Recommendations for antimicrobial prescribing in aged care

Results from the Aged Care National Antimicrobial Prescribing Survey (AC NAPS) suggest there is room for improvement when it comes to antimicrobial prescribing in aged-care settings.

Following the survey, recommendations include use of microbiological testing to guide prescribing, following national antimicrobial prescribing guidelines, documenting the indication for the antimicrobial and its start, stop and review dates, and monitoring and re-evaluating long-term antimicrobial use.

The survey collected data from residents’ medical records, which are entered into an online AC NAPS database by participating nurses, pharmacists or infection-control nurse consultants.

Aiming to identify local and national prescribing issues and guide antimicrobial stewardship goals, the survey found:

• Almost 10% of residents were prescribed at least one antimicrobial despite only 2.9% having signs or symptoms of infection.
• Nearly 65% of recently prescribed antimicrobials were for residents who did not have documented signs or symptoms of suspected infection in the week before they started treatment.
• Over a quarter (28.3%) of antimicrobials had been administered for longer than six months.
• Topical antimicrobials made up over one-third (36.3%) of antimicrobials prescribed.
• Incomplete documentation was a prominent barrier to proper review of antimicrobial therapy, with the indication, review date or stop date not documented for many prescriptions. The indication for the antimicrobial was not documented in a quarter of prescriptions (25.1%) and the review date or stop date was not documented for 58.9% of prescriptions.
• Skin, soft tissue or mucosal (18.3%), cystitis (16%) and pneumonia (9.4%) were the three most common indications presumed or documented for antimicrobials prescribed.
• Cefalexin (20.3%) was the most commonly prescribed antimicrobial, followed by clotrimazole (19%).
   

An independent review suggests that the discrepancy between the proportion of residents who were prescribed antimicrobials and those who were identified as having signs or symptoms of infection presents a potential target for quality improvement. In the latter group, the proportion of residents whose suspected infections met infection criteria was only 22.1%.

The review also found the observed practice of prolonged antimicrobial use (including for prophylaxis) surprising, suggesting that more frequent review and re-evaluation of antimicrobial therapy is required.

The following recommendations were suggested to improve antimicrobial use in aged-care homes:

• All health professionals should have easy access to endorsed national prescribing guidelines.
• Advance care planning documentation should be consulted, as necessary.
• Clinical care in aged-care homes should meet the Antimicrobial Stewardship Clinical Care Standard.
• The indication for antimicrobial use and start, stop and review dates should all be clearly documented in the resident’s medical record.
• Antimicrobial review plans and actions, including monitoring the resident’s clinical condition, reviewing the results of any investigations and appropriately adjusting any therapy, should be documented in the resident’s medical record and followed.
• Prolonged antimicrobial use should be avoided. If it is required, residents should be closely monitored and their therapy regularly re-evaluated.
• System-wide issues regarding access to, and continuity of, medical care for aged-care home residents should be addressed.
   

To meet Aged Care Quality Standards, Australian aged-care homes must demonstrate that they have infection control practices in place, as well as practices that promote appropriate antimicrobial prescribing and use. It is hoped that more aged-care homes will incorporate antimicrobial stewardship into their quality and safety framework, and actively engage in surveillance and other quality improvement activities.

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