Factors influencing antimicrobial resistance in residential care homes

A brief literature review by Christine Amedor

I am Christine, a third-year Medical Physiology undergraduate at the University of Leicester who recently worked alongside the SAPPHIRE research team as part of a 3-week ‘Accelerate your career’ internship. This blog post is one of the by-products of my work on the ‘Preserving Antibiotics though Safe Stewardship’ project. I predominantly aided the team in searching the existing literature for factors which influence antibiotic prescribing in residential care. The results of this are presented below.

Antibiotic resistance has become a major public health problem – even more so in residential care homes where there are higher rates of antibiotic use. There is a need for the development of interventions; to effectively deal with the root causes of antibiotic resistance.

Increased antibiotic use in residential care is particularly evident concerning urinary tract infections (UTIs) which is frequently connected to antibiotic-resistant organisms that lead to infections, resulting in increased hospital admissions. Studying the factors which can influence or contribute to the higher antibiotic prescribing rates in residential care homes has allowed me to gain further insight into the problem. Research has shown that individuals with catheters can be misdiagnosed with infections due to the presence of bacteria within the bladder, thereby leading to increased antibiotic prescriptions.

Another example of a factor which can lead to antibiotic misuse is the lack of antibiotic-related training. This is particularly evident as a recent study by Thornley et al. (2019) on antimicrobial use in long term care facilities revealed that after community pharmacists assessed a total of 644 long-term care facilities (LTCF) in a survey, only 6.8% had any antibiotic related training. During the survey, the community pharmacists were required to intervene in 9.5% cases of antibiotic prescriptions, showing just how much of a problem antibiotic misuse is. Therefore, residential care homes who do not educate their nursing staff on antibiotic training may mean that their understanding of the dangers of antibiotic resistance may be limited. The high staff turnover can make this even more challenging to implement good antimicrobial practice and ensure training levels are high.

Perhaps the most shocking discovery from the literature was how central the nurses (who worked in the nursing homes) were in the decision-making process during treatment i.e. the prescribing of an antibiotic. In a study by Schweizer et al. (2005), most GPs reported that they accepted the nursing staffs’ assessment and seldom visited patients in nursing homes for a UTI. This implies that should nursing staff be untrained in correct antibiotic usage, it is very much likely that the GP would still accept their decision for a prescription.

The relationship between the healthcare services is also an important factor as qualitative studies have shown that interprofessional relationships and inadequate GP visiting arrangements were found to impact prescribing and patient care. This gap in knowledge may be responsible for the high levels of residents being prescribed antibiotics.

The obvious question next is what can be done? What interventions have been put in place? Well, the literature suggests implementing more regular training programmes within residential care homes should support their nursing staff in comprehending the preventative measures, being able to correctly identify the warning symptoms and then accurately prescribe antibiotics. Regular training programmes being run should ultimately be able to combat the implications of the high staff turnover.

In addition, better collaborative working between residential home nursing staff and community healthcare services would allow carers to correctly identify the early signs of infection. Although the government is investing in programmes such as Medicines Optimisation in Care Homes in England to support the staff in residential homes, clearly more needs to be done (and urgently) as only 6.8% of residential homes with antibiotic training is a staggering statistic. This combined with the discovery through this internship that there is limited research in this area (especially in the UK) despite the severity of the problem highlights that more research needs to be carried out.

My experience at SAPPHIRE has been eye-opening to say the least. I was able to witness first-hand what it means to be able to communicate effectively and work collaboratively within a team- something I must really commend the team for. Personally, I was able to enhance my analytical and communication skills by carrying out the tasks I was given and also gained further insight into the rigorous research staging process.

Schweizer, A., Hughes, C., Macauley, D. and O’Neill, C. (2005) ‘Managing Urinary Tract Infections in Nursing Homes: A Qualitative Assessment’, Pharmacy World & Science, 27(3), pp. 159-165.
Thornley, T., Ashiru-Oredope, D., Beech, E., Howard, P., Kirkdale, C.L., Elliott, H., Harris, C. and Roberts, A. (2019) ‘Antimicrobial use in UK long-term care facilities: results of a point prevalence survey’, The Journal of Antimicrobial Chemotherapy.