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


To our knowledge, this is the first study exploring the perceptions and attitudes of a range of healthcare providers towards antibiotic prescribing behaviour, antibiotic resistance, and AMS implementation in the RACF setting. A greater proportion of GPs and pharmacists than nursing staff felt that there was over-prescribing of antibiotics, suggesting a lack of awareness amongst nurses about potential antibiotic misuse among this population. Antibiotic resistance and the emergence of MDR organisms were perceived as more of a concern from the infection control perspective as opposed to impacting empiric antibiotic selections. Additionally, this study has highlighted the prevailing attitudes amongst key healthcare providers that AMS interventions were needed and deemed useful in the RACF setting. A number of perceived barriers to AMS programs were identified, in particular, nursing staff workload and the logistical issues of off-site GPs and pharmacists. A range of potential AMS interventions have been suggested to provide insights into feasible AMS model for the RACF setting.

Published data describing the key stakeholders' views of antibiotic prescribing and antibiotic resistance have mainly focused on the general practice setting, with limited information from the RACF setting.[18,19] A study by Walker et al. has explored the views of the physicians and nurses about antibiotic prescribing in Canadian RACFs but it focused specifically on treatment for asymptomatic bacteriuria, reporting that education about asymptomatic bacteriuria was viewed as an important priority by both physicians and nurses.[20] In addition to concern about antibiotic treatment for asymptomatic bacteriuria, our study also identified a need for education to target other infective issues, including the widespread prescribing for viral upper respiratory tract infections, and repeated or prolonged antibiotic use without microbiological investigation. The current study found that the overuse of antibiotics in the Australian RACFs context was thought to be mainly related to widespread empiric prescribing or unnecessary antibiotic treatment, as opposed to the over-prescribing of broad-spectrum antibiotics such as intravenous antibiotics and oral fluoroquinolones that was more frequently reported in the US studies.[7,8]

Previous studies have reported that increasing the awareness about antibiotic resistance would potentially influence GPs' decisions in selecting antibiotics, underlining the importance of knowledge about MDR organisms in assisting clinical decisions.[18,21,22] Furthermore, education that promotes awareness about antibiotic resistance is likely to encourage more microbiological testing to identify causative organisms before initiating antibiotic treatment. Several international guidelines suggest that provision of antibiograms by local microbiology laboratories as fundamental requirement for an AMS program in the RACF setting.[12,23] However, the need for antibiograms to guide empiric antibiotic therapy has not been suggested as a useful or practical AMS initiative by any healthcare provider that participated in this study. The feasibility of this strategy may be hindered by limited microbiological investigations and involvement of multiple external pathology laboratories.

AMS interventions in the RACF setting have been few despite mounting evidence of inappropriate antibiotic prescribing among this elderly population.[9,24] Existing guidelines about the implementation of AMS have primarily been limited to the acute-care hospital setting.[25] An intensive form of AMS intervention with involvement of infectious diseases physicians or clinical pharmacists has been adopted in Veterans Affairs long-term care facilities in the US;[14] however, most key stakeholders in the present study indicated that such AMS interventions are not practical or necessary in the Australian RACF setting. From the current work, an approach to AMS tailored to the needs of key healthcare providers in RACFs is proposed (Table 5). Multifaceted interventions are likely to be most effective; however, such interventions should be tailored to the resources and expertise in individual RACFs. Overall, the important role of nursing staff in the day-to-day practice of AMS in RACFs cannot be under-estimated, and could function effectively if supplemented by education, infection management algorithms and training in the use of antibiotic utilization surveillance.

This study has predominantly involved high-level care hospital-affiliated RACFs. There may be differences in antibiotic prescribing behaviour in comparison to low-level care or private RACFs, and thus this study could be replicated more widely to other RACF setting for further exploration. Given the differences in long-term healthcare delivery models between different countries,[26] the findings and suggestions in the current study may not be generalizable outside the Australian setting. Nevertheless, the current findings are likely to be of interest to many, especially those who are closely affiliated with RACFs. Participation in this study was voluntary, thus the expression of personal perceptions may be skewed towards those who are more involved with or concerned about AMS. In order to minimize the potential bias, we have explored both the positive and negative views from a range of key stakeholders, and continued the recruitment and data analysis until we achieved data saturation amongst all stakeholder groups.