Antimicrobial use in Residential Care Facilities and Nursing Homes

Antibiotic treatment guidelines

Urinary Tract Infections

UTIs are the most common infection treated with antibiotics in residential care facilities.
50-70% of frail elderly residents have asymptomatic bacteriuria so it is important only to treat symptomatic patients rather than MSU reports.
Dipsticks are not a useful guide to management in assessing evidence of UTI for residents >65yrs in residential care and are not recommended.
It is not advisable to send a MSU unless a patient is symptomatic. See Useful guidance on interpreting MSU results in nursing home patients with or without a catheter.

Respiratory Tract Infections

Skin and Soft Tissue Infections

Other

Clostridioides difficile infection.

Useful Information

Successive HALT studies in long-term care facilities (in 2010, 2012, 2013 & 2016) have shown that Irish Nursing home residents are prescribed far more antibiotics than their European counterparts. Antibiotics are most commonly prescribed for urinary tract infection (UTI), respiratory tract infection (RTI) and skin and soft tissue infection (SSTI).

These findings were echoed and expanded upon in an antibiotic point prevalence survey conducted by CHO-based antimicrobial pharmacists in HSE Older Persons residential care facilities between October and December 2020 (for CHO 1,3,4,5,8) which was expanded to CHO 2,6,7,9 between April-August 2021. This study found that:

12% of residents were prescribed antibiotics on the day of survey (compared to a European rate of 4.9% in 2016).
6.3% of residents were prescribed prophylactic antibiotics, mainly for recurrent UTI (compared to a European rate of 1.5% in 2016).
Prophylactic prescriptions accounted for 50% of all active antibiotic prescriptions and 66% of those were in excess of 6 months duration.
Report of the findings of the Point Prevalence Survey of Antimicrobial Use in HSE Older Persons Residential Care Facilities 2021 (CHO 1,3,4,5,8)
Report of the findings of the Extended Point Prevalence Survey of Antimicrobial Use in HSE Older Persons Residential Care Facilities 2021 (includes CHO 2,6,7,9)

A further study was conducted in a sample of HSE Mental Health residential care facilities by CHO-based antimicrobial pharmacists between November 2021 and January 2022 (CHO 1, 4, 5, 6, 7, 8, 9). This study found that:

6.3% of residents were prescribed antibiotics on the day of survey.
3.3% of residents were prescribed prophylactic antibiotics, accounting for over 50% of total antimicrobial use.
Report of the findings of a Point Prevalence Survey of Antimicrobial Use in HSE Mental Health Residential Care Facilities 2022.pdf (size 2 MB)

Toolkit for AMS in residential care facilities (RCFs)

Multi-drug Resistant Organisms – including CPE

In October 2017, the Minister for Health declared a public health emergency in relation to CPE. This GP CPE toolkit contains a number of documents including guidelines for general practice, guidance for healthcare staff visiting patients at home, a set of facts sheets on CPE and patient information.

Safe Prescribing

Patients in nursing homes or other residential care facilities may be particularly frail or have other co-morbidities. Presence of polypharmacy, dysphagia, renal impairment and antibiotic resistance can be common. These factors are important considerations in selecting the optimal antibiotic agent and dosing regimen as they may influence the effects, side-effects and frequency of drug interactions of any antibiotic prescribed.

Reviewed Oct 2022