Antimicrobial use in Residential Care Facilities and Nursing Homes

Antibiotic guidance for the most common infections treated in residential care facilities are listed below. Further guidance on antimicrobial use for other indications is available under ‘Conditions & Treatments’ on the website homepage.

Urinary Tract Infections

• UTIs are the most common infection treated with antibiotics in residential care facilities.
• 50-70% of frail elderly residents have asymptomatic bacteriuria so it is important only to treat symptomatic patients rather than positive urinalysis reports.
• Urine dipsticks are not a useful guide to management in assessing evidence of UTI for residents over 65 years in residential care and are not recommended. (see below for further information on the SKIP THE DIP for UTI in over 65s campaign)
• It is not advisable to send a MSU unless a patient is symptomatic.
  • UTI in Residential Care Facilities/Nursing Homes
  • Recurrent UTI in adult, non-pregnant females
  • Deprescribing UTI prophylaxis
  • View all UTI guidelines

Respiratory Tract Infections

• Pneumonia (including aspiration pneumonia) in nursing homes/ residential care facilities.
• Infective exacerbation of COPD.
• Influenza.
• COVID-19.
• Azithromycin prophylaxis in adults with respiratory disease.

Skin and Soft Tissue Infections

• Cellulitis
• Shingles

Other

• Clostridioides difficile infection.

• Antimicrobial Stewardship Resources for Residential Care .pdf (size 996.5 KB)
• Infographic of key findings and recommendations from Antimicrobial PPS in HSE RCFs for Older Persons 2020/2021
• Infographic of key findings and recommendations from Antimicrobial PPS in HSE Mental Health 2021/2022
• Preferred antibiotic use in the Community Green/Red Table 
• Good Practice Points for antibiotics April 2024.pdf (size 665.9 KB)
• Supporting pneumococcal vaccination in long-term care facilities
• Position statements for the use of dipstick urinalysis in assessing evidence of UTI in adults
• SKIP THE DIP - Improving the Assessment of Suspected Urinary Tract Infection webinar, 13th October 2023. (YouTube link)
• SKIP THE DIP - Improving the Assessment of Suspected Urinary Tract Infection Slide Deck 13th October 2023 (PDF / size 3.9 MB)
• Decision Aid for Management of Suspected UTI in Older Persons (over 65yrs) in Residential Care.pdf (size 736.4 KB)
• E-learning: AMRIC Infection Prevention and Control & Antimicrobial Stewardship online education learning programme has an accredited course on ‘Prevention and Management of Urinary Tract Infection’. 
• HSEland e-learning module: Pneumococcal Polysaccharide Vaccine (PPV23) 
•  See below for further information on the SKIP THE DIP for UTI in over 65s campaign

SKIP THE DIP for UTI in over 65s is a quality improvement initiative in HSE older persons residential care facilities (RCFs) led by HSE Community Antimicrobial Pharmacists and the HSE Quality and Patient Safety Office, in collaboration with the national AMRIC team. Commencing in September 2023, this new initiative aims to reduce the levels of inappropriate prescribing for urinary tract infections (UTIs) in people aged 65 years and older.

UTIs are the most common reason for antibiotic prescribing in older persons RCFs. The diagnosis and management of UTI can be challenging in older persons. Asymptomatic bacteriuria (ASB) is the presence of bacteria in the urine without symptoms of a UTI. It can be present at any age but is particularly common in those aged over 65 years and is very common in those persons with an indwelling urinary catheter. Urine dipstick tests are not a useful marker to assess for evidence of UTI in older people as they do not distinguish between ASB and UTI. ASB can lead to positive results for markers of UTI in urine dipstick tests, even in those without a UTI.

Inappropriate use of urine dipstick tests can lead to unnecessary antibiotic prescribing.  This does not benefit the resident and may cause considerable harm including adverse effects, drug interactions and antimicrobial resistance.  The diagnosis of a UTI should be based on clinical signs and symptoms of UTI in those aged 65 and older, not a urine dipstick test result. Antibiotics should be prescribed in line with national guidance available at www.antibioticprescribing.ie 

The following resources are available to support the SKIP THE DIP for UTI in over 65s quality improvement initiative:

• Decision Aid for management of suspected UTI in older persons RCFs
• Older persons RCF staff handbook on SKIP THE DIP initiative
• Older persons information leaflet on UTI
• SKIP THE DIP poster for older persons RCFs
• National Position Statement on dipstick urinalysis for assessment of UTI
• SKIP THE DIP - Improving the Assessment of Suspected Urinary Tract Infection webinar, 13th October 2023. (YouTube link)
• SKIP THE DIP - Improving the Assessment of Suspected Urinary Tract Infection Slide Deck 13th October 2023 (PDF / size 3.9 MB)

Successive HALT studies in long-term care facilities (in 2010, 2012, 2013 & 2016) have shown that Irish Nursing home residents are prescribed far more antibiotics than their European counterparts. Antibiotics are most commonly prescribed for urinary tract infection (UTI), respiratory tract infection (RTI) and skin and soft tissue infection (SSTI).

These findings were echoed and expanded upon in an antibiotic point prevalence survey conducted by CHO-based antimicrobial pharmacists in HSE Older Persons residential care facilities between October and December 2020 (for CHO 1,3,4,5,8) which was expanded to CHO 2,6,7,9 between April-August 2021. This study found that:

• 12% of residents were prescribed antibiotics on the day of survey (compared to a European rate of 4.9% in 2016).
• 6.3% of residents were prescribed prophylactic antibiotics, mainly for recurrent UTI (compared to a European rate of 1.5% in 2016).
• Prophylactic prescriptions accounted for 50% of all active antibiotic prescriptions and 66% of those were in excess of 6 months duration.
• Report of the findings of the Point Prevalence Survey of Antimicrobial Use in HSE Older Persons Residential Care Facilities 2021 (CHO 1,3,4,5,8)
• Report of the findings of the Extended Point Prevalence Survey of Antimicrobial Use in HSE Older Persons Residential Care Facilities 2021 (includes CHO 2,6,7,9) 

A further study was conducted in a sample of HSE Mental Health residential care facilities by CHO-based antimicrobial pharmacists between November 2021 and January 2022 (CHO 1, 4, 5, 6, 7, 8, 9). This study found that:

• 6.3% of residents were prescribed antibiotics on the day of survey.
• 3.3% of residents were prescribed prophylactic antibiotics, accounting for over 50% of total antimicrobial use.
• Report of the findings of a Point Prevalence Survey of Antimicrobial Use in HSE Mental Health Residential Care Facilities 2022.pdf (size 2 MB)