Senior Care Pharmacy Services Update: Unnecessary Antibiotic Use Risks

At Grane Rx, we’re committed to providing the highest-quality senior care pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to long term care pharmacy and PACE pharmacy. Antibiotics account for 20 percent of all drug-related emergency department visits in the United States. This is a major cause of concern because while these are some of the commonly prescribed medications, they are not always necessary and/or appropriate. As antibiotic stewardship continues to gain momentum and become implemented at Skilled Nursing Facilities, the overprescribing of antibiotics should decrease. Until this happens, it’s important for LTC pharmacy services providers to be aware of what’s happening to/with your residents and the different risks associated with unnecessary antibiotic use. The most consequential risk from unnecessary antibiotic use is an increase in antibiotic resistance. As defined by the Centers for Disease Control and Prevention (CDC), antibiotic resistance is the ability of microbes to resist the effects of medications. The microbes are not killed, and thus their growth is not stopped. Simply using antibiotics creates resistance. When antibiotics are prescribed, they kill the bacteria causing the illness and the good bacteria protecting the body from infection but leave the few drug-resistant bacteria behind. The drug-resistant bacteria then grow and take over.  They even have the ability to give their drug resistance to other bacteria, which worsens the issue. These drug-resistant bacteria can then be spread from person to person or from nonhuman sources in the environment such as animals to humans.

Drug-resistant Threats to Be Aware of in Senior Care Pharmacy Services

The CDC identified the Top 18 Drug-Resistant Threats to the United States and categorized them as either being urgent, serious or concerning. Urgent Threats. Urgent threats are high-consequence antibiotic-resistant threats. These may not be currently widespread, but they have the potential to become so and require urgent public health attention to identify infections and to limit transmission.
  1. Clostridium difficle (C. Diff)
  2. Carbapenem-resistant Enterobacteriaceae (CRE)
  3. Drug-resistant Neisseria gonorrhoeae (cephalosporin resistance)
Serious Threats. Serious threats are significant antibiotic-resistant threats. These have the potential to worsen and may become urgent without ongoing public health monitoring and prevention activities.
  1. Multi-drug resistant Acinetobacter
  2. Drug-resistant Campylobacter
  3. Fluconazole-resistant Candida (a fungus)
  4. Extended spectrum beta-lactamase producing Enterobacteriaceae (ESBLs)
  5. Vancomycin-resistant Enterococcus (VRE)
  6. Multidrug-resistant Pseudomonas aeruginosa
  7. Drug-resistant Non-typhoidal Salmonella
  8. Drug-resistant Salmonella Typhi
  9. Drug-resistant Shigella
  10. Methicillin-resistant Staphylococcus aureus (MRSA)
  11. Drug-resistant Streptococcus pneumonia
  12. Drug-resistant tuberculosis (Mycobacterium tuberculosis and extensively drug-resistant tuberculosis)
Concerning Threats. Concerning threats have a low threat of antibiotic resistance and/or multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness—these threats require monitoring and, in some cases, rapid incident or outbreak response.
  1. Vancomycin-resistant Staphylococcus aureus (VRSA)
  2. Erythromycin-resistant Streptococcus Group A
  3. Clindamycin-resistant Streptococcus Group B
These resistant organisms have become more common as a result of unnecessary antibiotic use and are increasingly difficult to treat. A resident infected with antibiotic-resistant bacteria could experience more severe illness, increased mortality rates and an increased risk of complications, including admission to the hospital. If the amount of unnecessary antibiotics prescribed does not decrease, the World Health Organization predicts a post-antibiotic world where healthcare advances over the past 100 years would be null and simple infections would become unmanageable and potentially fatal—in part from unnecessary antibiotic use and the continued growth of antibiotic-resistant organisms. [Tweet “Learn the latest on antibiotic misuse in this #seniorcarepharmacyservices update”]

Adverse Effects Caused by Unnecessary Antibiotic Use in Senior Care Pharmacy Services

Another risk associated with the increased use of unnecessary antibiotics is the increased potential for adverse effects. Some of these are more closely related to certain classes of antibiotics, while others are broad and go across the board.
  • Nausea. Nausea is one of the most common adverse effects associated with antibiotics. This is especially problematic for long term care pharmacy providers when working with elderly residents who don’t have an appetite to eat or may be experiencing weight loss.
  • Renal Toxicity. Renal toxicity is another issue more commonly associated with our elderly residents. It occurs when a resident has declining renal function. Many antibiotics are renally eliminated, so unnecessary use has the potential to add to the renal toxicity and declining renal function a resident may already be experiencing.
  • Clostridium difficile (C. diff). The development of C. diff is another very serious complication that can occur from antibiotic use and, especially, unnecessary antibiotic use. This is a very debilitating disease that is also incredibly contagious. The antibiotics that are most commonly associated with C. diff are clindamycin, fluoroquinolones such as ciprofloxacin and levofloxacin and broad-spectrum (3rd and 4th generation) cephalosporins such as ceftriaxone and cefepime.
  • Cardiotoxicity. Cardiotoxicity is more commonly seen with quinolones and macrolides and occurs via QT interval prolongation.
  • Musculoskeletal toxicity. Musculoskeletal toxicity such as tendon rupture is commonly seen with quinolones.
  • Others. Other adverse effects seen with antibiotics are anaphylaxis and other allergic reactions, blood disorders such as anemia, leukopenia and thrombocytopenia, and dermatological reactions such as rash and Stevens-Johnson Syndrome.
Incidences of all of these adverse effects would be decreased with the elimination of unnecessary antibiotic use.

How Unnecessary Antibiotic Use Increases the Risk of Drug Interactions in Senior Care Pharmacy Services

A final risk associated with unnecessary antibiotic use is the increased occurrence of drug-drug interactions. Many common medications elderly residents take on a daily basis (such as warfarin) interact with antibiotics. Continuing to use antibiotics without a proper indication has the potential to add adverse interactions. If a resident has been placed on an antibiotic and then a maintenance medication is changed as a result, this places unneeded burden on the resident and nursing staff. There is also the potential for the changed maintenance medication to not be changed back to its appropriate dosing upon completion of the antibiotic. Avoiding unnecessary antibiotic use would eliminate the increased drug-drug interaction risk. It is important for senior care pharmacy services providers and other long term care staff to be aware of the risks associated with unnecessary antibiotic use and to become advocates for decreasing the amount of unnecessary antibiotics prescribed by really knowing what is happening to your residents, following appropriate prescribing guidelines and becoming advocates for appropriate antibiotic stewardship. At Grane Rx, we treat your residents with the utmost care. Our team of PharmDs specializes in caring for the unique needs of the geriatric population. Sign up here for a free consultation to learn how we can put our care to work for your Skilled Nursing Facility.]]>

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