Prevention of infections in nursing homes: antibiotic prophylaxis versus infection control and antimicrobial stewardship measures

ABSTRACT

Because of the lack of structural and human resources for implementing more effective and safe preventive procedures, antimicrobial prophylaxis is often used to prevent infections in nursing homes. However, if data on the efficacy of antibiotic prophylaxis in nursing homes are null, there is a plenty of evidence that the inappropriate use of antimicrobials in this setting is associated with a high rate of colonization and infection with multi-drug-resistant organisms (MDROs), and of Clostridium difficile infection (CDI). Here, we have reviewed the infection epidemiology, the burden of MDROs and CDI, the antibiotic use and some potential infection preventive measures in nursing homes, pointing up the peculiarities of this setting and the absolute need of a more prudential use of antimicrobials.

KEYWORDS:

• Nursing homes
• long term care facilities
• infection
• multi-drug resistant organisms
• preventive measures
• antimicrobial use
• appropriateness
• stewardship

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Key issues

• Infection is one of the most common complications in nursing home residents, it is associated with high morbidity and mortality and it is a frequent cause of hospital admission.

• Diagnosis of infection in nursing home residents is challenging due to both host-related factors and limited on-site diagnostic and human resources, which make it difficult to optimize the therapeutic management. The consequent high rate of inappropriate antimicrobial use favors the acquisition and spread of multidrug-resistant organisms (MDROs) and Clostridium difficile infection (CDI).

• The frequent use of prophylactic antibiotics in this setting is surprising as no evidence about their efficacy exists; on the contrary, a clear relationship with acquisition of MDROs has been shown.

• The prophylactic use of antibiotics is justified when benefits on relevant patient outcomes overcome risks and cost-effectiveness has been demonstrated, as in surgical prophylaxis. Consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to the community created by antibiotic overuse.

• Non-antimicrobial preventive measures must be preferred, targeting interventions to the most relevant infection types (urinary tract infections, respiratory tract infections), patients at risk (those with indwelling devices), or specific pathogens (CDI, MDROs).

• Antimicrobial stewardship programs are crucial in this setting, they should be tailored to the capacity of the specific nursing home, and potentially should include interventions focused on processes associated with both the initial antibiotic decision (e.g. urine testing) and post-prescription decision-making (e.g. earlier withdrawal).