Residential Aged Care Facilities – tackling the problem of very high levels of (inappropriate) antibiotic use
The problem: Residential Aged Care Facilities (RACFs) are known to have very high rates of antibiotic prescribing, with high prevalence of antibiotic use (nearly 10% of residents at any time), of which one-third were for no discernible infection, one-quarter were being used for >6 months, and there was no stop or review date for approximately half of the uses.29 However, the reasons are incompletely understood, although clearly complex. For example, there are large numbers of GPs who provide care for, and are ultimately responsible for prescribing antibiotics, for residents in RACFs but typically for only a few patients in a RACF. Residents are typically a frail population and have increased susceptibility to infection (for example, from long-term urinary catheters). Additional factors which need to be considered are the economic drivers for profit-driven institutions which operate in a tightly regulated environment. The combination of these factors, and others, means that interventions demonstrated to be effective at reducing antibiotic prescribing in mainstream general practice may be less likely to be effective in RACFs.
The solution: It is essential to conduct preliminary work to identify and understand the phenomena that dictate the enablers and barriers to reduced prescribing in RACFs. To do this, we will commence with qualitative studies. We will interview RACF staff (nursing staff and managers), GPs who provide care to RACF residents, and where appropriate, residents and a key family member. We will also analyse existing RACF policy documents, guidelines, and audit charts. We will systematically review the literature for evidence of interventions that might be effective in this environment. These will include general deprescribing interventions30, as well as specific interventions directed at improved antibiotic prescribing, and those that address the system changes that may be necessary, such as inappropriate testing of urine in asymptomatic residents.
Results from this work will enable the design of appropriate interventions. It is likely that some of the interventions needed will involve governance issues (who takes responsibility for specific tasks), the development of clear guidelines that are specific to antibiotic use in RACFs, and development and display of information related to antibiotic stewardship in RACFs. We have identified GPs who manage patients in RACFs (including AI Morgan) and we will establish research collaborations with private RACFs, in conjunction with the Gold Coast PHN. By the end of the CRE-MARC, we will have developed, and pilot tested interventions and be ready for a trial of multiple interventions in RACFs.