ABSTRACT
The overall approach to medication management in the long-term care setting remains an important topic of practical and clinical significance for clinicians. The number of residents receiving care in nursing homes in
the United States on any given day has increased by 27% over the years from 1.28 million in 1977 to 1.63 million in 1999 (see also Chapter 1). The percentage of residents aged 65 years and older has also increased during this time span from 13% of residents were under 65 years of age in 1977 to less than 10% of residents in 1999 (1). Traditionally, clinicians have hospitalized long-term care residents following the diagnosis of an infection. More recently, treatment of the long-term care resident occurs within the long-term care facility (LTCF). The availability of well-tolerated and effective oral and intramuscular antimicrobial agents (e.g., fluoroquinolones and ceftriaxone) has provided greater options in therapeutic management in the LTCF. The availability of newer and more potent medications is certainly not without risks. In one study, 40% of long-term care residents were prescribed drugs that were thought to be inappropriate by a panel of geriatricians and geropharmacologists (2). The average number of medications used by residents in LTCFs was reported as 7.2 in a Los Angeles study (2) and 8.1 in a Boston study (3). Antimicrobial agents are among the most commonly prescribed drugs in LTCFs except for gastrointestinal drugs, analgesics, and psychoactive medications (3). Antimicrobial usage may seem disproportionately low compared with the 1.5 million infections observed in the long-term care setting annually (4), but indiscriminate prescribing of antimicrobial agents with lack of adequate documentation of infection, potential adverse drugs reactions, and emergence of antimicrobial resistance are major concerns (5). Clinicians must thus exercise caution in their approach to antimicrobial prescriptions: vulnerable populations, for example frail elderly persons residing in LTCFs, need particular consideration because of the additional increased morbidity and mortality associated with age-related decline in immune function, debility, and comorbid illnesses (diabetes mellitus, cerebrovascular accidents, alcoholism, malnutrition, etc.). There should be a rational approach to antimicrobial prescribing in residents of LTCFs, with focus on age-related physiologic, pharmacokinetic, and pharmacodynamic changes that can affect the selection and dosing of such chemotherapeutic agents.
