Guest Writer, Glenn Eldridge, RPh, Chief Operating Officer and Director of Clinical Services, GrandView Pharmacy. There are many challenges when it comes to the use of Antibiotics in the elderly population. Some of the challenges include: difficulty diagnosing infection, predicting antibiotic resistance, dosing antibiotics, drug interactions, adverse effects and the simple over use of antibiotics.
Our elderly population is at a higher risk of health complications due to decreased immunity, chronic illness, increased use of invasive medical devices, increased exposure to organisms, poor nutrition, and immunosuppressive drugs. Therefore, they are a population that is subjected to the highest usage of antibiotics.
In older adults many “classic” signs and symptoms (i.e. fever) of infections or illness may not be present so it makes it difficult to detect infections or illnesses early. Presentation of an infection in the elderly may also be nonspecific, and difficulty with communication can make it even more difficult to diagnosis infection or illnesses in some cases.
All of the factors contributing to the difficulty of diagnosing infections ultimately leads to the overuse of antibiotics. Multiple clinical studies have shown that 60-80% of Long-term care residents are receiving an antibiotic every year. In these populations it has been found that up to 75% of the antibiotics are unnecessary.
So now the vicious cycle begins! The overuse of these drugs leads to antibiotic resistance, and this is not only the case in the elderly, but also in the general population. The over prescribing and use of antibiotics has created a global concern as our bodies have adapted to the consistent consumption of antibiotic medications.
There is a particular concern with in long term care facilities, continuing care retirement communities, and assisted living communities in regards to antibiotic resistance. The residents in these communities are at even more risk due to increased exposure to multiple healthcare systems, increased exposure to antimicrobials, decreased immune system, decreased functional status/hygiene, close contact with other residents and medical staff, and not following infection control polices. All of these factors, which contributes to increased illness/infections, which leads to overuse of antibiotics. This overuse of antibiotics then leads to antibiotic resistance, which can ultimately lead to hospitalization, rehospitalizations, MRSA, VRE, Fluoroquinolone resistance, multi-drug resistant (MDR) and gram-negative bacteria.
So what are some of the solutions? Multiple studies have shown that Urinary Tract Infections (UTI) in our elder population account for the largest portion of inappropriate antibiotic use in long term care settings. UTI’s account for roughly 25% of infections in senior living communities. Therefore, we have to do a much better job of properly identifying UTI’s and treating them appropriately. A basic step that needs to be taken includes reducing the inappropriate use of antibiotics related to UTI’s:
1. Always do a urinalysis/ R & M.
• Pyuria (WBC or leucocyte esterase does not mean there is an infection present)
• No Pyuria rules out infection (dip negative for LE)
2. Presence of bacteria in the urine (a positive culture) does not mean there is an infection present.
• A Negative culture rules out infection
3. If there are inadequate responses within 72 hours consider obstruction, complicated diseases, resistant organisms, or an alternative diagnosis.
Another simple solution is to pay attention to the dosing when the use of antibiotics is necessary. There are some care providers who believe that starting a lower dose of antibiotics and then increasing slowly is the most effective treatment. However, it is generally better to use the adult dose regimen, and then when the treatment has begun adjust for renal function and weight loss. Most antibiotic dose adjustments are necessary when renal dysfunction is present with an expectation of a few specific types of antibiotics.
Adverse effects to antibiotics and other medications is another big problem in our elderly population. There are several easy ways we can help combat this issue. One, solution is to implement a pharmacogenomic testing program. Pharmacogenomics is the study of the role of genome in drug response. Many labs and pharmacies are offering this type testing now. The more progressive institutional-pharmacies will have pharmacist who have had additional training to help interrupt the lab results.
The pharmacogenomics tests are covered under most Medicare D plans, and the test itself is a simple check swap that is taken and sent to the lab. The results are returned and a pharmacist can then interpret the data and make clinical recommendations in regards to a patient’s drug regimen. These test were designed to help determine what drugs actually work with that individual person’s genetic makeup. Therefore, consultant pharmacist can make recommendations to discontinue medications because the person’s body may not be metabolizing it correctly, and therefore, not getting any benefits of the medication.
Lastly, senior living communities need to adopt and implement an antimicrobial stewardship program. Some of the easiest and simplest polices to implement to begin an antimicrobial stewardship program include:
1. Develop a clear guideline for initiating antibiotics
2. Communicate ALL signs and symptoms of infection to the patient’s doctor
3. Consider non-infectious causes
4. Discriminate between colonization and infection
5. Always obtain cultures before antibiotics are started
6. Implement policy and procedures for preventive measures
7. Obtain and provide recent history of recent antibiotic use
8. Change the class of agent when possible and appropriate
9. Pay special attention to stop dates and the duration of therapies
10. Question the role of prophylaxis.
The positive side of this issue is that we have identified that there is a problem, and we recognize that we have to combat it. What I have described are some of the challenges and some simple solutions to get a decent start on the battle against the overuse of antibiotics in our elderly population. There are a lot of great people that work with our older population and by working together we can put an end to this epidemic that is leading to unnecessary illness and mortality.