Combating Infectious Pathogens Through Prudent Prescribing

This month’s issue of Annals of Long-Term Care^® (ALTC) focuses on infections in the long-term care (LTC) setting, where residents and staff are constantly exposed to a variety of bacterial, viral, and fungal pathogens. Although numerous measures can be taken to protect residents from various infections, such influenza vaccinations and enforcing strict hand hygiene practices among the staff, determining how best to proceed when an infection is suspected is challenging, yet this task is crucial to ensuring good outcomes, as demonstrated by our two feature articles.

Historically, antibiotics were prescribed whenever a bacterial infection was suspected. Although antibiotics have saved countless lives and are still an invaluable tool to combat bacterial infections, their overuse has contributed to the emergence of antimicrobial resistance, which is already rendering many of our currently available antibiotics ineffective against many pathogens.  Although some medical specialties, most notably pediatrics, are limiting prescribing of antibiotics, this practice is not yet common in LTC.

In our first article, “Ten Clinical Situations in Long-Term Care for Which Antibiotics are Often Prescribed but Rarely Necessary,” Khandelwal and colleagues outline 10 scenarios in which use of antibiotics have not been found to be beneficial in the LTC setting, such as in patients with asymptomatic bacteriuria, upper respiratory infections, or skin wounds without cellulitis, sepsis, or osteomyelitis. As the authors note, in addition to contributing to the emergence of multidrug resistant bacterial strains, overuse of antibiotics can lead to numerous complications in residents, such as antibiotic resistance, adverse drug reactions, multiple drug allergies, and secondary infections with organisms that are difficult to treat, such as Clostridium difficile and Candida albicans. In addition to describing the patient scenarios for which antibiotics are inappropriate, the authors describe what measures can be taken to effectively manage these patients’ symptoms and conditions, such as using supportive care measures (eg, rest, hydration, pain relievers and fever reducers) for patients with upper respiratory infections and consistent wound cleansing and dressing changes for those with skin wounds without cellulitis, sepsis, or osteomyelitis.

In LTC, urinary tract infection (UTI) is the second most commonly encountered infection, the most common cause for hospital transfer due to a bacterial infection, and a common reason for antibiotic use, accounting for between 30% and 50% of all antibiotic prescriptions in this setting. In our second feature article, “Urinary Tract Infections in Older Adults Residing in Long-Term Care," Genao and Buhr provide a comprehensive overview of UTIs in LTC, outlining their epidemiology, risk factors and pathophysiology, microbiology, diagnosis, laboratory assessment, and management in symptomatic patients.  Like Khandelwal and colleagues, the authors note that asymptomatic patients should not be treated; however, they acknowledge that symptomatic UTIs can be difficult to diagnose in LTC residents due to a variety of factors, including comorbidities that mimic symptoms of UTI, high prevalence of indwelling urinary catheters, communication difficulties from cognitive impairment, and the lack of a gold-standard laboratory test to confirm the presence of a symptomatic UTI. Until more definitive data are available regarding the diagnosis and management of UTI in the LTC settings, the authors suggest that guidelines established by McGeer and colleagues and Loeb and colleagues can be used for guidance.

ALTC will be at the American Geriatrics Society 2012 Annual Meeting in Seattle this May. We hope you will take the time to stop by our booth and let us know what you think of the journal, as your feedback is invaluable in helping us shape ALTC to meet your needs.

Thank you for reading!