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 behavior 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.