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Nicolle LE. Reducing Treatment of Asymptomatic Bacteriuria: What Works? Infect Dis Clin North Am 2024; 38:267-276. [PMID: 38575492 DOI: 10.1016/j.idc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Asymptomatic bacteriuria is common, but usually benign. Inappropriate antimicrobial treatment of asymptomatic bacteriuria contributes to negative antimicrobial outcomes. Optimizing antimicrobial use for bacteriuria is a component of antimicrobial stewardship programs and includes key practices of dissemination and implementation of guidelines, laboratory practices which support stewardship, and programs to monitor and implement optimal antimicrobial treatment for urinary infection. These activities vary in their effectiveness, costs, and complexity to institute. Stewardship strategies targeting unique populations with a high prevalence of bacteriuria and for whom symptom assessment is not straightforward need to be further developed and evaluated to support optimal stewardship.
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Affiliation(s)
- Lindsay E Nicolle
- Department of Internal Medicine, GC-443 Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg MB, R3A 1R9' MB, Canada.
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Bocquier A, Erkilic B, Babinet M, Pulcini C, Agrinier N. Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies. Antimicrob Resist Infect Control 2024; 13:29. [PMID: 38448955 PMCID: PMC10918961 DOI: 10.1186/s13756-024-01385-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes. METHOD We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings. RESULTS Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1). CONCLUSIONS Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.
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Affiliation(s)
- Aurélie Bocquier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France.
| | - Berkehan Erkilic
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
| | - Martin Babinet
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
| | - Céline Pulcini
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, F-54000, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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Wilcox CR, Worswick L, Muller I, Moore A, Hayward G, Lown M, Moore M, Little P, Francis N. Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study. BJGP Open 2023; 7:BJGPO.2023.0014. [PMID: 37225255 PMCID: PMC10646207 DOI: 10.3399/bjgpo.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/16/2023] [Accepted: 04/25/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families. AIM To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms. DESIGN & SETTING A qualitative interview study with primary care clinicians and care home staff in the UK. METHOD Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed. RESULTS Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas. CONCLUSION The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.
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Affiliation(s)
- Christopher R Wilcox
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Louise Worswick
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ingrid Muller
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Abigail Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Lown
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Francis
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
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Wretman CJ, Boynton MH, Preisser JS, Zimmerman S, Kistler CE. Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: A discrete choice experiment. Infect Control Hosp Epidemiol 2023; 44:1151-1154. [PMID: 36073169 DOI: 10.1017/ice.2022.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The overdiagnosis of urinary tract infections (UTIs) in nursing home residents is a significant public health threat. Using a discrete choice experiment and a diagnostic guideline, we examined which patient-level information was associated with the overdiagnosis of UTIs and found that urinalysis results and lower urinary tract status were most associated.
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Affiliation(s)
| | - Marcella H Boynton
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Christine E Kistler
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Feasibility of Algorithm-Based Clinical Decision Support for Suspected Urinary Tract Infections in Nursing Home Residents. Antibiotics (Basel) 2022; 11:antibiotics11101276. [PMID: 36289934 PMCID: PMC9599012 DOI: 10.3390/antibiotics11101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022] Open
Abstract
Urinary tract infections (UTIs) are commonly suspected in nursing home (NH) residents, commonly resulting in antimicrobial prescriptions, even when symptoms are non-specific. To improve the diagnosis and management of suspected UTIs in NH residents, we conducted a pilot test of a paper-based clinical algorithm across NHs in the southern U.S. with ten advanced practice providers (APPs). The paper-based algorithm was modified based on the clinical care needs of our APPs and included antimicrobial treatment recommendations. The APPs found the UTI antimicrobial stewardship and clinical decision support acceptable. The educational sessions and algorithm improved baseline confidence toward UTI diagnosing and treatment. The APPs thought the algorithm was useful and did not negatively impact workload. Feedback from the pilot study will be used to improve the next iteration of the algorithm as we assess its impact on prescribing outcomes.
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Wang W, Wang H. Nursing Management-Associated Factors Associated with Urinary Tract Infection in Residents from Nursing Home Based on LTCfocus Database. Urol Int 2022; 106:744-756. [PMID: 35045413 DOI: 10.1159/000520813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of the study was to identify nursing management-associated factors correlated with urinary tract infection (UTI) in residents from nursing homes. METHODS The data of 3,393 nursing homes were extracted from LTCfocus database. Variables statistically correlated with UTI rate were identified by Spearman correlation analysis. Tobit regression model was used for finding the factors associated with UTI rate. RESULTS The number of beds (β = 0.03, 95% CI: 0.02-0.05), number of occupied beds/the total number of beds (β = 0.05, 95% CI: 0.03-0.07), number of admissions/total number of beds (β = 0.27, 95% CI: 0.11-0.43), the proportions of residents whose primary support is Medicare (β = 0.03, 95% CI: 0.01-0.06), women residents (β = 0.04, 95% CI: 0.02-0.06), White residents (β = 0.02, 95% CI: 0.01-0.03), patients with bladder incontinence (β = 0.03, 95% CI: 0.02-0.05), hypertension patients (β = 0.03, 95% CI: 0.01-0.05), and long-stay residents with daily pain (β = 0.16, 95% CI: 0.12-0.19), hospitalizations per resident year (β = 0.76, 95% CI: 0.30-1.21), and average daily census (β = -0.02, 95% CI: -0.03 to 0.00) were factors associated with UTI rate. CONCLUSIONS Nursing homes with more females, White people, and patients with bladder incontinence, hypertension, or daily pain should be cared more and the number of occupied beds and admissions should be controlled to reduce the occurrence of UTI.
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Affiliation(s)
- Wei Wang
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hui Wang
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Kistler CE, Wretman CJ, Zimmerman S, Enyioha C, Ward K, Farel CE, Sloane PD, Boynton MH, Beeber AS, Preisser JS. Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. J Am Geriatr Soc 2022; 70:1070-1081. [PMID: 35014024 DOI: 10.1111/jgs.17638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. METHODS We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. RESULTS One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). CONCLUSIONS Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of North Carolina, Chapel Hill, NC, USA.,Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Chineme Enyioha
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Claire E Farel
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Marcella H Boynton
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Anna S Beeber
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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