HomeNews & TopicsPublic HealthReducing harm from unnecessary antibiotic use in long-term care

Reducing harm from unnecessary antibiotic use in long-term care

Published on

By Rita Ha and Bradley Langford

It has been estimated that up to 50 per cent of prescribed antibiotics in long-term care homes (LTCH) are not needed. Overuse of antibiotics, particularly in older adults, has been associated with an increased risk of harm.  These harms include increased risk of side effects, Clostridium difficile infection (CDI), and infection with antimicrobial-resistant organisms (AROs). Infections with AROs in long-term care residents are also associated with more severe infection, hospitalization, increased risk of death and increased cost of care. Antibiotic overuse also contributes to increasing rates of antimicrobial resistance, which has become a significant public health concern.

A retrospective analysis by Daneman et al (JAMA Internal Medicine 2013) examined the prevalence of antibiotic use in LTCHs in Ontario and found the majority of treatment courses were at least 10 days in duration.  Yet, randomized controlled trials and meta-analyses have demonstrated that short courses of antibiotics (7 days or less) for commonly seen infections in long-term care, including cystitis, pneumonia and cellulitis, result in similar outcomes compared to long durations (more than 7 days).  Additional advantages to short courses include less risk of side effects, less risk of CDI, and less risk of AROs.

Public Health Ontario has developed two suites of resources to address the overuse of antibiotics in long-term care.  The first suite, titled Shorter Is Smarter, focuses on the evidence to support shorter courses of antibiotic treatment for long-term care residents.  The second suite, titled Antimicrobial Stewardship Essentials in Long-Term Care, aims to help guide LTCHs to develop an antimicrobial stewardship program (ASP).

Shorter Is Smarter

All antibiotic use drives antimicrobial resistance.  Prolonged antibiotic use kills susceptible bacteria and allows resistant organisms to thrive and multiply. When shorter courses of antibiotics are as effective as longer courses, prolonged antibiotic use promotes unnecessary antimicrobial resistance.

We encourage long-term care prescribers to prescribe short durations of therapy, when appropriate, especially in cystitis, pneumonia and cellulitis.

Recommendations to reduce duration of antibiotic treatment for common infections in long-term care

  • Cystitis: Treat ≤ 7 days. For uncomplicated cystitis, evidence supports 3 days of trimethoprim-sulfamethoxazole or ciprofloxacin, or 5 days of nitrofurantoin. Asymptomatic bacteriuria should not be treated in long-term care.
  • Cellulitis: Treat 5-7 days. Treatment for 5 to 7 days is appropriate as long as there has been some improvement in erythema, warmth, tenderness, or edema.
  • Pneumonia: Treat 5-7 days. Treatment for 5 to 7 days is appropriate in residents with pneumonia who are clinically stable and afebrile for 48 to 72 hours.

Antimicrobial Stewardship Essentials in Long-term Care

Antimicrobial stewardship is an approach to ensure antibiotics are and remain effective for individuals and the population in general.  While there is much focus on antimicrobial stewardship in hospitals, it is recognized antibiotic use needs to be addressed in long-term care as well. Long-term care residents present unique challenges to antimicrobial stewardship.  The perception of risk can be variable amongst clinicians, caregivers and family members of residents. Antibiotics are often prescribed due to subjective influences, even when there is little evidence antibiotics will benefit.  Yet, we know they are a vulnerable population, prone to infection and colonization with AROs. Antimicrobial stewardship involves implementing strategies that target influences and decisions around antibiotic prescribing that can be modified through knowledge and behaviour changes.

Quality improvement steps for an ASP may begin with forming a comprehensive team that can impact antibiotic use in the home, and setting antibiotic use criteria and guidelines for common infections. Evidence-based antimicrobial stewardship strategies selected for implementation should be monitored and evaluated for changes in clinical outcomes to residents and antibiotic use metrics in the home.  Continuous quality improvement and feedback will also ensure antimicrobial stewardship efforts and awareness are sustainable within the home.

We encourage LTCHs to approach antimicrobial stewardship as an evidence-based quality improvement initiative. Understand the key components of antimicrobial stewardship programs and explore examples of successful antimicrobial stewardship initiatives and evidence-based strategies. Promoting the judicious use of antibiotics can improve the quality of care and support the safety of long-term care residents.

Rita Ha is a Pharmacist Consultant and Bradley Langford is the Pharmacist Lead of the Antimicrobial Stewardship Program at Public Health Ontario.

Latest articles

An ER doctor’s experience with long COVID – “My symptoms seemed endless”

On April 2022, another COVID wave was sweeping Toronto. It was the sixth since...

Tackling the issue of unused medication waste

When patients and programs don’t use all the medication that is prescribed, it is...

Obesity a risk factor for stillbirth, especially at term

Obesity is a risk factor for stillbirth, and the risk increases as pregnancy advances...

Prolonged cough? In most cases, patience is the treatment

Coughing after a respiratory infection is common and, in most cases, will resolve with...

More like this

Protecting patients and the planet from unnecessary tests

Climate change is a universal problem that impacts both environmental and human health. In...

We need health system solutions now: CMA, CFPC

Medical organizations call on governments to reimagine primary care to help stabilize, rebuild health...

Wait times in EDs are nothing new – and that’s the problem

The respiratory virus season is upon us, and those working in the emergency departments...

Ontario hospitals play critical role in Canadian health care advancements and innovation

Twenty Ontario research hospitals have been celebrated for their excellence in health research and...

Primary care lessons for Canada from OECD countries

To improve primary care, Canada can learn from Organisation for Economic Co-operation and Development...

How SCOPE is diverting patients from EDs and easing family physicians’ workloads

With busy emergency departments (EDs) during respiratory illness season and the shortage of access...