Systemic antibiotic use in nursing homes. A quality assessment.

In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.