The overuse of antibiotics in Australian residential aged care facilities requires special attention and guidelines beyond those used in other settings, according to research published in the Medical Journal of Australia.
Dr David Kong and his colleagues from the Monash University Centre for Medicine Use and Safety in Melbourne conducted one-on-one interviews and focus groups with 61 doctors, nurses and pharmacists servicing 12 Victorian residential aged care facilities (RACFs).
"Widespread and inappropriate antibiotic use in RACFs ... is especially concerning given emerging evidence of antibiotic resistance in RACFs", the researchers wrote.
"Older people are particularly susceptible to the adverse consequences of antibiotic use, including Clostridium difficile infection."
There were mixed opinions on nurse-driven infection management, ranging from GPs with confidence in the nursing assessment to nurses themselves reporting lack of knowledge on antibiotic prescribing and many considering "their responsibility in infection management overwhelming, given ... staffing and workload issues".
Rapid staff turnover, lack of experienced nurses and variability of assessment quality were cited as problems with nurse-led antibiotic prescribing.
"Several GPs also raised concerns about overreporting of symptoms and some perceived pressure from nurses to treat residents with antibiotics for minor complaints, leading to unnecessary antibiotic prescribing", the authors wrote.
All participants in the survey agreed that the lack of onsite doctors in RACFs was an important concern, with antibiotics most commonly prescribed over the phone. Additionally, most visiting GPs tended to prescribe antibiotics early rather than "waiting and observing". Routine use of locum services, particularly after hours and on weekends was also considered a factor in the greater use of antibiotics.
None of the RACFs in the survey had any antimicrobial restriction policy, and the Australian Therapeutic guidelines: antibiotic were rarely followed.
"There was no standardised method for infection surveillance across participating RACFs." Because of the frailty of RACF residents, most GPs and nurses interviewed felt that early initiation and the use of broader spectrum antibiotics was warranted, the researchers said. This perception could be driving inappropriate antibiotic overuse.
"Difficulties in assessing residents with behavioural problems or cognitive deficits also complicated the prescribing decisions."
Pressure from family members, often with unrealistic expectations about antibiotic efficacy, was also a factor in prescribing behaviours.
The findings reflect the need for targeted initiatives to optimise antimicrobial use (i.e. antimicrobial stewardship) in this setting, the authors concluded.
"Further intervention should consider the limitations of institutional resources and health care professionals' working relationships within this environment. Importantly, this study has highlighted areas and modifiable factors that will assist in developing future antimicrobial stewardship interventions."