Dallas, TX—Pharmacists are often asked to fill fluoroquinolone antibiotic prescriptions for patients living in long-term care (LTC) facilities. A new study asks whether that should be happening as much as it is.

The article in the Journal of the American Geriatrics Society points out that antibiotics are the most frequently prescribed class of medication in LTC, with fluoroquinolones being the most common.

Yet, according to Texas Tech University Health Center School of Pharmacy researchers, those antibiotics present considerable risks for patients aged 60 years or older, especially if they are receiving concomitant systemic corticosteroids.

The study team sought to assess the appropriateness of antimicrobial use to foster antimicrobial stewardship practices, as well as to minimize the risk of adverse events in as high-risk population. To do that, researchers conducted a retrospective chart review in 19 for-profit LTC facilities in patients prescribed an orally administered fluoroquinolone from September 1 to November 30, 2018.

The study determined the appropriateness of fluoroquinolone use based on a composite of three factors:
• Duration
• Dosage based on indication
• Dosage based on renal function

At the same time, the researchers sought to determine the number of patients with a risk factor for an FDA warning for fluoroquinolone use, including age older than 60 years, concomitant QT-prolonging medications, concomitant corticosteroids, and a risk for drug-drug interactions.

Included in the study were 200 patients, 48% male, who received at least one fluoroquinolone order within the study period. Results indicate that 222 oral fluoroquinolone orders were issued for either levofloxacin (61%), ciprofloxacin (38%), and moxifloxacin (1%).

Researchers determined that the most common indications were urinary tract infection (27%) and pneumonia (13.5%), with 39% noting no indication. Overall, 33 orders (15%) met all three individual components of the composite criteria for appropriate prescribing, although nearly (47%) of the orders had missing data, primarily serum creatinine and indication for use.

The authors emphasize that most patients (89%) had at least one risk factor for a serious adverse event, primarily age older than 60 years. Still, 26% of orders had one or more scheduled QT-prolonging medications, and 2.7% received an oral corticosteroid.

The study also found that 28% of the 61 positive culture and sensitivity reports came back as fluoroquinolone resistant, although six of those patients continued to receive the antibiotic.

“These findings indicate that fluoroquinolone prescriptions in LTC patients are routinely inappropriate and/or lack visible criteria to determine appropriateness,” the authors write. The large amount of missing data can hinder stewardship efforts in the LTC setting. This is an important consideration given the Centers for Medicare & Medicaid Services initiatives to optimize antimicrobial stewardship in LTC.”

The researchers warn that fluoroquinolones are primarily being used in at-risk LTC patients despite FDA warnings and precautions issued over the past several years, adding,

“Concomitant QT-prolonging agents are a modifiable risk factor that was present in 26% of patients in our sample. Antibiotic choices can be limited by allergy history (e.g, penicillin), but 86% had no known drug allergies. The indiscriminate use of fluoroquinolones in at-risk patients can result in avoidable severe adverse events including glycemic disturbances, aortic aneurysm, tendon rupture, Clostridioides difficile infections, and even psychosis. Fluoroquinolone-induced psychosis increases the risk of a prescribing cascade (e.g, prescribing of psychotropic medication).”

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