Better Antibiotic Stewardship Needed for Older Patients in Home-Based Care

Antibiotic prescriptions for conditions in which antibiotics are not commonly indicated were prevalent among veterans with dementia receiving home-based care.

The rate of antibiotic prescription fills was found to be substantial among older patients with dementia receiving home-based care between 2014 and 2018. More than two-thirds of prescribed antibiotics were for conditions in which antibiotics are not commonly indicated, and most prescriptions were for quinolones. These study findings were published in Open Forum Infectious Diseases.

Researchers conducted a national cohort study among 39,861 veterans (age, ≥65 years) with dementia who received at least 2 home-based primary care visits within 1 year from clinicians within the Veterans Affairs health care system between January 2014 and December 2018. The researchers evaluated the rate of intravenous, oral, intramuscular, and enema-based antibiotics prescribed within 3 days before or after a home-based visit. They also calculated the number of prescription fills and days of therapy per 1000 days of home-based care.

Among 39,861 patients included in the final analysis, the median age was 85 (IQR, 78-90) years, 97% were men, and 15% were Black. In addition, the median follow-up duration was 512 (IQR, 257-935) days, and 57.6% of patients died within the follow-up period. Of 16,956 (42.5%) patients who filled at least 1 antibiotic prescription within the study period, the majority were aged 85 years and older (46.5%), White (74.9%), married (52.0%), and had diabetes (42.2%).

Of 45,122 prescription fills, the most frequently prescribed class of antibiotics was quinolones (24.3%), followed by aminopenicillins (16.6%) and sulfonamides or other related agents (12.3%). The median duration of antibiotic therapy was 7 (IQR, 7-10) days, with an overall antibiotic fill rate of 1.8 fills per 1000 days of home-based care.

This work suggests that the rate of antibiotic use in HBPC approaches the rate of antibiotic use in some nursing homes.

The researchers calculated the antibiotic use rate as 20.7 days of therapy per 1000 days of home-based care. Despite antibiotic use rates varying across geographic regions, there was an overall trend showing a decline in antibiotic use rates during the 4-year study period.

Further analysis showed 67% of the 45,122 antibiotic prescription fills correlated with conditions for which antibiotics are not commonly indicated. These conditions included essential hypertension, uncomplicated diabetes, organic brain syndromes, and viral infections.

The remaining antibiotic prescription fills were prescribed for conditions in which antibiotics are always (14%) or sometimes (19%) indicated.

Study limitations include the lack of confirmation of actual patient consumption of antibiotics, potential misclassification and documentation errors, and the lack of generalizability outside of a veteran population.

“This work suggests that the rate of antibiotic use in HBPC [home-bound primary care] approaches the rate of antibiotic use in some nursing homes,” the researchers noted. “These data have implications for the design and implementation of antibiotic stewardship interventions tailored to HBPC,” the researchers concluded.

Disclosures: One author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Datta R, Fried T, O’Leary JR, et al. National cohort study of homebound persons living with dementia: antibiotic prescribing trends and opportunities for antibiotic stewardship. Open Forum Infect Dis. 2022;9(9):ofac453. doi:10.1093/ofid/ofac453