Fighting antibiotic resistance in residential aged care

Antibiotic resistance is an urgent problem that needs to be fought on a number of frontiers: in hospitals, animal agriculture, and within in the community.
 
As key prescribers of antibiotics, GPs are right on the frontlines, with a vital role in educating patients within consultations. But there is another area of antibiotic stewardship outside of the consultation room that has its own unique characteristics and challenges – the residential aged care facility (RACF).
 
‘There’s been a lot of research work that has elucidated a problem in RACFs,’ Professor Christopher
Del Mar, GP and Professor of Public Health at Bond University, told newsGP.
 
‘There seem to be some special pressures for GPs who manage patients there, which mean that a lot of patients are being treated with antibiotics, probably without much benefit, and that’s obviously a problem.’
 
One of the main factors presented by RACFs is their particularly frail patient population.
 
‘Because they’re a vulnerable group – they’re elderly, they’re prone to infections, their immune systems are less spritely than they used to be – that means they get prescribed antibiotics more often than people outside nursing homes,’ Professor Del Mar said.
 
Some RACFs may also lack a system for monitoring prescription regimens.
 
‘Quite often we find that people in nursing homes, once they go on antibiotics, never come off them, because there’s a less rigorous process for reviewing what they are taking antibiotic-wise or, in fact, any-drug-wise,’ Professor Del Mar said.
 
There can also be staffing issues at RACFs, which can make ongoing and consistent working relationships difficult for GPs.
 
‘GPs have often reported that staff turnover [at RACFs] is high, and that they never really have a chance to get to know the staff and form a trusting relationship,’ Professor Del Mar said.
 
‘On the other side of the coin, the nursing unit managers can be worried they don’t know the doctors very well.’
 
A situation of ‘too many cooks’ can also result in a lack of accountability and an overreliance on antibiotics at RACFs.
 
‘The decisions are very often made by a whole phalanx of visiting GPs; there’s no resident GP in the place and it’s hard to get help when you want it,’ Professor Del Mar explained.
 
‘So nurses, who are often trained in a hospital setting where they can get the intern or the resident to come if they’re worried about something, feel much more exposed in terms of their responsibility to the residents.’
 
In addition, managing patient and family expectations of treatment can present further challenges for GPs working in RACFs.
 
‘Other pressures GPs talk about are the residents’ relatives, who often, maybe because they feel guilty that their loved one is in a nursing home, sometimes become slightly belligerent, wanting more treatment,’ Professor Del Mar said.
 
‘And so GPs may get an earful from a relative: “Why aren’t they on antibiotics? They’ve got a cough”, that kind of stuff, even though it’s not the kind of cough that would respond to antibiotics.’
 
Professor Del Mar believes many of the unique conditions and challenges presented by RACFs are system-based, meaning a different approach to antibiotic stewardship is required.
 
‘There are things we can do in mainstream, office-based general practice that are rather different to the extra things that go on in residential aged care,’ he said. ‘The information systems are different, the responsibilities are different and the pressures, barriers and enablers are different.

‘I think we need to make a bespoke model for residential aged care.’
 
Professor Del Mar’s upcoming Centre of Research Excellence on Minimising Antibiotic Resistance in the Community [CRE] will have a strong focus on looking into just that – how to support GPs’ antibiotic stewardship within RACFs.
 
‘It’s one of our main streams,’ he said. ‘We’ll probably start by studying the problem with a view to designing interventions, and then testing them.’
 
Professor Del Mar hopes the CRE’s work will help build a better model to help solve the problem.
 
‘Maybe we can borrow from hospital antimicrobial stewardship, which is very different from general practice; [RACFs] are much more institutional,’ he said.
 
‘So perhaps there could be a process for borrowing the best of what happens in hospitals, to combine with the best way we can support GPs in the community.’

aged care antibiotic prescribing antibiotic resistance antibiotics antimicrobial resistance Centre for research excellence general practice research