Antibiotic use in the nursing home. Physician practice patterns

Antibiotic use in the nursing home. Physician practice patterns

American Journal of 2.~ Reviews INFECTION CONTROL cases occur in an institutional setting, a common source of origin should be suspected and inves...

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American Journal of




cases occur in an institutional setting, a common source of origin should be suspected and investigated. These infections can be particularly severe when they affect elderly or immunocompromised patients.

accompanying editorial by Dr. Gregory Filice emphasizes some of our failures in providing adequate pneumococcal immunization to highrisk patients and outlines strategies for improv-ing our efforts.

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Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Arch Intern Med 1990;150:1401-5. Reprint requests: Robert F. Breiman, MD, Respiratory Diseases Branch, Division of Bacterial Diseases, Bldg. 1, Room 5045 CO9, Centers for Disease Control, Atlanta, GA 30333.

A community-based study of pneumococcal bacteremia in Charleston County, South Carolina, from 1974 to 1976 yielded information on age-specific rates of pneumococcal bacteremia that has been used to support cost-effective pneumococcal vaccine programs for the elderly. The authors reevaluated the incidence of pneumococcal bacteremia in Charleston County in 1986 and 1987 to assess whether or not changes had occurred, given the widespread availability of pneumococcal vaccine. During 1986 and 1987, the overall annual incidence of pneumococcal bacteremia was 18.7 per 100,000 population, which represented a 2.3fold increase over the earlier rate. The annualized rate of bacteremia for adults 65 years of age and older increased from 18 to 53 cases per 100,000 population; for children less than 2 years of age, the rate increase went from 35 to 162 cases per 100,000, a 4.6-fold increase. The case fatality ratio for bacteremic patients 65 years of age and older was 44%. More than 90% of adults between 19 and 64 years of age with bacteremia had underlying medical conditions for which pneumococcal vaccine is recommended. The authors conclude that their findings emphasize the need for more effective programs to promote the use of pneumococcal vaccine in high-risk groups, particularly those 65 years of age and older, and the development of a more immunogenic vaccine for children less than 2 years old. Infection control practitioners should be aware of the data regarding incidence and morbidity of pneumococcal infections because more than 50% of infected patients have been hospitalized within the preceding 3 t o 5 years. It has been recommended that patients with high-risk conditions be immunized against pneumococcal infection at the time of hospital discharge. An

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Katz PR, Beam TR Jr, Brand F, Boyce K. Arch In}ern Meal 1990;150:1465-8. Reprint requests: P. R. Katz, MD, D i ~ n of Geriatrics, (111 -T), Veterans Administration Medical Center, 3495 Bailey Ave., Buffalo, NY 14215.

Investigators in upper New York state:studied the antibiotic-prescribing habits of a group of nursing home practitioners and assessed the outcomes of antibiotic treatments in nursing home residents over a 1-year period. They analyzed patterns of antibiotic use in two nonproprietary nursing homes that included 720 intermediatecare and skilled nursing home beds. They reviewed the medical records of residents receiving therapeutic antibiotics every fourth month for 1 year. Of 181 courses of antibiotic t r e a t m e n t that were identified, 41% were for presumed urinary tract infections, 35% for respiratory tract infections, and 14% for skin or soft tissue infections. The majority of antibiotic prescriptions (54%) were made by telephone order. Cultures were obtained in 60% of the suspected infections; two thirds of the cultures were of urine. Fever was present in 48% of the cases before treatment but had no predictive value for patient outcome. Eighty-one percent of the residents treated with antibiotics improved or were cured, 9.5% were hospitalized or died, and an additional 9.5% failed to improve but remained in the nursing home. The authors concluded that systemic antibiotics were frequently prescribed in the nursing home setting without clear or objective evidence of underlying infection. Antibiotic treatment was often initiated in the absence of fever, culture information, or examination of the patient. While the majority of nursing home patients treated with systemic antibiotics improved clinically, the basis for such improvement remained uncertain. It would be interesting for infection control practitioners who work in nursing homes to monitor antibiotic use in their o w n institutions to get a better idea of t h e indications, outcomes, and consequences of antibiotic therapies.