A surreal illustration representing the challenges of antimicrobial prescribing in long-term care facilities.

Decoding Antimicrobial Prescriptions: Are Second-Line Drugs Overused?

Kai Mendoza in Health & Wellness June 2025 • 4 min read.

"A deep dive into long-term care facilities reveals a potential overuse of second-line antimicrobials, highlighting the need for better education and prescription practices."

Antimicrobial resistance is a growing global health threat, and one of the key battlegrounds in this fight is within long-term care facilities (LTCFs). These facilities, which house a significant portion of the elderly and vulnerable populations, are often hotspots for infection and, consequently, antimicrobial use. While antimicrobials are essential for treating infections, their overuse and misuse can lead to the development of resistant bacteria, making infections harder to treat.

A recent study published in the Journal of the American Medical Directors Association (JAMDA) sheds light on antimicrobial prescribing practices in Irish LTCFs. The research, titled 'Improving Antimicrobial Prescribing: A Multinomial Model Identifying Factors Associated With First- and Second-Line Prescribing,' reveals a concerning trend: a significant proportion of antimicrobials prescribed are second-line agents, which should ideally be reserved for cases where first-line options have failed.

This article will delve into the findings of the JAMDA study, exploring the factors that contribute to the overuse of second-line antimicrobials in LTCFs. We will also discuss the implications of these findings and highlight potential strategies for improving antimicrobial prescribing practices, ultimately aiming to protect both individual residents and the broader community from the threat of antimicrobial resistance.

Why Are Second-Line Antimicrobials So Common in Long-Term Care?

A surreal illustration representing the challenges of antimicrobial prescribing in long-term care facilities.

The JAMDA study, led by Meera Tandan and colleagues, analyzed data from a point prevalence survey conducted in 77 LTCFs in Ireland. The survey included detailed information on resident characteristics, antimicrobial prescriptions, and facility-level factors. The researchers categorized antimicrobials as either first-line or second-line based on Irish national prescribing guidelines, which prioritize narrow-spectrum agents as first-line options for common infections.

The study revealed that nearly half (46%) of the antimicrobials prescribed in these LTCFs were second-line agents. This finding raises several questions about the appropriateness of antimicrobial prescribing practices. Why are second-line antimicrobials being used so frequently? What factors are driving this trend?

Interfacility Variation: The study found significant variation in prescribing practices between different LTCFs, suggesting that local factors play a crucial role.
Prescriber Education: LTCFs that provided education and training on antimicrobial prescribing were significantly less likely to use second-line antimicrobials.
Gender Differences: Male residents were less likely to be prescribed first-line antimicrobials compared to female residents.
Catheter Use: Residents with urinary catheters were more likely to receive first-line antimicrobials.

These findings suggest that a combination of factors, including lack of education, varying local practices, and patient-specific characteristics, contribute to the overuse of second-line antimicrobials in LTCFs. Addressing these factors is crucial for improving antimicrobial prescribing and combating resistance.

Taking Action: Promoting Antimicrobial Stewardship in Long-Term Care

The JAMDA study provides valuable insights into antimicrobial prescribing practices in LTCFs and highlights the need for targeted interventions to promote antimicrobial stewardship. By focusing on education, training, and evidence-based guidelines, we can empower healthcare professionals to make informed decisions about antimicrobial use, ultimately protecting vulnerable residents and preserving the effectiveness of these life-saving drugs.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.jamda.2018.10.028, Alternate LINK

Title: Improving Antimicrobial Prescribing: A Multinomial Model Identifying Factors Associated With First- And Second-Line Prescribing

Subject: Health Policy

Journal: Journal of the American Medical Directors Association

Publisher: Elsevier BV

Authors: Meera Tandan, Karen Burns, Helen Murphy, Sarah Hennessy, Martin Cormican, Akke Vellinga

Published: 2019-05-01

Everything You Need To Know

What did the JAMDA study reveal about the use of second-line antimicrobials in long-term care facilities (LTCFs), and what factors might contribute to this?

The JAMDA study, analyzing data from 77 Irish LTCFs, revealed that nearly half (46%) of prescribed antimicrobials were second-line agents. This suggests a deviation from guidelines that prioritize narrow-spectrum, first-line antimicrobials for common infections. Factors contributing to this include interfacility variation, prescriber education levels, gender differences in prescribing, and catheter use. The study implies that the selection of antimicrobials in LTCFs isn't consistently aligned with best practices, increasing the risk of antimicrobial resistance.

What does antimicrobial stewardship entail in long-term care facilities, and how can it help reduce the overuse of second-line antimicrobials?

Antimicrobial stewardship in LTCFs involves implementing strategies to optimize antimicrobial use. Key components of effective stewardship include prescriber education on appropriate antimicrobial selection and dosing, using evidence-based guidelines, and monitoring antimicrobial use to identify areas for improvement. By focusing on these areas, healthcare professionals can make more informed decisions about antimicrobial use, reducing the reliance on second-line antimicrobials and mitigating the risk of resistance.

How does prescriber education impact the usage of second-line antimicrobials according to the JAMDA study?

The JAMDA study found that LTCFs providing education and training on antimicrobial prescribing were significantly less likely to use second-line antimicrobials. This underscores the importance of ongoing education for healthcare professionals in LTCFs. Targeted education can improve understanding of antimicrobial guidelines, promote the appropriate use of first-line agents, and ultimately reduce the overuse of second-line antimicrobials.

Were there any gender-based differences observed in antimicrobial prescriptions within the long-term care facilities studied, and what could this indicate?

The study identified gender differences in antimicrobial prescribing, with male residents less likely to receive first-line antimicrobials compared to female residents. While the specific reasons for this disparity are not fully explored, it suggests potential biases or differing clinical assessments based on gender. This finding highlights the need for further research to understand and address these gender-based differences in antimicrobial prescribing practices to ensure equitable care.

How does the overuse of second-line antimicrobials in long-term care facilities contribute to the broader issue of antimicrobial resistance?

The overuse of second-line antimicrobials in LTCFs contributes to the broader problem of antimicrobial resistance. When bacteria are frequently exposed to broad-spectrum antimicrobials, they are more likely to develop resistance mechanisms. This resistance can then spread within LTCFs and beyond, making infections harder to treat and potentially leading to increased morbidity and mortality. By prioritizing first-line antimicrobials and implementing robust antimicrobial stewardship programs, LTCFs can play a critical role in slowing the spread of antimicrobial resistance and preserving the effectiveness of these essential drugs.