Ruth B. Veenhuizen

Antibiotic Use and Resistance in Long Term Care Facilities

INTRODUCTION The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance. METHODS Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations. RESULTS A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship. CONCLUSION The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.

Factors influencing antibiotic prescribing in long-term care facilities: a qualitative in-depth study.

BackgroundInsight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors.MethodsSemi-structured qualitative interviews were conducted with physicians (n = 13) and nursing staff (n = 13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff.ResultsThe analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians’ perceived risks, influence of others, and influence of the environment. Each category comprises several factors that may influence the decision to prescribe or not prescribe antibiotics directly (e.g. pressure of patients’ family leading to antibiotic prescribing) or indirectly via influence on other factors (e.g. unfamiliarity with patients resulting in a higher physician perceived risk of non-treatment, in turn resulting in a higher tendency to prescribe antibiotics).ConclusionsOur interview study shows that several non-rational factors may affect antibiotic prescribing decision making in long-term care facilities, suggesting opportunities to reduce inappropriate antibiotic use. We developed a conceptual model that integrates the identified categories of influencing factors and shows the relationships between those categories. This model may be used as a practical tool in long-term care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriate antibiotic prescribing.

Prevalence and severity of behavioural symptoms in patients with Korsakoff syndrome and other alcohol-related cognitive disorders: a systematic review

Experiences from clinical practice suggest that behavioural symptoms in patients with Korsakoff syndrome (KS) are a frequent problem. Knowledge about behavioural symptoms is important in understanding and managing these symptoms. The aim of this study is to review the prevalence and severity of behavioural symptoms in KS.

The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure

OBJECTIVES Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population. DESIGN A Delphi consensus procedure. SETTING AND PARTICIPANTS An international panel of practitioners recognized as experts in the field of UTI in frail older patients. MEASURES In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool. RESULTS Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter. CONCLUSIONS A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.

K16 Patient and informal caregiver outreaching care for huntington’s (PICOH): a pilot study on crisis occurrence and prevention

Background The occurrence of ‘crises’ – e.g. accidents, agression, dismissal, divorce, suicide – is high among Huntington’s Disease (HD) patients. These ‘crises’, combined with the occurrence of disinhibited behaviour and the degenerative nature of HD, pose high burden on informal caregivers, which frequently results in nursing home admission of the patient. Aims In this study, we aim to evaluate the feasibility of including ambulatory HD patients and their caregivers referred to an outpatient clinic for coordinated multidisciplinary HD care, and on the feasibility of measuring several outcome measures in this patient/caregiver group. If this pilot study is successful, we aim to conduct a larger study to investigate whether outreaching multidisciplinary care for HD patients results in crises-reduction and postponing nursing home admission, and at what costs. Methods Ten HD patients and caregivers, who are newly referred to the outpatient clinic, will be included in the study. At the time of referral and five months after receiving multidisciplinary care coordinated by the outpatient clinic, data will be verbally collected from patients on: crises, quality of life, functioning and experienced problems. Informal caregivers fill out a questionnaire covering burden, quality of life and experienced problems. In addition, data on care consumption, medication use and costs is collected through an online patient diary and by reviewing patient files at general practice. Discussion This session addresses feasibility of the described pilot study. In addition, we will present our preliminary results on characteristics of the patient-informal caregiver couples that are referred to the outpatient clinic.

Urineweginfecties bij ouderen in het verzorgingshuis

SamenvattingVan Buul LW, Veenhuizen RB, Stobberingh EE, Hertogh CMPM. Urineweginfecties bij ouderen in het verzorgingshuis: Huisarts Wet 2016;59(10):430-3.DoelOnderzoeken in hoeverre het antibioticabeleid van de NHG-Standaard Urineweginfecties, dat uitgaat van verwekkers en resistentiepatronen in een gemiddelde praktijkpopulatie, ook van toepassing is op de bewoners van verzorgingshuizen.MethodeScreening van de medisch dossiers van 289 bewoners van vier verzorgingshuizen op het platteland van Noord-Brabant en Zuid- en Noord-Holland, over de periode tussen januari 2010 en september 2013.ResultatenDe onderzoekers registreerden de uitslagen van 143 urinekweken van 66 bewoners. Bij 67% van de kweken werd een verwekker geïsoleerd, bij 20% trad groei van mengflora op en bij 13% trad geen groei op. De meest voorkomende verwekkers waren Escherichia coli (41%), Proteus mirabilis (17%) en Klebsiella pneumoniae (15%). In 81% van de kweken was de verwekker resistent tegen minstens een antibioticum. E. coli was relatief vaak resistent tegen amoxicilline, amoxicilline/clavulaanzuur, ciprofloxacine, trimethoprim en norfloxacine, P. mirabilis tegen trimethoprim en K. pneumoniae tegen nitrofurantoïne, fosfomycine, norfloxacine en trimethoprim.ConclusieHet behandelbeleid van de NHG-Standaard Urineweginfecties is niet goed toepasbaar bij ouderen in verzorgingshuizen omdat de frequentie- en resistentiepatronen van de betrokken micro-organismen afwijken van die in de reguliere (oudere) praktijkpopulatie. Idealiter wacht de huisarts bij een urineweginfectie in het verzorgingshuis de kweekuitslag af alvorens gericht te behandelen. Als het klachtenpatroon van de patiënt dat onwenselijk maakt, is fosfomycine als empirische behandeling een goede optie. Bij uitblijvend effect of bij tekenen van weefselinvasie kan desnoods gestart worden met cotrimoxazol of ciprofloxacine.AbstractVan Buul LW, Veenhuizen RB, Stobberingh EE, Hertogh CMPM. Urinary tract infections in elderly residents of residential care facilities. Huisarts Wet 2016;59(10): 430-3.AimTo investigate whether the treatment policy recommended by the Dutch College of General Practitioners’ guideline ‘Urinary tract infections’, which is based on causative agents and resistance patterns in an average general practice population, is appropriate for people living in residential care facilities.MethodThe medical files of 289 residents of four residential care facilities in rural areas of North Brabant and South and North Holland, the Netherlands, were screened for the period January 2010 until September 2013.ResultsThe results of 143 urine cultures from 66 residents were available. The causative agents was identified in 67% of the cultures, in 20% there was mixed growth, and in 13% there was no growth. The most common bacteria were Escherichia coli (41%), Proteus mirabilis (17%), and Klebsiella pneumoniae (15%). Bacteria were resistant to at least one antibiotic in 81% of the cultures. E. coli was relatively often resistant to amoxicillin, amoxicillin/clavulanate, ciprofloxacin, trimethoprim, and norfloxacin. P. mirabilis was resistant to trimethoprim, and K. pneumoniae was resistant to nitrofurantoin, fosfomycin, norfloxacin, and trimethoprim.ConclusionThe treatment policy recommended in the Dutch College of General Practitioners’ guideline ‘Urinary tract infections’ is not appropriate for elderly residents of residential care facilities because the causative microorganisms and their patterns of antibiotic resistance are different from those in the average (elderly) general practice patient population. Ideally, general practitioners should await urine culture results before treating urinary tract infections in people living in residential care facilities. If the patient’s symptoms do not allow this, empirical treatment with fosfomycin is a good choice, with the option of starting cotrimoxazole or ciprofloxacin if treatment fails or if there are signs of tissue invasion.

A14 Multidisciplinary Care In The Netherlands: Where Science Meets Best Practice, Quality Care Is Based On Knowledge

Background About 40 years ago the Dutch Huntington Association was funded and from then on this lay organisation, supported by ‘experts-in-the-field’, strived for coordination of care and dissemination of knowledge on HD. Specialised nursing homes, taking care of late stage HD patients, improved their quality of care through many years of practice based experience. From 2007 on these institutes supported the initiative from the lay organisation to develop a network for knowledge and multidisciplinary care. Aims How to make quality care available to all Dutch HD patients and their families and how to find evidence for this care. Methods In the formation of a nationwide network (Huntington Network Netherlands, HNN) of professionals and lay experts harmonisation of guidelines, education and research projects are initiated. To develop this network regular meetings are organised and exchange of professionals is enabled. International guidelines are discussed in groups of para-medic professionals. Availability of knowledge, advice and support is provided from either the HD association or professional members of the network. Results Regular meetings of a steering committee lead to the formation of this solid network which already resulted in consensus on education programmes. Close contact with academic research groups will lead to practice driven research proposals. A front office with easy access to knowledge for HD-patients, families, and care workers at home will be developed. Conclusions and future perspectives Nationwide similarity in education for nurses, paramedical and medical personnel leads to easy access to practice based care for patients and family. Allignment of clinimetric instruments may lead to research projects on efficacy of treatment regimens.