macrolide
Chest Infection
• 31% were prescribed antibiotics following a telephone consultation which should be
discouraged
• The audit identified seven residents (19.4%) who had been prescribed cephalosporin for
the treatment of chest infections which is not advocated by the PCT
Results: Antibiotic prescribing for chest infections
• It is evident from the audit
that Amoxicillin is the most
commonly used antibiotic;
however the duration of
treatment is not always in line
with recommendations.
• This graph demonstrates the type
of antibiotic prescribed, duration of
treatment and whether or not a
sample was taken prior to an
antibiotic being prescribed
Results: Antibiotic prescribing for UTIs
12
10
8
Unknown or not stated
Telephone
6
Face to face
4
2
0
Trimethoprim
Nitrofurantoin
Cephalosporin
Penicillin
UTI
• The PCT guidelines recommend the first line treatment for UTIs to be
Trimethoprim, second line treatment Nitrofurantoin and third line treatment to be
determined by sensitivity studies.
• The guidelines also recommend treatment duration as three days in women and
seven days in men.
Results: Antibiotic prescribing for chest infections
• The audit demonstrated the duration of
treatment for patients with urinary tract
infections was variable, from three days to
long term, with the most common duration
of treatment being seven days (12 residents).
• There were also 10 residents who where
on long term antibiotic treatment for
recurrent urinary tract infections.
• The audit demonstrates that the PCT
guidelines for the prescribing of urinary tract
infections are not followed
• Urinary tract infections in the elderly may
be misdiagnosed due to symptoms possibly
being indicative of other indications.
• Telephone consultations describing these
symptoms may lead to inappropriate
prescribing
Results: Antibiotic prescribing for skin & soft tissue infections
16
14
12
10
Unknown or not stated
8
Telephone
6
Face to face
4
2
0
Penicillin
Macrolide
Quinolone
Mupriocin Tetracycline
• The PCT guidelines for prescribing for skin infections are to use the Penicillin group
and if allergic, then to use the macrolides: This appears to be common practice,
alongside the recommended duration of treatment.
Discussion and Conclusions
The results of this audit demonstrate that care homes are
predominantly using the formulary guidelines as set by NHS North
Lancashire, though there are improvements that can still be made.
There were a large number of telephone consultations which led to
antibiotics being prescribed and this is considered to be a practice
that should be discouraged as it may lead to inaccurate diagnosis
and ineffective treatment.
It is noted that UTIs are difficult to diagnose, particulary in elderly
patients, but it is nevertheless common that patients are given
‘inappropriate doses, for inappropriate durations, and/or with
inappropriate classes of antibiotics on the basis of diagnosis (or
misdiagnosis) of UTI’
Whilst the evidence from this audit demonstates that the formularies
for use and duration of treatment with antibiotics are being adhered
to, there are improvements that can be made
Discussion and Conclusions
It remains an ongoing issue that antibiotics are often overused
within the elderly population without necessarily looking at the
‘ramifications’ of their use (Schwaber & Carmeli, 2008:350).
Overuse, and misuse, of antibiotics, can have a wider, negative impact
on the health community as discussed previously, including antibiotic
resistance and an increase in the risk of HCAIs such as C.diff.
It is noted that despite national guidelines that aim to reduce the
use of antibiotics to assist in the reduction of HCAIs the overuse
and inappropriate prescribing of antibiotics remains a problem
Discussion Points
Telephone Consultations
When should tests be
administered?
Number of available drugs – support and mentoring
for appropriate use
Difficult to diagnose UTIs
‘Inappropriate doses, for inappropriate durations,
and/or with inappropriate classes of antibiotics on
the basis of diagnosis (or misdiagnosis)’
Phamacists to be involved in
reviewing medications and
producing guidelines has
positive affects
Care home managers educated to
recognise the value of patient medication
reviews
Treatment of UTIs
should ideally be 3 days
Better management of
medications
Community nurses and
pharmacists collaborating to assist
clinicians in realising their
requirements of prescribing and
treatment in elderly patients