Critical Appraisal Essay

This essay critically appraises five research articles focusing on antibiotic resistance in elderly patients, particularly those residing in nursing homes. The essay examines the research methodologies, findings, and limitations of each study, providing a comprehensive overview of the growing concern of antibiotic resistance in this vulnerable population. The analysis highlights the importance of effective antibiotic stewardship and the need for further research to address this critical public health issue. Desklib provides past papers and solved assignments for students.

Critical Appraisal Essay

Table of Contents
INTRODUCTION AND BACKGROUND....................................................................................1
Keyword.................................................................................................................................1
Research question............................................................................................................................1
Research methodology.....................................................................................................................1
Inclusion – Exclusion Criteria................................................................................................2
CRITICAL APPRAISAL OF RESEARCH ARTICLES................................................................2
Findings and limitation of the articles.............................................................................................5
Result...............................................................................................................................................7
Discussion......................................................................................................................................10
CONCLUSION..............................................................................................................................11
REFERENCES..............................................................................................................................12

INTRODUCTION AND BACKGROUND
Numerous bacterial diseases are treated with antibiotics. In some cases, the microscopic
organisms change to secure themselves against the anti-microbial. At the point when this
happens, the antibiotics become useless. The problem is termed as antibiotic resistance and it is a
serious concern around the globe. Antibiotic resistance occurs when bacteria can survive despite
the antibiotic treatment causing further infection- the antibiotic is no longer effective against that
bacterial population. Questions may arise to use other antibiotics to which bacterial population
aren’t resistant with. However, it is not a sensible solution as it may create side and adverse
effect and moreover bacteria with grow resistance to that antibiotic too. Exposure of bacteria to
antibiotic for a longer period helps them to develop resistance. Using antibiotic when not needed
and not taken in prescribed time will further assist bacteria to become resistant
(Healthdirect.gov.au, 2018). This article critically reviews the five-research article on the
growing concern of antibiotic resistant.
Keyword
Antibiotic resistance, Bacteriuria, Homes for the aged, Anti-bacterial agents, Family practice,
Urinary tract infection, Antibiotic stewardship, Pneumonia, mortality, infections, Health Care.
Research question
The research question for this article is “antibiotic resistance in elderly people living in nursing
home or aged care facilities to people living in home or community.” Here the population of
interests in elderly people.
Research methodology
For the critical appraisal of the researched article, a reliable data base was selected such as
pubmed, sciencedirect, TUA library, scopus. Article however contains varieties of information
depending upon the types of case studies. Articles contain studies such as retrospective, cross
sectional, retrospective longitudinal cohort.
A recent search was conducted on August 2018 where the articles which were published
between 2007 to 2018 were selected. A keyword research was also conducted in order to point
out refined set of articles. This was done with the help of 2 Boolean operators which were AND
1

& OR. The following search string was taken into consideration “Antibiotic Resistance or
Antibiotic Stewardship and Antimicrobial Resistance and Clinical Outcomes.”
Inclusion – Exclusion Criteria
Basis of Selection Inclusion Exclusion
Date of publication Articles which published after
2007 were selected and
considered for analysis
purpose.
Articles which published
before 2007 were excluded and
were not taken for research and
analysis purpose.
Type of publication Originally, it carried out
cohort studies that were taken
into consideration.
Studies which were not cohort
were excluded and not
considered for research and
analysis purpose.
Exposure of interest Community acquired
infections in older patients,
Antibiotic use in the care
home setting, Antimicrobial
Resistance and Clinical
Outcomes were included in
the study.
Those studies were on older
patients but not related with
antibiotics or its use in care or
home setting were excluded
from the study.
Geographic location of the
study
Studies which were conducted
in context of Australian, UK
and Korea regions were
included and considered for
the research study.
Studies which were undertaken
in any other regions excluding
Australia, UK and Korea were
not taken into consideration.
Language Those articles which were
written and published in
English language were only
considered.
Articles which published in
language other than English
have been excluded from the
study.
2

CRITICAL APPRAISAL OF RESEARCH ARTICLES
In the critical appraisal, strengths and weaknesses of the five selected articles will be
identified in order to assess the usefulness and validity of research findings. In this context, the
critical appraisal of articles will be based on questions which assist in appraising the articles
effectively and efficiently.
“Antibiotic use in the care home setting: a retrospective cohort study analysing routine data”
In the retrospective longitudinal cohort study, researchers examined the use of antibiotic
on patients in care setting and on those who are not in care homes. The data collected from
Hampshire Health and the study aimed to describe the paradigm of antibiotic prescribing on
patients of 75 years and above. The data were collected from Hampshire area, UK which covered
1.24 million residents. Researchers extracted data from 2011 through Hampshire Health Record
(Sundvall and et.al. 2015). It was identified in the study that antibiotics are used mainly to treat
the urinary tract infections (UTI). The strengths of article were effective use of research methods.
The hypothesis of the study explicitly defines the motive of carrying out the study. Researchers
further clearly articulate the strengths and limitations of these articles. The weaknesses were
identified in data analysis where researchers were not able to precisely articulate the data.
“Antibiotic resistance patterns of bacteria causing urinary tract infections in the elderly living
in nursing homes versus the elderly living at home: an observational study”
In the article, researchers focused on resistance of elderly people for consuming
antibiotics in care homes. The study was cross sectional observation study which aims to
compare elderly people urine culture who is living in nursing homes and elderly people living in
their own residents in the particular community. For collection of data on 34 nursing homes by
survey on the research in Vestfold County.
The participants from 65 years and above with positive urine culture has been surveyed
during period from 16 November 2009 to 31st December 2010 (Fagan and et.al. 2015). In the
article, researcher explicitly explained the issues and propose precise hypothesis. Data has been
analysed with the help of SPSS and Pearson Chi2 test which has been used to compare
differences in gender distribution and independent t-test has been selected for comparing mean
age of both the groups.
3

Researcher explicitly articulates the results and establishes a robust conclusion. The
weakness of article was the uncertainty about the compliance of Norwegian guidelines which
were used for urine sampling.
“Community acquired infections in older patients admitted to hospital from care homes versus
the community: cohort study of microbiology and outcomes.”
In the research article, researcher focused on the harmful impact on elderly people living
in home suffering from infections and cannot be treated with antibiotics. Researchers enrolled
the patients of Ninewells Hospital in 2005 and participants were 64 years and above (Marwick
and et.al. 2013). Samples were acquired from respiratory tract, urinary tract or skin and soft
tissue infection.
The strengths of articles were robust analysis of the data collected. Hypothesis of the
study helps in understanding the direction of research. It was cohort study which helps in
comprehending the issues faced by the elderly living in care setting and homes. Comparison was
very effectively made by the researchers that helped in establishing precise meaning.
“Antimicrobial Resistance and Clinical Outcomes in Nursing Home-Acquired Pneumonia,
compared to Community-Acquired Pneumonia”
The focus of the study was comparing antimicrobial resistance and clinical outcomes
between Nursing Home Acquired Pneumonia to Community Acquired Pneumonia. Researchers
carried out an extensive research in order to make robust comparison. Participants surveyed were
above 65 years who suffered from either infection from 2008 to 2014 (Kang and et.al. 2017).
Other patients were excluded from the study. The major strength of the research paper was the
effective analysis which was made by the researchers. Limitations of the article were the
articulation part. Researchers were not able to present and articulate the article in efficient
manner.
“Health Care-Associated Pneumonia and Community-Acquired Pneumonia: a Single-Center
Experience”
In the article researcher made the comparison between patients who have health care
associated pneumonia (HCAP) and Community Acquired pneumonia (CAP). Researchers carried
out retrospective cohort analysis where participants where the different cultured patients visited
4

and diagnosed with pneumonia at Barnes-Jewish Hospital from period between 1st Jan 2003 to
31st December 2005 (Micek and et.al. 2007). The major strength of the article was strong
research design. The research hypothesis was precise and analysis of data was done in efficient
manner. Researchers though fail to explain explicitly about pneumonia. Data collection was done
in appropriate manner by using precise tools and analysis was done by using statistical
applications.
Findings and limitation of the articles
In the retrospective longitudinal cohort study carried out by Sundvall and et.al. (2015)
elaborates the use of antibiotics in care home setting to eliminate the bacterial infections in
elderly people living in those care centres. In order to collect data, authors have selected
Hampshire Health and routine data was gathered from Hampshire area in UK which covers 1.24
million citizens. Out of 1.24 million citizens 102020 residents were aged greater than and equal
to 75 years. Antibiotics were majorly used to treat urinary tract infections which suffered by
elderly people. In order to identify the relationship and anticipation of antibiotic prescriptions,
univariate analysis and logistics regressions were performed. It was identified in the article that
26 per cent of total participants which were 329291 were administered with antibiotics at least
once during 2011 and 12 per cent (149968) were administered with antibiotics more than once
(Sundvall and et.al. 2015). Thus, researchers found that elderly people living in care setting were
mostly prescribed with antibiotics especially to treat UTI. The limitations stated by authors were
lack of clinical coding with care home residency, identification of residents by postcode which in
result increases the time of researchers.
In the cross sectional observational study carried out by Fagan and et.al.
(2015) discussed the patterns of those bacteria who have evolved themselves to adapt antibiotics
and which cause urinary tract infections in elderly people living in home and those living in care
homes. Data has been collected from 34 nursing homes in Vestfold County. Participants were
selected of age 65 years and above living in nursing homes. In the results section researchers
found 232 positive urine cultures in Nursing Homes and 3554 in community group. There were
not significant differences found in resistance as Escherichia coli was isolated in 145 urines
sample in NH group (64%) and 2275 (64%) in the community group (Fagan and et.al. 2015).
Limitations were discussed by the researchers where they stated that due to uncertainty of
Norwegian guideline researcher were not sure about correct urine sampling techniques of both
5

the groups. In both NH and CD, urinary catheter was not reported precisely and systematically.
In the cohort study carried out by Marwick and et.al. (2013) elaborated community acquired
infections in older patients which admitted to hospitals and those who remains in community
homes. In the result section researcher found 161 patients from 60 care homes and 101
community. Patients in care home have more co-morbidiates and higher rates of resistant
bacteria. Researchers performed multivariate logistic regression and identified that older patient
have high 30 days mortality. Authors also discussed the limitations of their paper in which they
stated that bias was occurred when using discharge codes of hospitals. Limited available of data
became limitation in their paper.
In research paper proposed by Kang and et.al. (2017) compared the nursing home
acquired pneumonia and community acquired pneumonia occurred in elderly people. In the
research paper, researcher carried out study with the patients who have either nursing home-
acquired pneumonia (NHAP) or Community-Acquired Pneumonia. In the findings, authors
concluded that out of 317 patients there were 212 patients who suffered with Community-
Acquired Pneumonia (CAP) and 105 patients suffered with nursing home-acquired pneumonia
(NHAP). It was further identified that patients who have NHAP posses higher mortality than
patients suffered with CAP. The excess mortality in patients who possess both NHAP and CAP
was in regards with the severity in disease (Kang and et.al. 2017). Researchers explicitly
describe the weakness of articles. They contends that data has been acquired from single
institution which affects the outcomes. Instead of defining pathogens in quantitative or semi-
quantitative cultures, it was based on positive culture of sputum. Researchers also said that viral
pathogens were not identified during the study.
In the retrospective cohort study carried out by Micek and et.al. (2007) compared Health
Care-Associated Pneumonia and Community-Acquired Pneumonia occurred in elderly people.
For their study, data has been collected from 639 patients with positive culture HCAP and CAP
who admitted between 1st January 2003 to 31st December 2005 in Barnes-Jewish Hospital. In
the findings researchers concluded that HCAP was more common among the patients than CAP
with culture positive pneumonia. Researchers stated that patients admitted for treatment of
pneumonia must be treated carefully and should be aware of risk factor. The limitation of the
study was investigators investigated only culture positive pneumonia. Furthermore, researchers
6

only conduct study on those patients who identified with bacterial pneumonia and exclude all
other patients.
Result
To assess research question 5 articles were reviewed. In table 1, CASP checklist – 2009 has been
used which possess 11 close ended questions. In Table 2, NHMRC (national health and medical
research council) body of evidence matrix has been used.
7

8

9

10

Discussion
From the above analysis it can be understood that researcher carried out extensive
analysis and proposed robust study which uncovers the various aspects related with antibiotics
and antibiotics resistant bacteria. Researchers in their respective cohort studies conducted
detailed analysis to ascertain the precise information and obtain meaningful data. In order to
attain the aim and objectives of the study researchers conducted extensive analysis by using
statistical tools and applications. Data has been collected in efficient manner and articulation of
data has been done in lucid manner.
This helps the readers to enhance their comprehensive understanding about the topic. In
the articles authors have presented their viewpoints regarding the issue for which they carried out
the research study. Most of the articles were retrospective cohort study and cross sectional
observational study. In one study authors compared dosage of antibiotics given to elderly people
11

living in care home setting and those living in their own home in the community. In another
study researchers compared resistance of antimicrobial bacteria especially in elderly patients
living in Nursing Home and own home. In the study author identified that those elders who
suffered with pneumonia (Kang and et.al., 2017). In this context, it was discussed in their paper
that elders suffered from pneumonia in nursing home setting tends to have higher mortality than
those who have community-acquired pneumonia.
To analyse the data, statistical tools and applications has been used by the researchers.
This helps in generating robust output through which better understanding of the subject matter
has been made. In the articles researchers discussed also discussed about the side effects of
antibiotics and also elaborates bacteria who have resistance to the antibiotics. In one article,
investigators compared community acquired infections that occurred in elder people admired in
hospitals from care homes and community. Researcher made diligent efforts in making the
comparison and also collected data from reliable sources. This helps in enhancing the quality and
effectiveness of the research paper. In the conclusive statement, researcher stated that elder
people tends to have acute infection and had very high 30 days mortality (Sundvall and et.al.,
2015). The research papers were critically examined and it can be said that these papers provide
great detail and understanding of the subject area. Each paper was structured systematically and
researchers stated their objectives and aim clearly. This helps in increasing the understanding
ability of the readers.
CONCLUSION
In the conclusion it can be summarised that older people tends to be more risk in
developing antibiotic resistant infections. In the above article, critical appraisal of five articles
has been made which demonstrate efficient understanding regarding the subject matter. It was
identified that researchers carried out retrospective cohort study in order to carry out the research
study. The articles were systematically structured and researchers also stated the strengths and
weaknesses in the articles which is considered to be a good practice in research study.
12