Keywords: antibiotic therapy, antibiotic resistance, nursing homes, targeted therapy

Background:

In nursing homes (NH), appropriate targeted antibiotic therapy (AT) is essential for the adequate treatment of frail patients with multiple comorbidities and risk infective factors. Often, the choice of the antibiotic must be made promptly based on clinical and epidemiological criteria, keeping the patient in the facility.

Research questions:

Quantification of empirical or aetiological criteria used to select AT with subsequent in-depth examination of the diagnostic and organizational possibilities available to support clinical decisions.

Method:

Analysis of 240 patients registered to 6 GPs, in 3 NHs of ULSS 9 Scaligera (Veneto Region), selecting those with at least one infectious event in 2022 treated with antibiotics. The availability of diagnostic procedures or organizational pathways for the clinical management of patients was analysed using 39 questionnaires out of 70 sent to facilities in the same area.

Results:

Included 86 patients (15% M, 85% F) with 247 infectious events (IE). IE sites: 46.2% urinary tract; 33.6% pulmonary; 10.9% skin; 9.4% others. Main antibiotics used: quinolones 25.4%; amoxicillin+clavulanic acid 17.7%, fosfomycin 17%; cephalosporin 13.3%, sulfonamides 8%, macrolides 7.6%. AT was prescribed empirically in 86% of cases. Availability of diagnostic tests (within 24h / 2x/week / ≤ 1x/week): Blood count/CRP 40.5% - 40.5% -18.9%; Urine cultures 29.7% - 48.6% - 21.6%; Blood cultures: 25% - 22.2% - 8.4%, not available in 44.4%; Skin swabs: 21.6% - 37.8% - 35.1%. Chest X-rays and Abdominal ultrasound were available respectively in 27% - 37.8% - 35.1% and 2.7% - 18.9%- 78.4% with regard to direct access / referral to the emergency department / scheduled examination.

Conclusions:

We have found that in nursing homes, the choice of antibiotic therapy is usually based on empirical criteria, given the need to start treatment early to avoid life-threatening complications. However, diagnostic tests to support clinical decisions regarding targeted antibiotic therapy are not sufficiently available.

Points for discussion:

How can we maintain appropriateness when patient frailty or the severity of infections require empirical antibiotic therapy? (Antibiotic stewardships projects specific to this care setting?)

Targeted antibiotic therapy is more effective in combating antimicrobial resistance (AMR): however frail patients usually need to be treated early and locally, where diagnostic tools are not readily available to reach an aetiological agent. How can we improve the critical issues relating to the organization of diagnostic pathways and the lack of availability of diagnostic tools? (Preferential pathways for nursing home residents? POCT tools? POCUS?)