David W. Bentley

Antimicrobial use in long-term-care facilities

There is intense antimicrobial use in long-term-care facilities (LTCF), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and virtual absence of relevant clinical trials. This article recommends approaches to management of common LTCF infections and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the article acknowledges the unique aspects of provision of care in the LTCF.

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.

Rational Approach to the Antibiotic Treatment of Pneumonia in the Elderly

SummaryThe incidence of pneumonia is highest among the aged compared with other adult populations, and causes significant morbidity and mortality among this group. Most episodes of pneumonia are caused by aspiration of oropharyngeal flora into the lungs and failure of lung defence mechanisms to eliminate the aspirated bacteria.Studies in elderly patients have shown a high rate of oropharyngeal carriage of Gram-negative bacilli and polymicrobial/mixed flora pneumonias, especially in debilitated elderly patients in nursing homes or hospitals. This information is helpful to practitioners in prescribing empirical antibiotic therapy for elderly patients with pneumonia.Because of the many additional concerns which must be considered in the rational selection of an antibiotic regimen, e.g. route of administration, compliance, drug pharmacokinetics and pharmacodynamics, drug toxicity, and drug-disease interactions, it is also helpful for practitioners to become familiar with a small number of the large group of available antibiotics. Based on these considerations and the presumed bacteriology of pneumonia in the elderly in the 3 clinical settings (community, nursing home and hospital), a limited number of antibiotics are recommended for empirical antibiotic regimens for elderly patients with pneumonia. In particular, β-lactamase inhibitors and cotrimoxazole (trimethoprim-sulfamethoxazole) are recommended, with ciprofloxacin as an alternative agent. There is a limited role for third-generation cephalosporins and extended-spectrum penicillins. Aminoglycosides are only recommended for patients with pneumonia in the intensive care unit on mechanical ventilation. Monotherapy (single agent) should be used whenever possible.

Seizure with Ciprofloxacin and Theophylline Combined Therapy

Ciprofloxacin has been reported to cause theophylline toxicity by inhibiting theophylline metabolism. A 93-year-old woman without a known seizure history, while on ciprofloxacin and theophylline combined therapy, experienced a grand mal seizure. Her serum theophylline concentration at the time was 20 μg/mL. On previous occasion of theophylline toxicity, she had a serum theophylline concentration of 27 μg/mL but the patient did not experience any seizure. Several reports suggest that the combination of theophylline and ciprofloxacin has an additive inhibitory effect on gamma-aminobutyric acid (GABA) sites. Inhibition of the binding of GABA to its receptor sites has been related to the convulsant effects of other drugs. The seizure in our patient may have been caused by altered pharmacokinetics and pharmacodynamics brought about by combined therapy of theophylline and ciprofloxacin.

Disposition of intramuscular cefonicid in elderly patients.

Objective: To examine the disposition of intramuscular (IM) cefonicid in elderly patients with bacterial pneumonia.

Rimantadine and Seizures

Excerpt To the editor: The withdrawal of anticonvulsant drugs in patients free of seizures for more than 2 years has been recommended recently (1). Because of similar concerns about the long-term t...