Antimicrobial Stewardship in Residential Aged Care Facilities

Need and Readiness Assessment

Ching Jou Lim; Megan Kwong; Rhonda L Stuart; Kirsty L Buising; N Deborah Friedman; Noleen Bennett; Allen C Cheng; Anton Y Peleg; Caroline Marshall; David CM Kong


BMC Infect Dis. 2014;14(410) 

In This Article


Twelve high-level care RACFs within the four major healthcare networks participated. From these RACFs, 40 nursing staff [four executive nurses, 15 nurse unit managers (NUMs), and 21 registered nurses (RNs)], 15 GPs and six pharmacists consented to participate in the study. The majority of participants were interviewed individually, with 15 RNs participating in three focus groups (range 4–6 RNs per focus group). All except four interviews were conducted face-to-face with participants. The demographic characteristics of the participants are described in Table 1. Five major themes that illustrate the prevailing perceptions and attitudes towards the need and readiness for AMS program in this setting emerged:

Perceptions of Current Antibiotic Prescribing Behaviour

There were mixed views about existing antibiotic prescribing behavior (Table 2). Several nurses and pharmacists believed that current antibiotic use in RACFs was not excessive; most indicated that perceived patient frailty or behavioral changes often precluded the potential strategy of withholding antibiotic treatment and observing for development of further clinical signs. Likewise, a few GPs felt that empiric prescribing of broad-spectrum antibiotics was fairly reasonable for the elderly population in RACFs (Table 2, Q1-Q3). In contrast, twelve of 15 GPs perceived that there was over-prescribing of antibiotics, with many admitting to prescribing antibiotics "just in-case" in light of the potential risk for patient deterioration if treatment was not initiated. A number of GPs indicated that pressure from nursing staff and family members was an important reason leading to unnecessary antibiotic prescribing (Table 2, Q4- Q5). Relatively fewer nurse participants were concerned about excessive antibiotic use among RACF residents. Those nurses who were concerned felt that there was liberal prescribing of antibiotics for futile reasons including viral illness and asymptomatic bacteriuria. Some were concerned about frequent empiric antibiotic prescribing without microbiological investigations to confirm causative organisms (Table 2, Q6-Q7). The main concern raised by participating pharmacists was about prolonged durations of antibiotic treatment (Table 2, Q8). They indicated that antibiotics were generally prescribed for an average of 7–10 days; however, it was not uncommon for antibiotics to be administered for longer periods when doctors had not documented a planned cessation date for treatment of acute infections, or where antibiotics were utilized for long-term prophylaxis against infection.

Perceptions of Antibiotic Resistance in RACFs

There were also mixed perceptions about antibiotic resistance (Table 2). Several GPs claimed they had not encountered many MDR organisms within their clinical practice; however, they admitted that cultures of relevant clinical samples were seldom requested. Similarly, the majority of nursing staff did not see this as an important issue, as they believed it was encountered less frequently than in the hospital setting, and often did not change management of residents within the RACFs (Table 2, Q9-Q10). In comparison, about half of the GPs believed that antibiotic resistance was an emerging issue in RACFs, reporting that MDR organisms were often seen in residents with recurrent urinary tract infections (especially those with indwelling urinary catheters), long-term antibiotic prophylaxis and chronic wound colonization (Table 2, Q11-Q12). However, only a minority of GPs were concerned that antibiotic resistance would affect their choice of empiric antibiotics. Whereas from the nurses' perspective, only a small proportion were worried about the increasing rates of MDR organisms; their main concerns were about low staff awareness and inadequacy of existing infection control efforts in preventing MDR organism transmission as opposed to clinical impact on residents (Table 2, Q13).

Attitude Towards and Understanding of AMS

The majority of participating nursing staff were unaware of the concept of AMS. In comparison, more GPs and pharmacists were aware of AMS, although they generally felt that AMS was relatively new in the RACF setting. AMS refers to integrated activities that help to optimize antibiotic therapy, ensuring the best clinical outcomes whilst minimizing the risk for the emergence of antimicrobial resistance. When this concept of AMS was explained, in general, all key stakeholders were supportive of AMS programs in RACFs. Amongst GPs, the main value of AMS was thought to be in promoting evidence-based practices for antibiotic prescribing in this setting (Table 3, Q1). All executive nursing staff felt that AMS was applicable, and welcomed future intervention as part of quality improvement strategies in their RACFs (Table 3, Q2). Likewise, the NUMs and RNs felt that AMS interventions would be helpful as an additional source of educational support for nurses, given their relative lack of knowledge regarding antibiotic use (Table 3, Q3-Q4). The pharmacists were also supportive of AMS interventions, particularly to achieve more uniformity in antibiotic prescribing and consistency with adopting guidelines (Table 3, Q5-Q6).

Perceived Barriers to and Facilitators of AMS Interventions

A number of perceived barriers and facilitators in relation to implementation of AMS interventions were raised. From the GPs' perspective, several raised concerns about the potential for doctor autonomy to hinder acceptance of institutional policies and guidelines. Heterogeneity in prescribing practices amongst GPs from different practices pose another barrier, thus having fewer GPs with greater patient loads working in each facility would promote more consistent prescribing practices (Table 3, Q7-Q8). Nursing staff had mixed attitudes. The executive nursing staff anticipated that AMS interventions might not be easily accepted by nursing staff in view of their high workload. Conversely, most of the NUMs did not foresee major resistance from nursing staff given their past experiences with other quality improvement initiatives, instead, having more concern about GP acceptance of any AMS interventions (Table 3, Q9-Q10). It emerged that nursing staff would need to play an essential role in delivering any future AMS intervention, with facilitation of AMS programs being driven by on-site staff such as NUMs or clinical nurse coordinators. The nursing staff would be in a good position to disseminate relevant information to family members and GPs (Table 3, Q11-Q12). Both community and consultant pharmacists perceived several logistical barriers to providing additional clinical support, in particular, their lack of on-site availability, inadequate access to patients' clinical information, and limited communication with GPs. All consultant pharmacists were willing to undertake additional clinical roles; however, they acknowledged that current funding resources offered little prospect for this to occur (Table 4, Q13-Q14).

Feasible AMS Interventions

Three major areas of AMS interventions emerged as potentially useful and practical in the RACF setting (Table 4). The most commonly suggested intervention was ongoing education to nurses, GPs and family members of residents, with the objective of promoting awareness of judicious antibiotics use amongst those working in the RACFs (Table 4, Q1-Q3). Various suggestions for how this could be achieved were identified, including in-service training (for nurses), web-based education, provision of educational material in poster or brochure form, and invited speaker sessions. Another area identified was the emphasis on evidence-based practice around aged-care specific management. Importantly, more than half of the GPs indicated a need for aged care-specific antibiotic guidelines, as current guidelines were thought to be lacking evidence and recommendations specific to the aged care population. The nursing staff perceived a need for consistent, RACF-based guidance and support on the matter of infection management; for example, a clinical protocol guiding the management of symptomatic versus asymptomatic bacteriuria was frequently recommended (Table 4, Q4-Q6). The third main potential area for future AMS identified was surveillance and auditing of antibiotic use. It was believed that monitoring of antibiotic use with regular feedback to GPs would be helpful to guide and target reduction of specific antibiotic use, and consultant pharmacists were deemed most suitable to perform such activity (Table 4, Q7-Q9). In contrast to more proactive hospital-based AMS interventions (such as pre-authorization of broad-spectrum antibiotics or review by infectious diseases teams), passive surveillance of antibiotic use was thought to be sufficient and more practical in this setting. Other suggestions included additional staff resources via introduction of the nurse practitioner model, and re-institution of aged care interest groups to further support and educate GPs.