Optimising antibiotic prescribing across aged care homes
Antibiotics can be life-saving for older people, yet prescribing decisions in residential aged care are often complicated by frailty, dementia, multiple health conditions, communication barriers, and symptoms that do not clearly indicate infection. A network-wide quality improvement project can help care teams make consistent, evidence-informed decisions while protecting residents from avoidable harm.
Brisbane Diamantina Health Partners is well placed to connect aged care providers, clinicians, researchers, universities, and health services around this challenge. By combining local knowledge with shared measures and practical implementation support, the network can translate antimicrobial stewardship research into everyday care.
The goal is not to reduce antibiotic use at any cost. It is to ensure that the right resident receives the right medicine, at the right dose, for the right duration, with a clear review plan and careful attention to comfort, safety, and personal preferences.
Why aged care antibiotic use needs coordinated action
Older residents have higher rates of urinary, respiratory, skin, and wound infections. They also experience higher risks from antibiotic exposure, including adverse drug reactions, drug interactions, Clostridioides difficile infection, and antimicrobial resistance. Symptoms such as confusion, falls, fatigue, or reduced appetite may be mistaken for infection, even when another cause is more likely.
Prescribing can vary between homes, shifts, and medical practices. Differences in assessment skills, access to pathology, after-hours services, documentation, and family expectations may all influence treatment. A shared improvement program creates a common standard without ignoring the clinical judgment required for individual residents.
A network approach also makes it easier to identify system barriers. If several homes report delays in specimen collection, unclear escalation pathways, or limited access to nurse practitioner review, the response can address the underlying workflow rather than focusing on individual prescribers.
Establish a reliable baseline
The project should begin with a baseline review of antibiotic prescribing and infection management across participating facilities. Useful measures include antibiotic starts per 1,000 resident days, treatment duration, indication, documentation of symptoms, urine culture use, hospital transfers, and the proportion of prescriptions reviewed within 48 to 72 hours.
Data should be interpreted alongside resident characteristics and care goals. A home caring for residents with advanced illness may have different prescribing patterns from a facility with a younger, more independent population. Reporting should therefore combine quantitative measures with case reviews, staff interviews, and feedback from residents and families.
Clear definitions are essential. For example, a urinary tract infection should not be recorded solely because a urine test is positive. The project can encourage structured assessment, clinical criteria, and documentation that explains why treatment was started, continued, changed, or stopped.
Create a shared improvement framework
A practical framework can use the same core standards across the network while allowing each home to adapt implementation to its staffing model. Standardised infection assessment tools, antibiotic review prompts, medication charts, and escalation pathways can reduce variation and support safer decisions.
The framework should also include education for registered nurses, enrolled nurses, personal care workers, general practitioners, pharmacists, and visiting specialists. Short, repeated learning sessions are often more effective than a single annual presentation. Topics may include recognising infection, avoiding treatment of asymptomatic bacteriuria, collecting specimens correctly, communicating uncertainty, and documenting treatment goals.
Frailty and functional status should form part of clinical reasoning. Guidance on frailty assessment before surgery illustrates how structured assessment can reveal risks and care needs that may be missed by a diagnosis-focused approach. In aged care, a similar focus can help teams weigh likely benefits, burdens, prognosis, and the resident’s goals before prescribing.
| Improvement area | Shared network measure | Practical change in a care home |
|---|---|---|
| Assessment | Proportion of prescriptions with documented indication and symptoms | Use an infection assessment template before contacting the prescriber |
| Review | Prescriptions reviewed within 48–72 hours | Add a review date and stop or step-down prompt to the medication chart |
| Urinary care | Unnecessary urine cultures and antibiotics | Apply symptom-based criteria before collecting specimens |
| Respiratory care | Antibiotic use for suspected respiratory infection | Use observations, examination, and escalation criteria together |
| Learning | Staff participation and confidence | Provide brief case-based education during handovers |
| Resident partnership | Goals-of-care discussions documented | Include residents, substitute decision-makers, and carers in planning |
Make prescribing safer at the point of care
Decision support should be available when clinicians are busy. A concise pathway can prompt staff to record temperature, respiratory rate, oxygen saturation, pain, hydration, skin findings, urinary symptoms, recent antibiotics, allergies, and changes from baseline. This information gives prescribers a stronger clinical picture than a vague report that a resident “seems unwell.”
Every antibiotic order should include an indication, intended duration, review date, and criteria for escalation. Pharmacists can support medication reconciliation, dose adjustment, renal function checks, and review of interactions. Nurse-led monitoring can identify deterioration early and ensure that residents receiving treatment are reassessed.
Improvement work should also address access to diagnostics. Point-of-care testing may be useful in selected circumstances, but tests should support rather than replace clinical assessment. A positive result without compatible symptoms can lead to unnecessary treatment, while a negative result should not delay urgent care when serious infection is suspected.
Involve residents, families, and carers
Antibiotic stewardship works best when residents and families understand the reasoning behind a decision. Some people may expect antibiotics whenever there is confusion, a cough, or a change in urine appearance. Respectful communication can explain what clinicians have found, what they are monitoring, and when treatment would be reconsidered.
Advance care planning is especially important for residents living with dementia or advanced frailty. Discussions about hospital transfer, intravenous treatment, symptom relief, and comfort-focused care should happen before an acute episode where possible. Research on reducing carer burnout reinforces the value of supporting families who often carry significant emotional and practical responsibilities.
Priority actions for participating homes
- Nominate an antimicrobial stewardship lead and a small multidisciplinary improvement team.
- Introduce a standard infection assessment and antibiotic review form.
- Audit a small sample of prescriptions each month and discuss findings without blame.
- Provide residents, families, and staff with plain-language information about antibiotic decisions.
- Share successful changes, barriers, and resident outcomes across the network.
Engagement should be culturally safe and accessible. Information may need to be available in different languages and formats, with additional support for residents who have hearing, cognitive, or communication difficulties.
Sustain improvement through shared learning
A quality improvement cycle can begin with a small test of change, such as introducing a review prompt on one ward. Teams can measure the effect, gather feedback, refine the process, and expand it gradually. This approach reduces disruption and allows staff to shape tools around real clinical workflows.
Network meetings can provide a forum for comparing results, discussing complex cases, and identifying practices that can be adapted elsewhere. Brisbane Diamantina Health Partners can support this learning through research expertise, education, governance advice, publication opportunities, and connections between health services and academic partners.
Evaluation should consider resident-centred outcomes as well as prescribing rates. These may include treatment-related harm, hospital transfers, symptom relief, functional recovery, satisfaction with communication, and confidence among care staff. A fall in antibiotic use is meaningful only when it occurs alongside safe clinical care and timely treatment for genuine infection.
A coordinated project can turn antimicrobial stewardship from an isolated policy requirement into a routine part of aged care practice. Care homes, health services, researchers, residents, and families can work together to test reliable processes, share evidence, and improve decisions across Queensland. Organisations ready to participate should connect with the Brisbane Diamantina network to develop a shared measurement approach and begin with a focused pilot.
