Antimicrobial use in aged care: the need for action

The prevalence of antimicrobial resistance in Australian aged-care homes, combined with high levels of inappropriate antibiotic use, support the need for increased action both in activities to improve antimicrobial stewardship and in infection prevention and control.

The Antimicrobial Use and Resistance in Australia (AURA) Surveillance System is coordinated by the Australian Commission on Safety and Quality in Health Care (the Commission) and funded by the Australian Government Department of Health and the states and territories. The AURA Surveillance System collects data on the appropriateness of antibiotic use and antimicrobial resistance in Australian aged-care homes and multipurpose services; in this article these are referred to as aged-care facilities.

AURA 2019: Third Australian report on antimicrobial use and resistance in human health (AURA 2019), which was recently released by the Commission, shows inappropriate antimicrobial use and antimicrobial-resistant organisms are safety issues for aged-care home residents.^[1]

Rates of antimicrobial resistance found in aged-care facilities are as high as, or higher than, rates in hospitals for some organisms. This makes aged-care facilities particularly important reservoirs for antimicrobial-resistant bacteria, and their residents at increased risk of infections caused by them.

In facilities with frequent and inappropriate antimicrobial use, there is an increased risk for all residents of acquiring an antimicrobial-resistant infection. Even residents who are not receiving antimicrobial therapy are vulnerable, because of the potential for infections to spread within aged-care facilities. Other high-risk factors in aged-care facilities include:

• a close living environment and frequent contact between residents, visitors and staff who may be infected;
• residents moving relatively frequently in and out of hospitals;
• higher use of invasive devices such as urinary tract catheters;
• higher levels of colonisation with multidrug-resistant organisms.
   

The Aged Care National Antimicrobial Prescribing Survey (AC NAPS), which forms part of AURA, is conducted by the National Centre for Antimicrobial Stewardship. An increasing number of Australian aged-care homes and multipurpose services have been participating in AC NAPS on a voluntary basis since it commenced in 2015.^[2]

In 2017, approximately 10% of aged-care facilities nationally participated in AC NAPS. The involvement of these facilities in AC NAPS provides them with substantial data to inform their infection control and prevention and antimicrobial stewardship practices. The AC NAPS shows consistently high rates of antimicrobial use for unconfirmed infections; antimicrobial use for long periods of time; the widespread use of topical antimicrobials such as antifungal creams; and gaps in recording the reason for using antimicrobials or the length of time they should be taken.

In 2017, more than half (55.2%) of the antimicrobial prescriptions were for residents with no signs and/or symptoms of infection in the week prior to the start date, compared with 45.4% in 2016.

The most frequently used antimicrobials reported by AC NAPS contributors are cefalexin and clotrimazole (a topical antimicrobial). Cefalexin is not recommended as first-line treatment for either urinary or skin infections. In both 2016 and 2017, almost one-third of antimicrobial prescriptions were for topical use. Most minor skin infections, for which clotrimazole is understood to be used either therapeutically or prophylactically in aged-care homes, are self-limiting and resolve with standard skin hygiene care. If an antibiotic is required, topical antibiotics are only appropriate for patients with minor localised areas of impetigo.

Of all antimicrobial prescriptions dispensed for residents with signs and/or symptoms of infection in 2017, only 18.4% met internationally recognised infection definitions, compared with 36.5% in 2016.^[3]

The three most common reasons, when recorded, for prescribing antimicrobials in 2017 were cystitis (17.1%), pneumonia (10.9%) and non-surgical wound infections (5.1%).

Data on antimicrobial resistance in aged-care home residents is also available from the AURA Surveillance System. This data indicates that the proportion of methicillin resistance in Staphylococcus aureus (MRSA), which was 32.1% in 2017, is higher in aged-care homes than in other settings.

The prevalence of antimicrobial resistance in Australian aged-care homes, combined with high levels of inappropriate antibiotic use, support the need for increased action both in activities to improve antimicrobial stewardship and also in regard to infection prevention and control through improved hand hygiene and cleaning of surfaces and equipment.

To complement efforts to improve antimicrobial use, a focus on clinical and personal care that addresses urinary, respiratory and skin health is also important to minimise the risk of development of infections and the likelihood that antimicrobials will be prescribed.

The new ‘Aged Care Quality Standard 3: Personal care and clinical care’ that took effect from 1 July 2019 requires aged-care providers to demonstrate implementation of infection prevention and control measures and practices to promote appropriate antibiotic prescribing and use. Standard 8 requires antibiotic stewardship programs as part of clinical governance.

The guidance for the Aged Care Quality Standards notes that aged-care organisations need to do their part to change those practices that have contributed to the development of resistance and implement new initiatives to reduce inappropriate antibiotic usage and resistance.

The Australian Commission on Safety and Quality in Health Care will work with the Aged Care Quality and Safety Commission to promote ongoing surveillance of antimicrobial resistance and antibiotic use, effective infection and control programs and the development and implementation of antimicrobial stewardship programs in aged-care homes.

Aged-care homes and multipurpose services are encouraged to participate in monitoring programs, such as AC NAPS, that enable them to identify their antimicrobial use and appropriateness.

For more information, visit: https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/aura-2019/.

^{1. Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2019: third Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2019.}

^{2. National Centre for Antimicrobial Stewardship and Australian Commission on Safety and Quality in Health Care. Antimicrobial Prescribing and Infections in Australian Aged Care Homes: Results of the 2017 Aged Care National Antimicrobial Prescribing Survey. Sydney: ACSQHC; 2018.}

^{3. Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, et al. Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. Infection Control and Hospital Epidemiology. 2012;33(10):965-77.}

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Other AURA 2019 highlights

Antimicrobial use — hospitals

• In 2017, a national shortage of piperacillin–tazobactam had a considerable impact on patterns of antibiotic use in hospitals, including increased use of cephalosporins.
• The overall rate of inappropriate prescribing in hospitals that participated in the National Antimicrobial Prescribing Survey (NAPS) has been static since 2013, with almost one-quarter (23.5%) of prescriptions assessed being inappropriate.
• From 2013 to 2017, there has been an improvement in prescribing of surgical prophylaxis; prescriptions that extended beyond the recommended 24 hours dropped in NAPS contributor hospitals from 41.1% to 30.5%.
• Cefalexin and amoxicillin–clavulanic acid had the highest rates of inappropriate prescribing in NAPS contributor hospitals.
   

Antimicrobial use — primary care

• In 2017, 41.5% (n = 10,215,109) of the Australian population had at least one systemic antibiotic dispensed under the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS).
• There was an improvement in the rate of antibiotic dispensing under the PBS/RPBS, with a downward trend from 2015 to 2017.
• Approximately 50% of all antibiotic prescriptions were ordered with repeats; of those repeats, approximately half were filled within 10 days of the original prescription.
   

Antimicrobial resistance

• In Escherichia coli, resistance to ciprofloxacin and other fluoroquinolones continued to rise in community-onset infections, despite restricted access to these agents on the PBS. These changes in resistance may mean increasing treatment failures and greater reliance on last-line treatments such as carbapenems.
• In Enterococcus faecium, the overall rates of vancomycin resistance are declining nationally, although the absolute number of isolates with vancomycin resistance continues to increase.
• In Staphylococcus aureus, patterns of methicillin resistance continue to evolve; community-associated methicillin-resistant S. aureus has become prominent in remote and very remote regions.
• Carbapenemase-producing Enterobacterales (CPE) were the most commonly reported critical antimicrobial resistance (CAR) in 2018.
• Critical antimicrobial resistances reported from aged care were predominantly CPE or daptomycin-nonsusceptible S. aureus.
   

Assessment of AURA 2019 data has identified the following focus areas for improvement action:

Amoxicillin–clavulanic acid and cefalexin prescribing

• Reducing inappropriate prescribing of these antibiotics, and promoting use of narrower-spectrum antibiotics, such as amoxicillin, will reduce the volume of broad-spectrum antibiotic use in hospitals and the community, and contribute to preventing and containing antimicrobial resistance (AMR).
   

Chronic obstructive pulmonary disease

• Exacerbation of chronic obstructive pulmonary disease (COPD) is a common condition for which broad-spectrum antibiotics are prescribed; people with COPD are prone to developing AMR in respiratory isolates.
• There is a long-term trend in hospitals of high levels of inappropriate prescribing of antibiotics for exacerbation of COPD.
• Targeted strategies to improve the appropriateness of antibiotic prescribing for treatment of COPD in hospitals will be developed in collaboration with clinicians involved in antimicrobial stewardship and the specialists managing patients with COPD.
   

*Professor John Turnidge, is a Senior Medical Advisor with the Australian Commission on Safety and Quality in Health Care.

Image credit: ©stock.adobe.com/au/Leonid