Another Setting for Stewardship: High Rate of Unnecessary Antimicrobial Use in a Veterans Affairs Long‐Term Care Facility

Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). Unfortunately, a significant proportion of antimicrobial use in LTCFs is inappropriate. Specifically, one study1 found inadequate rationale for 38% of antimicrobial prescriptions in 42 skilled nursing facilities. To develop effective stewardship interventions, there is a need for additional data on current patterns of unnecessary antimicrobial prescribing in LTCF residents, particularly those in Veterans Affairs (VA) facilities. Therefore, a retrospective study was performed to determine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in a VA LTCF. A retrospective chart review was performed to evaluate the necessity of systemic antimicrobial regimens administered to residents of a 160-bed skilled nursing facility during the 6-month period from October 1, 2008, to March 31, 2009. One hundred antimicrobial regimens were randomly selected for review. Information regarding resident demographic characteristics, clinical syndromes, and complications of therapy was obtained through the VA Computerized Patient Record System. Infectious disease specialists (CJD, RLPJ) determined whether antimicrobial regimens were necessary or unnecessary. If an antimicrobial regimen was necessary, additional assessments were made regarding whether all components of the regimen were necessary. Determination of the necessity of prescribed antimicrobials was based on standard practice guidelines for management of infectious diseases that the Infectious Diseases Society of America has developed or endorsed.2 If standard practice guidelines were not available, diagnostic and treatment recommendations from a current textbook of infectious diseases were used.3 The Louis Stokes Cleveland VA Medical Center institutional review board approved the study protocol. The 100 randomly selected antimicrobial regimens were prescribed to 70 LTCF residents for a total of 1,351 days of antimicrobial therapy. Figure 1 summarizes the findings regarding the necessity of antimicrobial regimens. Overall, 575 (43%) of the 1,351 days of antimicrobial therapy were deemed unnecessary, and 34 (49%) of the 70 residents received at least 1 day of unnecessary antimicrobial therapy. Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n = 21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer-than-recommended treatment durations accounting for 226 (94%) of those unnecessary days of therapy. Ciprofloxacin, amoxicillin or amoxicillin with clavulanate, piperacillin with tazobactam, metronidazole, and vancomycin were the most commonly prescribed antimicrobials and the most commonly prescribed unnecessary antimicrobials. Within 30 days of completing their antimicrobial regimens, five residents developed Clostridium difficile infection, five had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse events (gastrointestinal complaints and renal complications). Forty-two percent of the antimicrobial regimens reviewed in this study were entirely unnecessary. These unnecessary regimens accounted for 25% of all antimicrobial days of therapy reviewed. Although most unnecessary regimens were prescribed in the LTCF, 17% of unnecessary regimens were initiated in the hospital and continued in the LTCF. The most common reasons for unnecessary regimens were administration of antimicrobials for asymptomatic bacteriuria or pyuria and treatment of other noninfectious or nonbacterial syndromes. Educating prescribers and nursing staff on diagnosis and treatment guidelines and potential adverse effects of unnecessary antimicrobials may reduce unnecessary treatment of asymptomatic bacteriuria as described previously.4 Nearly half of all unnecessary days of antimicrobial therapy (241 of the 575 unnecessary days of therapy) occurred when only part of a treatment regimen was unnecessary. The most common reason for part of a regimen being unnecessary was administration of antimicrobials for longer-than-necessary durations, deemed as such because treatment duration was longer than is recommended in current guidelines or because therapy was not discontinued when there was no evidence of infection. For seven regimens in which longer-than-recommended durations of therapy were prescribed, recommendations on duration of therapy from the hospital's infectious diseases consultation service were documented in the medical record but not followed. Some unnecessary days of therapy could potentially have been avoided by placing the medication stop date in the medication order at the time of the patient's transfer to the LTCF. One limitation of this study is that categorization of therapy as necessary or unnecessary was based on retrospective review of medical records, so it is possible that some regimens were misclassified because of inadequate documentation of the indications for treatment. This study was conducted in a single VA LTCF; additional studies are needed in other settings to determine the generalizability of these findings. Antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria. Poster presented at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy, Boston, Massachusetts, September 2010. The authors wish to acknowledge Jon Laich for his assistance with acquisition of a listing of potential subjects. Robin L.P. Jump gratefully acknowledges the T. Franklin Williams Scholarship with funding provided by Atlantic Philanthropies, Inc., the John A. Hartford Foundation, the Association of Specialty Professors, the Infectious Diseases Society of America, and the National Foundation for Infectious Diseases. Conflict of Interest: This work was supported by the National Institutes of Health (R03-AG040722 to Robin L.P. Jump), the VA Merit Review Program (Curtis J. Donskey), and the Veterans Integrated Service Network—10 Geriatric Research, Education and Clinical Center (Lucy A. Jury, Robin L.P. Jump, Curtis J. Donskey). At the time of this study, Emily P. Peron was a postgraduate year-2 geriatric pharmacy resident at the Louis Stokes Cleveland VA Medical Center. Robin L.P. Jump reports having consulted for GOJO and Pfizer and has received grant support from Steris, Merck, and ViroPharma. Curtis J. Donskey reports having consulted for BioK, Optimer, and GOJO and has received grant support from ViroPharma, Merck, and Pfizer.