Over-prescribing antibiotics to nursing home residents dangerous for all

Antibiotics are frequently and often inappropriately prescribed to nursing home residents, according to a new study in JAMA Internal Medicine. These antibiotics pose direct risks to recipients and indirect risks to other residents.

Dr Daneman

“There is very large variability in antibiotic use across nursing homes, and residents in nursing homes with high antibiotic use are at greater risk of adverse events than residents of low antibiotic use nursing homes,” according to lead author Nick Daneman, MD, of the Sunnybrook Health Sciences Center at the University of Toronto.

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“Not only does high antibiotic use in a nursing home cause adverse events for residents directly receiving these drugs, but it also causes adverse events for those not directly receiving these drugs,” he added. “However, this should not be that surprising, because many of the harms of antibiotics are transmissible between patients including C difficile infection and antimicrobial-resistant bugs.”

The most commonly prescribed antibiotics in nursing homes, according to Dr Daneman, are:

• Penicillins

• Second-generation fluoroquinolones

• Sulfonamides

• Nitrofurantoin

• First-generation cephalosporins.  

“These are probably all overprescribed with respect to unnecessarily prolonged treatment durations,” Dr Daneman said. “The urinary tract anti-infectives [ciprofloxacin, TMP-SMX, and nitrofurantoin] are also commonly overprescribed related to inappropriate treatment of asymptomatic bacteriuria in nursing home residents.”

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For the study, Dr Daneman and colleagues used linked province-wide healthcare datasets in Ontario, Canada, including information on all nursing home residents, all medication prescriptions, all physician visits, and all emergency room visits and hospitalizations. They studied 110,656 older adults residing in 607 nursing homes in Ontario, Canada, from January 1, 2010, through December 31, 2011. Nursing home-level antibiotic use was defined as use-days per 1,000 resident-days, and facilities were classified as high, medium, and low antibiotic use according to tertile of use. Multivariable logistic regression modeling was performed to assess the effect of nursing home-level antibiotic use on the individual risk of antibiotic-related adverse outcomes. The researchers then compared the risk of antibiotic-related adverse events in residents of those homes, after accounting for other resident risk factors (such age, underlying illness, etc.)

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Antibiotics were provided on 2,783 000 of 50,953,000 resident-days in nursing homes (55 antibiotic-days per 1,000 resident-days). Antibiotic use was highly variable across homes, ranging from 20.4 to 192.9 antibiotic-days per 1,000 resident-days. Antibiotic-related adverse events were more common (13.3%) in residents of high-use homes than among residents of medium-use (12.4%) or low-use homes (11.4%) (P< .001); this trend persisted even among the residents who did not receive antibiotic treatments, the authors wrote. The primary analysis indicated that residence in a high-use nursing home was associated with an increased risk of a resident experiencing an antibiotic-related adverse event (adjusted odds ratio, 1.24; 95% CI, 1.07-1.42; P=.003). A sensitivity analysis examining nursing home-level antibiotic use as a continuous variable confirmed an increased risk of resident-level antibiotic-related harms (adjusted odds ratio, 1.004 per additional day of nursing home antibiotic use; 95% CI, 1.001-1.006; P=.01).

“Nursing homes, like acute care hospitals, could benefit from better antibiotic stewardship to ensure that antibiotics are used in an optimal way to maximize their benefits while minimizing their harms,” Dr Daneman said. “Antibiotic use is highly variable across nursing homes, and higher antibiotic use is associated with greater harms."

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