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

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. Antibiotic Use in Care Homes

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) The prevention and control of healthcare-associated infections (HCAIs) continues to remain a major challenge for the NHS 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:

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 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 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’ The Issues Continued:

Whilst it is acknowledged that elderly patients may require multiple prescriptions (polypharmacy) the effects of these need to be closely monitored. 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. In addition ‘the harmful consequence of inappropriate prescribing for older people unnecessarily add to overall health care expenditure and the work load on staff’ Impacts on Patients and 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

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 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 It is therefore important that antibiotic guidelines are followed as closely as possible for the majority of patients Guidance for use of Antibiotics

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. Purpose of the Audit

Methodology: Making the Audit Effective! 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. Experiences of Pilot Study in 2008 Easy to use Collate appropriate information Good return rate QS&E Involvement Meeting to discuss audit Changes to the audit tool Changes to audit process

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 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 NHS North Lancashire guidelines offer advice on which antibiotic to use first line and the duration of treatment.

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 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 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 Phamacists to be involved in reviewing medications and producing guidelines has positive affects Telephone ConsultationsNumber of available drugs – support and mentoring for appropriate use When should tests be administered? Difficult to diagnose UTIs ‘Inappropriate doses, for inappropriate durations, and/or with inappropriate classes of antibiotics on the basis of diagnosis (or misdiagnosis)’ Better management of medications Care home managers educated to recognise the value of patient medication reviews Community nurses and pharmacists collaborating to assist clinicians in realising their requirements of prescribing and treatment in elderly patients Treatment of UTIs should ideally be 3 days