Antimicrobial use in aged care

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I'm Dhineli Perera, your host for this episode, and it's a pleasure to be speaking to Associate professor Noleen Bennett. Noleen is a Senior infection control consultant at the Victorian Healthcare Associated Infection Surveillance System. Noleen and her team write about the results from the 2018 Aged Care National Antimicrobial Prescribing Survey. Noleen, welcome to the program.

Thank you for inviting me, especially during Antibiotic Awareness Week.

Yes, it's very appropriate. Noleen, can you start by telling us about why the aged-care sector has been a focus area for this survey?

Well, I think it's fair to say residents in our aged-care homes are vulnerable to acquiring infections and this is because of multiple reasons – advanced age, underlying disease, impaired mental and functional status. They also have close contact with potentially infected or colonised staff and other residents, and they may require frequent or prolonged hospitalisation.

So that's multifactorial, I guess. Your article touches on the role played by aged-care homes in the community hospital transmission of drug-resistant organisms. Could you expand on this notion for us?

Sure. Aged-care homes play a significant role and it's for two combined reasons, if you like. One is that the rates of antimicrobial resistance found in our aged-care homes is as high as, or even higher, than rates in hospitals for some organisms. And the second reason is that our aged-care home residents frequently present to the emergency departments and have increased lengths of stay in both the emergency departments and our hospitals.

Okay, so they're just basically exposed more than your average community resident, if you say.

That's right.

Before we discuss the survey results, it is worth pointing out that this survey was conducted as a point prevalence survey. Can you briefly describe how this is carried out and what are the pros and cons with this approach?

Yeah, sure. A point prevalence survey looks to measure the proportion of a population that has the condition or surveillance event at a specific point in time. And it looked to measure two important proportions. They were the proportion of residents that have signs and/or symptoms of an infection on a single day, and the proportion of residents who were prescribed an antimicrobial on a single day.

Now the advantages of a point prevalent survey are that they are usually less time consuming, less expensive, and operationally less complex than other survey designs. But you do need to interpret any results with caution because these surveys are snapshots only. They might not pick up on rare or short infections, which affect few persons at a given point in time. And they also may vary because of the season in which they're undertaken.

So for example, the Aged Care NAPS is conducted during winter, so certain respiratory infections may be frequently reported.

Yeah, okay. Onto the results, almost 10% of residents were prescribed at least one antimicrobial with about 3% actually having signs or symptoms of infection. I guess lacking a true indication for an antimicrobial must be one of the most important, but difficult, potential targets for improvement. Can you tell us more about the recommendations in this area that have come out of the survey results, and perhaps in the context of UTIs?

Sure. Well, I think you've picked up on it there, and it's important to note first that it actually can be really challenging to formulate an accurate and appropriate diagnosis of infection in an elderly person, and this is for several reasons. They often present with altered signs and symptoms to infectious diseases that can have long complex histories.

Micro specimens are not always taken because they're difficult to obtain. So indication, not surprisingly, is not always documented. That said, at a national level, there has been some discussion about further developing and promoting the use of evidence-based infection assessment tools to support the staff working in these aged-care services in making a diagnosis.

An example of that is a really helpful flowchart in the Therapeutic Guidelines Antibiotic that outlines how to assess, and then treat if necessary, aged-care facility residents with a suspected UTI.

Okay, so that would be one of the areas to look into, I guess, as a prescriber, if you're frequently prescribing antimicrobials for UTIs in this population?

Absolutely, cannot recommend it enough. Yep.

Excellent. And little to no documentation was noted for about 65% of recently prescribed antimicrobials. What exactly should prescribers be documenting and where?

Well, when an antimicrobial is prescribed, now this is regardless of where this occurs, whether it's a primary, secondary or tertiary healthcare setting, the indication, or the reason for commencing the antimicrobial, the drug name, the dose, the route of administration, the intended duration and review plan should be documented in the individual's health record.

Now, in a residential aged-care facility, these key prescribing elements should be clearly documented on the national residential medication chart or the equivalent chart.

Okay, excellent. Now, extended duration of therapy is a perennial problem in the world of antimicrobials. About 28% of antimicrobials in this survey had been prescribed for more than six months. Why do you think this is occurring in the aged-care sector?

Well, it's concerning that it is occurring. I think it's because stop or review dates are frequently and consistently not documented. I think the clinical aged-care staff, with absolute highest respect to these staff members, may not be knowledgeable or feel empowered enough to question the value of continuing or discontinuing an antimicrobial. And the prescribers are usually off site, and so they're somewhat reliant on clinical aged-care staff to assess and communicate the need for ongoing or discontinuation of therapy.

Okay, so there's a bit of a gap, I guess then, between both the staff that see the patient day to day and then the prescriber as well?

Correct. Yeah.

I guess bridging that gap is maybe a step in the right direction in addressing this. Over a third of antimicrobials prescribed were topical, so that's creams and lotions and things like that. Can you please expand on why this is a significant concern and what are some common misconceptions about topical antimicrobials?

Okay, well, yes, it is concerning because there's limited evidence to support the widespread prophylactic or therapeutic use of topical antimicrobials. And I think that's where a lot of our clinical staff are unaware of this.

The other thing is the misuse of topical antimicrobials contribute to increasing rates of antimicrobial resistance, the same as other antimicrobials administered via other routes. Topical antimicrobials can also lead to local hypersensitivity reactions. So there's a few reasons there why we need to address this use of topical or, you know, one-third of all descriptions being used for topical antimicrobials.

Okay, and then cystitis and pneumonia were both identified as priority infections in the aged-care sector. What are some common issues with antimicrobial prescribing for these conditions?

Well, the most commonly prescribed antimicrobial for cystitis was cephalexin. The most commonly prescribed antimicrobial for community-acquired pneumonia was amoxicillin and clavulanic acid. Now this is concerning because these two antimicrobials are actually not the first preferences as recommended by the latest Therapeutic Guidelines.

For both acute, uncomplicated cystitis and continuous prophylaxis of recurrent UTIs, the first preference is in fact trimethoprim. And for community-acquired pneumonia, it's amoxicillin. So here we have antimicrobials being commonly prescribed that we need to look at as to why they've been prescribed as first preference.

And it could be just more of a habit, rather than intentionally stepping to a second-line agent. So I guess perhaps increased awareness about the updates in the new guidelines would be useful to prescribers, too.

Absolutely.

Finally, Noleen, what would be your top three enablers and barriers to aged-care homes incorporating antimicrobial stewardship into their quality and safety framework?

Well, aged-care homes do face unique barriers to implementing an AMS program. There's prescribers, the pharmacist, and the diagnostic laboratory services are offsite, so there's not easy access to expert advice. There's variation in access to technology and data expertise. We've picked up on that in working with the aged-care sector on AC NAPS, and collecting and submitting data.

And there's also a lack of staff training on antimicrobial stewardship, or dedicated time for these activities. If I speak about the enablers, I'm going to count the new aged-care quality standards as an enabler. Since July 2019, accreditors will be checking for the first time that aged-care services can demonstrate practices to promote appropriate antibiotic prescribing and used to support optimal care.

This is important because this standard is actually and ultimately the governing body of an aged-care service's responsibility. So we can't just dismiss it. We've got to be looking at antimicrobial stewardship in our aged-care services. The other enabler is that Center for Disease Control has published a really useful document, and it's recommended by the Australian Commission on Safety and Quality in Healthcare as a self-assessment tool, and it's titled The Core Elements of Antibiotic Stewardship for Nursing Homes. It outlines a framework that our aged-care services can use for implementing an AMS program in this setting.

I think that framework is really helpful because I can well imagine for staff currently in our aged-care homes, it's a new concept, this AMS, and it could be overwhelming to think that they need to be implementing it. So this provides an easy-to-use framework that I would recommend they look at.

Excellent. Yeah, that sounds like a really useful tool. I hadn't heard of that. And is that just freely available on the CDC website?

It is. It is. If you simply type in "Core Elements of Antibiotic Stewardship for Nursing Homes," you'll find it.

Fantastic. That's unfortunately all the time we've got for this episode. Thanks so much for joining us today, Noleen. It's been a pleasure.

Thank you for inviting me.

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The views of the hosts and guests on that podcasts are their own, and may not represent Australian Prescriber or NPS MedicineWise. I'm Dhineli Perera and thanks for joining us on the Australian Prescriber Podcast.