Antimicrobial use and infections in Finnish long-term care facilities

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Background and aims. The rapidly growing ageing population results in a demand for new types of housing that may face the same challenges as nursing homes (NHs) do today. Elderly persons are at particular risk for healthcare-associated infections, since few long-term care facilities (LTCFs) have in-house expertise in infection control or in infectious diseases. This may lead to inappropriate prescription of antimicrobials and promote development of multidrug-resistant bacteria. The movement of residents between LTCFs and acute-care hospitals facilitates the spread of resistant bacteria. The aim of the present study was to determine the use of antimicrobials and prevalence of infections in LTCFs in Finland. An additional aim was to evaluate the feasibility of different methods in assessing antibiotic use and prevalence of infections in LTCFs. Methods. A team comprising an infectious disease consultant, an infection control nurse, and a geriatrician visited all 123 LTCFs for elderly persons in the Central Finland Healthcare District during 2004 2005. The site visits consisted of a structured interview concerning patients, ongoing systemic antimicrobial use, diagnostic practices for urinary tract infection (UTI), and monthly amount in liters of alcohol-based hand rubs used and in patient-days. Following the visits, regional guidelines for prudent use of antimicrobials in LTCFs were published and the use of antimicrobials was followed up by an annual questionnaire during 2006-2008. All residents present in nine voluntary NHs for ≥ 24 hours (n = 5,791) and receiving systemic antimicrobials on the day of the survey were included in the study. Data on antibiotics and their indications (prophylaxis or treatment, type of infection) were collected in April and November 2009 and May-September 2010. All residents for whom a Minimum Data Set (MDS) form (n = 12,784) was completed in 753 LTCFs using a Resident Assessment Instrument (RAI) in April and September 2011 were included. Results. The proportions of patients receiving antimicrobials in surveys varied between 10% and 19%. Most of the antimicrobials were used for UTI prophylaxis (42-69%) and treatment (13-25%). The proportion of patients on UTI prophylaxis decreased in the Central Finland Healthcare District from 13% to 6% and in eight NHs from 12% to 6%. The most common antimicrobial used was methenamine (36-44%), followed by trimetoprim (14-31%), cephalexin (6-9%), and pivmecillinam (6-11%). In Central Finland Healthcare District LTCFs, the total amount of alcohol-based hand rub used increased by 70%, from the mean (SD) of 7.3 (5.1) L/1000 patient-days on the baseline visit in 2005 to 12.4 (14.9) L in 2008. In LTCFs using RAI, the risk factors for antimicrobial prescription included female sex, age < 85 years, urinary catheter, urinary incontinence, confusion, restriction to bed, pressure ulcers, diarrhea, and hospital stay during the previous 90 days. Conclusions. Antimicrobial use was common in Finnish LTCFs and most were used for UTI prophylaxis and treatment. The decrease in antimicrobial usage during the surveys suggests that LTCFs may benefit from antimicrobial stewardship interventions focused on UTI. The multidisciplinary team succeeded in promoting hand hygiene in LTCFs, which was sustained over the 3-year follow-up. RAI with MDS data also constitutes a feasible tool for collecting data on antibiotic use and infections in LTCFs.

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