Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
J Am Med Dir Assoc. 2023 Nov;24(11):1619-1628. doi: 10.1016/j.jamda.2023.06.034. Epub 2023 Aug 9.
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
一种改善养老院抗生素处方的方法是评估开始抗生素治疗的适宜性。然而，确定适宜性一直是一个挑战。为了解决这个问题，文献综述确定了评估养老院开始抗生素治疗适宜性的研究。最常使用两个标准来评估适宜性：感染监测标准或专门设计用于协助临床医生开抗生素处方的标准。对这些标准的制定和使用这些标准的研究结果进行了回顾。对于这些标准，开始治疗的适宜性百分比存在相当大的差异，进行这些研究的方法存在差异，并且标准存在局限性。感染监测标准的主要局限性在于它们专门设计为高度特异性，但这导致敏感性低。因此，不应使用监测标准来评估抗生素治疗的适宜性。另一个标准是有限的，因为它只使用感染的定位体征和症状，并且在回顾性评估适宜性时，这些发现可能不会记录在医疗记录中。确定了几种替代方法来评估适宜性，但尚未发表对这些方法的评估。建议进行一些更改以改善对养老院居民开始抗生素治疗适宜性的评估：卫生与公众服务部和医疗保险和医疗补助服务中心确认监测定义不应用于评估适宜性；为居民制定和验证临床感染的定义；通过设施抗菌药物管理计划前瞻性地评估适宜性的方法标准化；教育临床医生和护理人员评估适宜性的标准；并调查提供者、居民、家庭和设施层面因素对养老院居民抗生素使用的影响。
