Dr. Weeks’ Comment: Patient beware! (and hire an advocate to watch over your parents in the elderly home!)
New Push to Stop Overuse of Antibiotics in Nursing Homes
Up to 75% of prescriptions are incorrect as heath officials open a new front in war on overuse
Oct. 12, 2015 9:01 a.m. ET
A new front is emerging in the war on the overuse of antibiotics: the nursing home.
Health officials and health-care executives, concerned by a rise in dangerous drug-resistant infections, are turning more attention to nursing homes, where antibiotics are some of the most frequently prescribed medications. They have concentrated over the past several years on curbing misuse of antibiotics in hospitals.
Up to 70% of nursing home residents receive one or more courses of antibiotics every year for urinary tract infections, pneumonia, cellulitis and other suspected conditions, according to researchers. Yet up to 75% of those prescriptions are given incorrectly—either unnecessarily or the prescription is for the wrong drug, dose or duration, the Centers for Disease Control and Prevention says.
One of the biggest culprits, researchers say: misdiagnosed urinary tract infections. Only a quarter to a third of people in nursing homes who are diagnosed have actual symptoms, according to several studies. Most have only vague symptoms like confusion or bacteria in their urine that aren’t actually causing an infection, says David Nace, director of long-term care and flu programs at the University of Pittsburgh. UTIs are “the poster child of inappropriate antibiotic use,” he says.
Such practices spawn the spread of drug-resistant bacteria that can be particularly harmful to the elderly and are very difficult if not impossible to treat, researchers say. They can also lead to drug interaction problems or diarrhea from Clostridium difficile—a common complication in long-term care facilities that can be deadly for people over age 65, says Ghinwa Dumyati, an infectious disease physician in the Center for Community Health at the University of Rochester Medical Center.
Curbing antibiotic overuse is a particularly tall order for nursing homes. Doctors can be reluctant to hold off on prescribing medications because patients are frail, and they sometimes have milder fevers or other symptoms that differ from those in younger adults. Many patients also suffer from dementia or other forms of cognitive impairment and can’t tell nurses or doctors what their exact symptoms are.
On top of that, turnover in nursing home staff is high, and antibiotics are frequently prescribed by clinicians who haven’t seen the patients, geriatricians say. At many nursing homes, nurses evaluate patients and consult with off-site medical staff for prescriptions.
“A lot of the decision-making is done remotely by phone,” says Christopher Crnich, an infectious disease specialist at the University of Wisconsin School of Medicine and Public Health who studies antibiotic use and drug-resistant infections in long-term care facilities.
The government and professional groups are taking action. Calling nursing homes the “next frontier” for antibiotic resistance, the Centers for Medicare & Medicaid Services recently proposed new requirements for facilities to track and curb unnecessary use of antibiotics. In September, the CDC issued guidelines to help nursing homes implement such practices.
To comply, geriatricians say they will have to dispel a myth—widespread among doctors, nurses, patients and families—that confusion alone or even a fall signals a possible urinary tract infection, says Diane Kane, chief medical officer for St. Ann’s Community, a not-for-profit health-care system in Rochester, N.Y. Doctors often order urine tests for such patients which come back positive because about 50% of women and 25% of men in nursing homes have bacteria in their urine, says Dr. Crnich. But the bacteria don’t automatically indicate an infection, he says. Bacteria can develop in the urinary tract due to immune system, hormonal, and other changes in aging people, experts say.
Instead, patients should be checked for actual UTI symptoms such as fever, pelvic pain, incontinence or urgency to urinate, and urine tests should be done only on those with UTI symptoms, according to guidelines and campaigns issued in recent years by several professional societies.Others with symptoms of concern should be observed, geriatricians say.
Patients with the most bizarre symptoms are diagnosed with UTIs, says Robin Jump,assistant professor of medicine at Case Western Reserve University and an infectious-disease physician at a veterans hospital in Cleveland. One patient who had bad dreams was treated twice with antibiotics after positive urine tests, she says.
Dr. Jump and other infectious-disease colleagues helped a 160-bed VA long-term care facility reduce use of antibiotics by 30% over 18 months by coaching staff to evaluate patients more carefully for UTIs and other steps, she says.
Genesis HealthCare Corp., which operates more than 500 skilled nursing centers in 34 states, is developing a campaign, set to launch next year, to reduce overdiagnosis of UTIs. It will include clinical education for doctors and nurses, brochures, meetings with families and other initiatives, says JoAnne Reifsnyder, senior vice president of clinical operations and chief nursing officer.
The Kennett Square, Pa., company says it has also increased its roster of full-time providers and trains them to avoid UTI overdiagnosis.
In Rochester, Dr. Dumyati is working with three nursing homes as part of a larger effort to reduce C. difficile infections in the overall community. Over the first six months of 2014, 66% of patients who were treated for UTIs at those facilities had no UTI symptoms. One, part of health-care system St. Ann’s Community, took 227 urine cultures during the third quarter of 2014, or 76 on average a month, Dr. Dumyati says. This past July and August, after months of educating staff, urine cultures were down to a monthly average of 44, she says.
Dr. Kane has helped Dr. Dumyati lead the charge to reduce antibiotic overuse. A passionate critic of UTI overdiagnosis, she says Dr. Dumyati’s data and her voice as an infectious disease specialist have helped. The data were “eye opening,” Dr. Kane says. “When you have dementia, you’re going to have good days and you’re going to have bad days. When you have dementia and you have a bad day, please don’t send a urine, because it’s going to be positive.”
When his 91 year-old mother, Clarinda, started acting confused recently, John Kirkmansays friends and relatives told him it was probably a urinary tract infection. They said, “You just have your doctor prescribe an antibiotic and it takes care of it,” he recalls.
Mr. Kirkman, a retired Xerox Corp. field engineer, got a test kit, which gave mixed results. Dr. Kane told him emphatically when she visited Clarinda in her assisted living facility at St. Ann’s that confusion alone did not indicate a UTI. “She said if a person has a urinary tract infection they are in pain,” he said. “It’s not confusion. It is serious pain.”