Antibiotic prescribing in Dutch nursing homes: how appropriate is it?

Implementation of a tailored multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for urinary tract infections in frail older adults (ImpresU) in four European countries: a process evaluation alongside a pragmatic cluster randomized controlled trial

BACKGROUND

We previously performed a pragmatic cluster randomized controlled trial (RCT) in general practices and older adult care organizations in Poland, the Netherlands, Norway, and Sweden. We found that a multifaceted antibiotic stewardship intervention (ASI) substantially reduced antibiotic use for suspected urinary tract infections (UTIs) in frail older adults compared with usual care. We aimed to evaluate the implementation process of the ASI to provide recommendations for clinical practice.

METHODS

We conducted a process evaluation alongside the cluster RCT. The ASI consisted of a decision-tool and a toolbox, which were implemented using a participatory-action-research (PAR) approach with sessions for education and evaluation. We documented the implementation process of the intervention and administered a questionnaire to health care professionals (HCPs) from participating organizations in the intervention and usual care clusters. We evaluated the multiple components of the intervention and its implementation following a structured framework.

RESULTS

The questionnaire was completed by 254 HCPs from the 38 participating clusters. All components were largely delivered according to plan and evaluated as useful. The decision-tool and toolbox materials were reported to facilitate decision-making on UTIs. Regarding the PAR approach, educational sessions focusing on the distinction between UTIs and asymptomatic bacteriuria were held in all 19 intervention clusters. In 17 out of these 19 clusters, evaluation sessions took place, which were reported to help remind HCPs to implement the ASI. During both sessions, HCPs valued the reflection that took place and the resulting awareness of their behavior. It allowed them to explore implementation barriers and to tailor their local implementation process to overcome these. For example, HCPs organized extra educational sessions or revised local policies to incorporate the use of the decision-tool. Various HCPs took key roles in implementation. Staff changes and the COVID-19 pandemic were important contextual barriers.

CONCLUSIONS

We found each component of the multifaceted ASI and its implementation to have added value in the process to improve antibiotic prescribing for suspected UTIs in a heterogeneous older adult care setting. We recommend using a multifaceted, multidisciplinary approach that enables HCPs to reflect on their current practice and accordingly tailor local implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03970356. Registered on May 31, 2019.

Factors associated with antibiotics for respiratory infections in Swiss long-term care facilities

BACKGROUND

Long-term care facility (LTCF) residents are twice as likely to receive antibiotics compared with elderly living in the community, and studies have reported up to half of prescriptions in LTCFs as inappropriate.

AIM

To identify factors contributing to general and inappropriate antibiotic prescription among LTCF residents with lower respiratory tract infections (LRTIs).

METHODS

In this prospective, multicentric, observational study, residents with LRTIs were recruited among 32 LTCFs in Western Switzerland during winter 2022-2023. Residents underwent lung ultrasound (LUS) within three days of LRTI onset, serving as the pneumonia diagnosis reference standard. Multivariate logistic regression and backward selection were used with P < 0.1 cut-off to identify factors among demographics, vital signs, diagnostic tests, and LTCF characteristics associated with (i) antibiotic prescription and (ii) inappropriate prescription.

FINDINGS

A total of 114 residents were included, 63% female, median age 87 years. Fifty-nine (52%) residents underwent diagnostic tests: 50 (44%) polymerase chain reaction (PCR) for respiratory viruses and 16 (14%) blood test with C-reactive protein and/or blood count. Sixty-three (55%) residents received antibiotics. Factors associated with antibiotic prescriptions were Rockwood Clinical Frailty Scale score ≥7, oxygen saturation <92%, performing a blood test, rural LTCFs, and female physician. Among residents receiving antibiotics, 48 (74%) had inappropriate prescriptions, with performance of respiratory virus PCR test as the only protective factor.

CONCLUSION

Whereas half of LRTI residents received antibiotics, falling within lower ranges of European LTCFs prescription rates (53-80%), most antibiotic prescriptions were inappropriate. Utilization of diagnostic tests correlates with lower overall and inappropriate prescription, advocating for their use to optimize prescription practices in LTCFs.

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study

BACKGROUND

Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs).

OBJECTIVE

This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes.

METHODS

A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements.

RESULTS

A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025.

CONCLUSIONS

This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60099.

Instruments and Warning Signs for Identifying and Evaluating the Frequency of Adverse Events in Intermediate and Long-Term Care Centres: A Narrative Systematic Review

INTRODUCTION

There is a lack of data about adverse events (AE) in intermediate and long-term care centers (ILCC). We aimed to synthesize the available scientific evidence on instruments used to identify and characterize AEs. We also aimed to describe the most common adverse events in ILCCs.

MATERIAL AND METHODS

A narrative systematic review of the literature was conducted according to Prisma recommendations. The PubMed database was searched for articles published between 2000 and 2021. Two reviewers independently screened and reviewed the studies through blind and independent review. We evaluated bias risk with Cochrane's risk of bias tool. Disagreements were resolved by consensus. Discrepancies that were not resolved by discussion were discussed with a third reviewer. Descriptive data was extracted and qualitative content analysis was performed.

RESULTS

We found 2191 articles. Based on the inclusion and exclusion criteria, 272 papers were screened by title and abstract, and 66 studies were selected for full review. The instruments used to identify AEs were mostly tools to identify specific AEs or risks of AEs (94%), the remaining 6% were multidimensional. The most frequent categories detected medication-related AEs (n=26, 40%); falls (n=7, 11%); psychiatric AEs (6.9%); malnutrition (4.6%), and infections (4.6%). The studies that used multidimensional tools refer to frailty, dependency, or lack of energy as predictors of AEs. However, they do not take into account the importance of detecting AEs. We found 2-11 adverse drug events (ADE) per resident/month. We found a prevalence of falls (12.5%), delirium (9.6-89%), pain (68%), malnutrition (2-83%), and pressure ulcers (3-30%). Urinary tract infections, lower respiratory tract infections, skin and soft tissue infections, and gastroenteritis were the most common infections in this setting. Transitions between different care settings (from hospitals to ILCC and vice versa) expose AE risk.

CONCLUSION

There are many instruments to detect AEs in ILCC, and most have a specific approach. Adverse events affect a significant proportion of patients in ILCC, the nurse-sensitive outcomes, nosocomial infections, and adverse drug events are among the most common. The systematic review was registered with Prospero, ID: CRD42022348168.

Diagnosing probable urinary tract infections in nursing home residents without indwelling catheters: a narrative review

BACKGROUND

Overdiagnosis of urinary tract infections (UTIs) is one of the most common reasons for the unnecessary use of antibiotics in nursing homes, increasing the risk of missing serious conditions. Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents. However, due to the lack of a clear reference standard, these tools vary widely and can be complex, with some requiring urine testing. As part of the European-funded IMAGINE project, aimed at improving antibiotic use for UTIs in nursing home residents, we have reviewed the recommendations.

OBJECTIVES

This review provides a comprehensive summary of the more relevant tools and algorithms aimed at identifying true UTIs among residents living in nursing homes and discusses the challenges in using these algorithms based on updated research.

SOURCES

The discussion is based on a relevant medical literature search and synthesis of the findings and published tools to provide an overview of the current state of improving the diagnosis of UTIs in nursing homes.

CONTENT

The following topics are covered: prevalence of asymptomatic bacteriuria, diagnostic challenges, clinical criteria, urinary testing, and algorithms to be implemented in nursing home facilities.

IMPLICATIONS

Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and nonspecific urinary tract signs and symptoms among those with suspected UTIs. The fear of missing a UTI and the perceived antibiotic demands from residents and relatives might lead to overdiagnosis of this common condition. Despite their widespread use, urine dipsticks should not be recommended for geriatric patients. Patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions. Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety.

YELLOW RoUTIne prospective cohort study protocol: insight in the dynamics of bacteria in the elderly bladder

BACKGROUND

Asymptomatic bacteriuria (ASB) - the presence of bacteria in urine without urinary tract infection (UTI) related signs & symptoms (S&S) - is common in the elderly bladder and is not considered pathogenic for UTI. We hypothesise that colonisation with non-uropathogenic bacteria could protect the bladder from invasion of more harmful bacteria. The exact role and dynamics of bacteriuria in the relation to the development of a UTI is still unknown. We aim to provide insight into the course of bacteriuria in the elderly bladder and its relation to UTI in frail older adults.

METHODS AND ANALYSIS

A prospective observational cohort study is being conducted in Dutch nursing homes (NHs) between February 2024 and December 2025. Urine samples and case report forms (CRF) on UTI-related S&S will be collected from each consenting NH resident every 3 months for a follow-up period of 18 months. Whenever a UTI-suspicion occurs in between the 3 monthly time points, additional data and a urine sample will be collected. Urine samples undergo several urinalyses (e.g. dipstick and bacterial culture). Additional molecular analysis will be conducted on a selection of cultured Escherichia coli (E. coli) for virulence genes. Primary analyses will be conducted between residents with and without ASB at each time point. The primary outcome is UTI incidence during follow-up. In secondary analyses we will also take into account the low versus high presence of virulence genes of the E. coli.

DISCUSSION

The combination of high ASB prevalence and a reduced ability of frail older adults to express UTI-related S&S may lead to UTI misdiagnosis and inappropriate antibiotic use. To our knowledge, this is the first study to investigate the dynamics and role of bacteriuria in the elderly bladder and their potential protective effect on the development of UTI. The study findings with comprehensive analysis of epidemiological, clinical and molecular data could set the fundamental base for future guidelines and studies, and contribute to improving prevention, diagnosis and treatment of UTI in frail older adults, in addition to contributing to antibiotic stewardship in NHs.

Urinary Tract Infection Guideline Adherence in a Dutch Sentinel Nursing Home Surveillance Network

OBJECTIVES

To investigate guideline adherence 3 years after the introduction of a national guideline on urinary tract infections (UTIs) in frail older adults. Appropriate use of urine dipstick tests, treatment decisions, and antibiotic drug choices in residents with (suspected) UTIs without a catheter were examined.

DESIGN

Observational prospective study.

SETTING AND PARTICIPANTS

Nineteen nursing homes participating in a Dutch Sentinel Nursing Home Surveillance Network.

METHODS

As of September 2021, for a 3-month period, medical practitioners recorded additional clinical information in the electronic health record in case of a (suspected) UTI. Based on this information, adherence to guideline recommendations was assessed. Nonadherence was classified into 2 categories: (1) "intentional nonadherence" as reported by practitioners and (2) "nonadherence otherwise" applied to all other cases where the recorded information was discordant with the guideline recommendations.

RESULTS

A total of 532 cases of (suspected) UTIs from 469 residents were analyzed. In 455 cases (86%), dipsticks were used. For the 231 cases where clinical signs and symptoms already indicated no UTI treatment according to the guideline, a dipstick was still inappropriately ordered in 196 cases (85%). The decision to prescribe or withhold antibiotics was in 69% of the cases adherent, in 6% intentionally nonadherent, and in 25% nonadherent otherwise. The type of prescribed antibiotic was adherent to the recommended antibiotics for cystitis in 88% and for UTIs with signs of tissue invasion in 48%. Overall, for 40% of suspected UTIs, adherence to all relevant recommendations could be established, and in 9% practitioners reported intentional nonadherence to the guideline.

CONCLUSIONS AND IMPLICATIONS

There is considerable room for improvement in all clinical stages of managing a suspected UTI in Dutch nursing homes, particularly with regard to the importance of patient's clinical signs and symptoms for appropriate dipstick use and antibiotic UTI treatments.

Use of antibiotics for urinary tract infections up to and after care home admission in Denmark: a nationwide study

PURPOSE

Older people have the highest use of antibiotics for acute and chronic urinary tract infection (UTI), despite diagnostic uncertainty and the growing problem of antibiotic resistance. We aim to describe use-patterns of UTI antibiotics two years prior to and following care home admission in Denmark.

METHODS

This was a register-based nationwide drug-utilization study. In a cohort comprising all Danish residents admitted into a care home from 2015 to 2021, we described the use of UTI antibiotics, and examined differences between regions and individual care homes in rates of UTI antibiotic use. Further, we described trends in UTI-related contacts with hospitals in the two years prior to and following care home admission.

RESULTS

The cohort comprised 101,297 residents (61% female; median age 84 years). UTI antibiotic use doubled from 7 to 14 treatments/100 residents/month two months prior to care home admission and remained at 10 treatments/100 residents/month the following two years. Prescription of pivmecillinam (55%) was most common. Primary care practitioners prescribed the majority (92%) of UTI antibiotics. UTI-related hospital contacts peaked at two months prior to care home admission, with 6 admissions/100 residents/month, subsequently dropping to 2 admission/100 residents/month. We found considerable variation in UTI antibiotic use, with 10% of care homes responsible for 20% of treatments in 2021.

CONCLUSION

Use of UTI antibiotics increased prior to and remained at a stable high level following care home admission in Denmark. Despite variation in use across regions and individual care homes, an overall decrease was seen throughout the years 2016-2021.

Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies

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.

Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis

Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.

Sociodemographic characterisation of antibiotic heavy users in the Danish elderly population

AIMS

The development of effective interventions to reduce inappropriate use of antibiotics in the elderly population requires knowledge on who can benefit from such interventions. Thus, we aimed to identify and characterise antibiotic heavy users among elderly patients in general practice with respect to sociodemographic variables.

METHODS

We conducted a retrospective nationwide register-based study on all Danish elderly citizens (⩾65 years) who redeemed an antibiotic prescription in 2017. Heavy users were defined as the 10% with the highest excess use, that is, their recorded use minus the average use for their sex, age group and comorbidity level as estimated from a linear regression model. Comparative analyses of sociodemographic characteristics (civil status, employment status, urbanity, educational level and country of origin) of heavy users and non-heavy users were performed using logistic regression models.

RESULTS

The study population consisted of 251,733 elderly individuals, who in total redeemed 573,265 prescriptions of antibiotics. Heavy users accounted for 68% of all excess use of antibiotics. In multivariable analyses, individuals with an educational level above basic schooling, non-retired, residing in an urban municipality and being born in a country outside Scandinavia all had lower odds of being a heavy user. Widowed, divorced or single individuals had higher odds of being a heavy user compared with married individuals. Relative importance analyses showed that civil status and educational level contributed considerably to the explained variance.

CONCLUSIONS

This study found an association between sociodemographic characteristics and risk of being a heavy user, indicating that sociodemographic variation exists with regard to antibiotic prescribing.

Prevalence of healthcare-associated infections in Dutch long-term care facilities from 2009 to 2019

OBJECTIVE

We assessed trends in the prevalence of healthcare-associated infections (HCAIs) and associated resident and facility characteristics in a national network of long-term care facilities (LTCFs) in the Netherlands from 2009 to 2019.

METHODS

Participating LTCFs registered the prevalence of urinary tract infection (UTI), lower respiratory tract infection (LRTI), gastrointestinal infection (GI), bacterial conjunctivitis, sepsis and skin infection, using standardized definitions, in biannual point-prevalence surveys (PPSs). In addition, resident and LTCF characteristics were collected. Multi-level analyses were performed to study changes in the HCAI prevalence over time and to identify resident and LTCF-related risk factors. Analyses were performed for HCAIs overall and for UTI, LRTI and GI combined as these were recorded throughout the period.

RESULTS

Overall, 1353 HCAIs were registered in 44,551 residents with a prevalence of 3.0% (95% confidence interval: 2.8-3.1; range between years 2.3-5.1%). When including only UTI, LRTI and GI the prevalence decreased from 5.0% in 2009 to 2.1% in 2019. Multi-variable regression analyses for UTI, LRTI and GI combined indicated that both prolonged participation and calendar time were independently associated with HCAI prevalence; in LTCFs that participated ≥4 years, the HCAI risk was decreased (OR 0.72 (0.57-0.92)) compared with the first year, and the OR per calendar year was 0.93 (0.88-0.97).

CONCLUSIONS

Over 11 years of PPS in LTCFs the HCAI prevalence decreased over time. Prolonged participation further reduced the HCAI prevalence, in particular UTIs, despite the increasing age and associated frailty of the LTCF population, illustrating the potential value of surveillance.

Antibiotic prescription patterns in patients with suspected urinary tract infections in Ecuador

BACKGROUND

Urinary tract infections (UTI) are among the most common cause to prescribe antibiotics in primary care. Diagnosis is based on the presence of clinical symptoms in combination with the results of laboratory tests. Antibiotic therapy is the primary approach to the treatment of UTIs; however, some studies indicate that therapeutics in UTIs may be suboptimal, potentially leading to therapeutic failure and increased bacterial resistance.

METHODS

This study aimed to analyze the antibiotic prescription patterns in adult patients with suspected UTIs and to evaluate the appropriateness of the antibiotic prescription. This is a cross-sectional study of patients treated in outpatient centers and in a second-level hospital of the Ministry of Public Health (MOPH) in a city in Ecuador during 2019. The International Classification of Disease Tenth Revision (ICD-10) was used for the selection of the acute UTI cases. The patients included in this study were those treated by family, emergency, and internal medicine physicians.

RESULTS

We included a total of 507 patients in the analysis and 502 were prescribed antibiotics at first contact, constituting an immediate antibiotic prescription rate of 99.01%. Appropriate criteria for antibiotic prescription were met in 284 patients, representing an appropriate prescription rate of 56.02%. Less than 10% of patients with UTI had a urine culture. The most frequently prescribed antibiotics were alternative antibiotics (also known as second-line antibiotics), such as ciprofloxacin (50.39%) and cephalexin (23.55%). Factors associated with inappropriate antibiotic prescribing for UTIs were physician age over forty years, OR: 2.87 (95% CI, 1.65-5.12) p<0.0001, medical care by a general practitioner, OR: 1.89 (95% CI, 1.20-2.99) p = 0.006, not using point-of-care testing, OR: 1.96 (95% CI, 1.23-3.15) p = 0.005, and care at the first level of health, OR: 15.72 (95% CI, 8.57-30.88) p<0.0001.

CONCLUSIONS

The results of our study indicate an appropriate prescription rate of 56.02%. Recommended antibiotics such as nitrofurantoin and fosfomycin for UTIs are underutilized. The odds for inappropriate antibiotic prescription were 15.72 times higher at the first level of care compared to the second. Effective strategies are needed to improve the diagnosis and treatment of UTIs.

A practice guide on antimicrobial stewardship in nursing homes

A practice guide to help nursing homes set up an antimicrobial stewardship (AMS) program was developed based on experiences gained during a project at one of the largest providers of elderly care in the South-east of the Netherlands. The guideline for the implementation of AMS in Dutch hospitals served as a starting point and were tailored to the unique characteristics of a nursing home setting. This practice guide offers recommendations and practical tools while emphasizing the importance of establishing a multidisciplinary approach to oversee AMS efforts. The recommendations and practical tools address various elements of AMS, including the basic conditions to initiate an AMS program and a comprehensive approach to embed an AMS program. This approach involves educating nurses and caregivers, informing volunteers and residents/their representatives, and the activities of an antibiotic team (A-team). The practice guide also highlights a feasible work process for the A-team. This process aims to achieve a culture of continuous learning and improvement that can enhance the overall quality of antibiotic prescribing rather than making individual adjustments to client prescriptions. Overall, this practice guide aims to help nursing homes establish an AMS program through collaborative efforts between involved physicians, pharmacists, clinical microbiologists, and infection control practitioners. The involved physician plays a crucial role in instilling a sense of urgency and developing a stepwise strategy.

Observation of urinary tract infection signs and symptoms in nursing home residents with impaired awareness or ability to communicate signs and symptoms: The development of supportive tools

BACKGROUND

Antibiotics are often inappropriately prescribed for urinary tract infections (UTIs) in nursing home (NH) residents. Research emphasises the importance of prescribing antibiotics only if there are UTI-related signs and symptoms (S&S). However, for many NH residents it is challenging to find out whether such S&S are present, for example due to cognitive disorders.

OBJECTIVES

To provide insight into the assessment of UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S, and to develop supportive tools for the observation of UTI-related S&S in this subgroup of NH residents, by nursing staff.

METHODS

We performed a practice-based study using mixed methods. Data of 295 cases of suspected UTI were analysed to determine how often UTI-related S&S were 'not assessed/non-assessable' in residents with and without dementia. Barriers and facilitators in observing UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S were derived from interviews and focus groups with nursing staff. Literature review, focus group data, additional telephone interviews and questionnaires with nursing staff were used in a step-by-step process, including pilot testing, to develop supportive tools for the observation of UTI-related S&S.

RESULTS

UTI-related S&S were assessable in the majority of NH residents with dementia. The proportion 'not assessed/non-assessable' S&S in residents with dementia increased with increasing severity of dementia. In residents with very severe dementia, up to 58% of the S&S were 'not assessed/non-assessable'. Knowing the resident, working methodologically, and being sufficiently skilled to interpret observations in residents facilitate the assessment of UTI-related S&S. Insights acquired during the different study elements resulted in the development of an observation checklist and a 24-h observation tool.

CONCLUSIONS

The more NH residents have impaired awareness of ability to communicate S&S, the more difficult it seems to be to assess UTI-related S&S. The observation checklist and 24-h observation tool developed in the current study may support nursing staff in their observation of UTI-related S&S in this group of NH residents.

A Multifaceted Intervention and Its Effects on Antibiotic Usage in Norwegian Nursing Homes

We explored the impact of an antibiotic quality improvement intervention across 33 nursing homes (NHs) in one Norwegian county, compared against four control counties. This 12-month multifaceted intervention consisted of three physical conferences, including educational sessions, workshops, antibiotic feedback reports, and academic detailing sessions. We provided clinical guiding checklists to participating NHs. Pharmacy sales data served as a measure of systemic antibiotic use. The primary outcome was a change in antibiotic use in DDD/100 BD from the baseline through the intervention, assessed using linear mixed models to identify changes in antibiotic use. Total antibiotic use decreased by 15.8%, from 8.68 to 7.31 DDD/100BD (model-based estimated change (MBEC): -1.37, 95% CI: -2.35 to -0.41) in the intervention group, albeit not a significantly greater reduction than in the control counties (model-based estimated difference in change (MBEDC): -0.75, 95% CI: -1.91 to 0.41). Oral antibiotic usage for urinary tract infections (UTI-AB) decreased 32.8%, from 4.08 to 2.74 DDD/100BD (MBEC: -1.34, 95% CI: -1.85 to -0.84), a significantly greater reduction than in the control counties (MBEDC: -0.9, 95% CI: -1.28 to -0.31). The multifaceted intervention may reduce UTI-AB use in NHs, whereas adjustments in the implementation strategy may be needed to reduce total antibiotic use.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

Older patients are at high risk of infections, which often present atypically and are associated with high morbidity and mortality. Antimicrobial treatment in older individuals with infectious diseases represents a clinical challenge, causing an increasing burden on worldwide healthcare systems; immunosenescence and the coexistence of multiple comorbidities determine complex polypharmacy regimens with an increase in drug-drug interactions and spread of multidrug-resistance infections. Aging-induced pharmacokinetic and pharmacodynamic changes can additionally increase the risk of inappropriate drug dosing, with underexposure that is associated with antimicrobial resistance and overexposure that may lead to adverse effects and poor adherence because of low tolerability. These issues need to be considered when starting antimicrobial prescriptions. National and international efforts have been made towards the implementation of antimicrobial stewardship (AMS) interventions to help clinicians improve the appropriateness and safety of antimicrobial prescriptions in both acute and long-term care settings. AMS programs were shown to decrease consumption of antimicrobials and to improve safety in hospitalized patients and older nursing home residents. With the abundance of antimicrobial prescriptions and the recent emergence of multidrug resistant pathogens, an in-depth review of antimicrobial prescriptions in geriatric clinical practice is needed. This review will discuss the special considerations for older individuals needing antimicrobials, including risk factors that shape risk profiles in geriatric populations as well as an evidence-based description of antimicrobial-induced adverse events in this patient population. It will highlight agents of concern for this age group and discuss interventions to mitigate the effects of inappropriate antimicrobial prescribing.

Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries

OBJECTIVE

To evaluate whether antibiotic prescribing for suspected urinary tract infections in frail older adults can be reduced through a multifaceted antibiotic stewardship intervention.

DESIGN

Pragmatic, parallel, cluster randomised controlled trial, with a five month baseline period and a seven month follow-up period.

SETTING

38 clusters consisting of one or more general practices (n=43) and older adult care organisations (n=43) in Poland, the Netherlands, Norway, and Sweden, from September 2019 to June 2021.

PARTICIPANTS

1041 frail older adults aged 70 or older (Poland 325, the Netherlands 233, Norway 276, Sweden 207), contributing 411 person years to the follow-up period.

INTERVENTION

Healthcare professionals received a multifaceted antibiotic stewardship intervention consisting of a decision tool for appropriate antibiotic use, supported by a toolbox with educational materials. A participatory-action-research approach was used for implementation, with sessions for education, evaluation, and local tailoring of the intervention. The control group provided care as usual.

MAIN OUTCOME MEASURES

The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year. Secondary outcomes included the incidence of complications, all cause hospital referrals, all cause hospital admissions, all cause mortality within 21 days after suspected urinary tract infections, and all cause mortality.

RESULTS

The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). No differences between intervention and control group were observed in the incidence of complications (<0.01 v 0.05 per person year), hospital referrals (<0.01 v 0.05), admissions to hospital (0.01 v 0.05), and mortality (0 v 0.01) within 21 days after suspected urinary tract infections, nor in all cause mortality (0.26 v 0.26).

CONCLUSIONS

Implementation of a multifaceted antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infections in frail older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03970356.

C‐reactive protein, procalcitonin, and erythrocyte sedimentation rate for the diagnosis of lower urinary tract infection in older people

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

The role of Dutch guidelines in the diagnostic outcomes and treatment decisions of hospitalised older adults with a suspected urinary tract infection: a retrospective cohort study

PURPOSE

Urinary tract infections (UTIs) are highly prevalent and difficult to diagnose in older adults. We aimed to evaluate the applicability of Dutch Association of Urology (NVU) and Dutch Association of Elderly Care Physicians (Verenso) guidelines in terms of diagnostic outcomes and treatment decisions in hospitalised older adults with suspected UTIs.

METHODS

A retrospective cohort study was conducted on 225 geriatric patients with a urine culture taken in 2019, to determine conformity of the studied population to NVU and Verenso.

RESULTS

Of 225 patients with suspected UTI (mean age 86 years; 56.4% female), 67.6% had urinary tract-related symptoms, of whom 96 received antibiotics, including those with a negative urine dipstick (n = 12) or urine culture (n = 28). Hundred seventy-seven and 147 patients were assessed and treated conforming to the NVU and Verenso guidelines, respectively. The 38 patients who were assessed and treated non-conforming to NVU, including patients with negative urine diagnostics, received antibiotics more often compared with 177 patients treated conforming to NVU (p < 0.001). A large number of patients with negative urine tests were treated conforming to Verenso and antibiotics were withheld in 75.5% of the patients. The non-conforming Verenso-treated patients with prescribed antibiotics had significantly more negative dipstick results (p = 0.05), fewer urinary tract-related symptoms (p < 0.001) and more often a different infectious focus (p < 0.001).

CONCLUSION

The common practice performed on the studied geriatric population was more in accordance with the NVU guideline than Verenso. The results indicated that compliance with the guidelines might lead to fewer antibiotic prescriptions in the study population.

Prevalence of Antimicrobial Prescribing in Long-Term Care Facilities in a Local Health Authority of Northern Italy

BACKGROUND

Almost half of antimicrobial prescriptions in long-term care facilities (LTCFs) is inappropriate. This broad use might represent a strong contributor to antimicrobial resistance in these facilities. This study aimed to assess antibiotic use patterns and potential associated factors with a survey of LTCFs in the local health authority (LHA) of Novara.

METHODS

A cross-sectional study was conducted in 25 LTCFs in the LHA of Novara following the healthcare-associated infection in LCTFs (HALT) protocol. Information on residents and facilities was assessed. Antibiotic usage and potential determinants were also estimated.

RESULTS

In total, 1137 patients were screened for antibiotic usage. Mean age was 84.58 years (SD 9.77), and the majority were female (76.52%). Twenty-six were antibiotic users (prevalence rate 2.29%, 95%CI 1.50-3.33). Antimicrobials were mainly prescribed orally (84.62%). Potential risk factors for antibiotic prescription were catheter use (central and peripheral venous, p-values 0.0475 and 0.0034, respectively, and urinary, p-value 0.0008), immobilization (p-value < 0.0001), and sex (p-value 0.0486).

CONCLUSIONS

This study identified a low prevalence of antimicrobic consumption in LTCFs. Further surveillance studies are warranted to identify trends and changes in pathogen incidence and antimicrobial resistance and to inform public health authorities on the necessity of prudent use of antimicrobials in LCTFs.

Preventive effect of methenamine in women with recurrent urinary tract infections - a case-control study

BACKGROUND

Urinary tract infection (UTI) is the most common bacterial infection in women. In Norwegian general practice, methenamine has been prescribed for many years as long-term prevention and accounted for 20% of the total antibiotic prescribing in 2015, as measured in defined daily dosages (DDDs). The efficacy of methenamine is unknown. If shown to be effective, this drug may become an important preventive against UTI.

OBJECTIVE

To examine whether methenamine is preventive against recurrent UTI in women.

DESIGN

Data for all antibiotics used for UTIs dispensed from all pharmacies from 2005 to 2015 were collected from the Norwegian prescription database (NorPD).

SUBJECTS

Women aged ≥ 40 years with recurrent UTI, defined as ≥3 courses of UTI antibiotic/year, were included.

MAIN OUTCOME MEASURES

Patients using methenamine (cases) and those not using methenamine (controls) were compared. The numbers of UTI prescriptions during the 2 years before and after inclusion were analysed. Results: The yearly prevalence for recurrent UTI was 2.4% in women ≥ 40 years. The change in antibiotic use from 2 years before to 2 years after inclusion in the study differed significantly between groups: 44.6 and 34.9% reductions in the number of antibiotic prescriptions for UTI in the methenamine and control groups, respectively. The decrease in UTI antibiotic prescriptions (58.9%) was greater in patients with a higher consumption of antibiotics before starting methenamine.

CONCLUSIONS

Methenamine seems to be effective against recurrent UTI over the time span studied. The effect seems to be greater in patients with the highest number of recurrent UTIs. Key pointsMethenamine has been used for many years for prevention of recurrent UTI, but no studies have demonstrated a significant preventive effect of long time use.This study shows that methenamine seems to be effective for prevention in patients having recurrent UTI over 2 years or more.The effect seems to be larger in patients with a high number of UTIs over 2 years.

Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries

BACKGROUND

a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions.

OBJECTIVES

(1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults.

METHODS

we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers.

RESULTS

participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care.

CONCLUSIONS

decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program - a nested qualitative study

BACKGROUND

Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.

METHODS

After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.

RESULTS

We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.

CONCLUSIONS

Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

Resident-Related Factors Influencing Antibiotic Treatment Decisions for Urinary Tract Infections in Dutch Nursing Homes

The aim of this cohort study was to identify resident-related factors that influence antibiotic treatment decisions for urinary tract infections (UTIs) in nursing home residents and to provide an overview of the appropriateness of antibiotic treatment decisions according to the updated Dutch guideline for UTIs in frail older adults. The PROGRESS study dataset, consisting of 298 suspected UTI episodes in Dutch nursing home residents, was used. The presence of dysuria was associated with the highest frequency of antibiotic prescription (87.8%). Positive leukocyte esterase dipstick results showed the greatest increase in the risk of antibiotic prescription (RR 2.1, 95% CI 1.44 to 3.06). Treatment decisions were considered adequate in 64.1% of the suspected UTI episodes. Overtreatment occurred more often than undertreatment. Of the inadequate treatment decisions, 29.3% was due to treatment of UTI episodes in which solely non-specific symptoms were present. A high proportion of nitrofurantoin prescriptions were incorrect in UTIs with signs of tissue invasion (54.8%), indwelling catheter-associated UTIs (37.5%), and UTIs in men (29.2%). Although this is considered inadequate, non-specific symptoms were associated with antibiotic prescription for suspected UTIs in Dutch nursing home residents and nitrofurantoin was inadequately prescribed in particular groups, such as men.

Guideline Adherence of Asymptomatic Bacteriuria Could Be Improved among General Practitioners in The Netherlands: A Survey Study

Asymptomatic bacteriuria (ASB) is a common finding in certain populations. This study assessed general practitioners’ (GPs’) knowledge about ASB and their current clinical practice regarding urine testing. Methods: An online survey was used for GPs in the Netherlands from October to December 2020. Results: In total, 99 surveys were included in the analyses. All GPs strongly agreed with the statements about their knowledge and self-confidence regarding urine diagnostics and treatment of ASB. The median knowledge score was 4 out of 6 (IQR 2 to 6). Most GPs (64 of 92; 70%) followed the guideline for the choice of urine diagnostics and reported appropriate indications for urine testing. However, 71/94 (75.5%) GPs would treat patients for ASB if they have diabetes mellitus. Further, 34 (37%) of 92 participants would inappropriately repeat a urine test after a patient was treated for a urinary tract infection (UTI). One-third of the GPs responded that ASB was insufficiently addressed within the guidelines for UTI. Conclusion: These results indicate that knowledge about ASB could be improved in primary care in the Netherlands, mainly in diabetic patients that have ASB, as well as for follow-up tests after treatment for UTI.

Pharmacist-driven antimicrobial stewardship program in a long-term care facility by assessment of appropriateness

METHODS

A prospective quasi-experimental study to implement an ASP in a LTCF. Antibiotic prescriptions for suspected infections initiated in any setting for LTCF residents were included. We assessed appropriateness and prospective audits and feedback of each inappropriate antimicrobial prescription were carried out. Associations of variables with appropriate antibiotic prescribing were estimated using logistic regression.

RESULTS

A total of 416 antibiotic prescriptions were included. The mean consumption of antibiotics was reduced from 63.2 defined daily doses per 1000 residents days (DRD) in the preintervention period to 22.8 in the intervention period (- 63.8%), with a significant drop in fluoroquinolones (81.4%). Overall, 46.6% of antibiotic prescriptions were judged inappropriate, mainly because of a use not recommended in treatment guidelines (63.2%). Multivariable analysis showed that empirical therapy, some classes of antibiotics (cephalosporins, fluoroquinolones, fosfomycin calcium, macrolides) and prescription initiation in the emergency department were independent predictors of antimicrobial inappropriateness.

CONCLUSIONS

Pharmacist-led ASP in a LTCF has being effective in reducing consumption of antibiotics by improving appropriateness of treatment decisions. However, ASP should include interventions in the emergency department because of the high inappropriate use in this setting.

An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial

OBJECTIVE

To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents.

DESIGN

Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual.

SETTING AND PARTICIPANTS

212 residents with suspected UTI, from 16 NHs in the Netherlands.

METHODS

Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level.

RESULTS

295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02).

CONCLUSION AND IMPLICATIONS

Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.

Presumed Urinary Tract Infection in Patients Admitted with COVID-19: Are We Treating Too Much?

Despite the low rates of bacterial co-/superinfections in COVID-19 patients, antimicrobial drug use has been liberal since the start of the COVID-19 pandemic. Due to the low specificity of markers of bacterial co-/superinfection in the COVID-19 setting, overdiagnosis and antimicrobial overprescription have become widespread. A quantitative and qualitative evaluation of urinary tract infection (UTI) diagnoses and antimicrobial drug prescriptions for UTI diagnoses was performed in patients admitted to the COVID-19 ward of a university hospital between 17 March and 2 November 2020. A team of infectious disease specialists performed an appropriateness evaluation for every diagnosis of UTI and every antimicrobial drug prescription covering a UTI. A driver analysis was performed to identify factors increasing the odds of UTI (over)diagnosis. A total of 622 patients were included. UTI was present in 13% of included admissions, and in 12%, antimicrobials were initiated for a UTI diagnosis (0.71 daily defined doses (DDDs)/admission; 22% were scored as ‘appropriate’). An evaluation of UTI diagnoses by ID specialists revealed that of the 79 UTI diagnoses, 61% were classified as probable overdiagnosis related to the COVID-19 hospitalization. The following factors were associated with UTI overdiagnosis: physicians who are unfamiliar working in an internal medicine ward, urinary incontinence, mechanical ventilation and female sex. Antimicrobial stewardship teams should focus on diagnostic stewardship of UTIs, as UTI overdiagnosis seems to be highly prevalent in admitted COVID-19 patients.

Use of a Telemedicine Team to Improve Guideline-Based Antibiotic Prescribing

OBJECTIVES

Assessing the impact of a virtual antibiotic team (VAT) on appropriateness of antibiotic prescribing behavior of older care physicians, regarding urinary tract (UTI), respiratory tract (RTI), and skin and soft tissue infections (SSTI), in residents of long-term care facilities (LTCF).

DESIGN

Before-after trial; introduction of a VAT consisting of a clinical microbiologist, older care physician, and a pharmacist.

SETTING AND PARTICIPANTS

Eight LTCFs in Amsterdam, the Netherlands.

METHODS

The VAT was introduced on April 1, 2019. Meetings were held via weekly teleconferencing. VAT advised about treatment indication, antibiotic choice, and additional diagnostics. Data were retrospectively extracted from resident files regarding infection episodes for which antibiotics had been prescribed during 12 months before (period I) and 11 months after VAT introduction (period II). Appropriateness of antibiotic prescriptions was assessed using national guidelines and an algorithm developed for antimicrobial stewardship in nursing homes. Antibiotic prescription rates per 100 person-years (py) were estimated and compared between periods using incidence rate ratio (IRR) with 95% confidence intervals (CIs). Proportions of appropriate antibiotic prescriptions were compared between periods using the chi-squared test.

RESULTS

A total of 524 infection episodes for which antibiotics were prescribed were identified: 284 in period I and 240 in period II. Antibiotic prescription rates before VAT introduction were 73 per 100 py in period I and decreased to 68 in period II (IRR 0.9, 95% CI 0.8-1.1). Of all prescriptions, 23.9% were assessed as appropriate during period I, which increased to 40.4% in period II (P < .001). Appropriate antibiotic use increased after VAT introduction for RTI (12.5% to 48.2%, P < .001) and SSTI (47.5% to 74.3%, P = .02) but remained similar for UTI (23.5% to 28.8%, P = .29).

CONCLUSIONS AND IMPLICATIONS

After implementation of VAT in LTCFs, appropriate antibiotic use increased significantly overall, and for RTI and SSTI particularly. Improving prescribing behavior regarding UTI might need extra strategies.

Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial

INTRODUCTION

Almost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting.

METHODS AND ANALYSIS

First, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents ≥70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021.

ETHICS AND DISSEMINATION

Ethical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03970356.

Pharmacist-driven antimicrobial stewardship program in a long-term care facility by assessment of appropriateness

Antimicrobials are the most frequently prescribed drugs in long-term care facilities (LTCF). Antibiotic stewardship programs (ASP) are coordinated interventions promoting the responsible use of antibiotics to improve patient outcomes and reduce antibiotic resistant bacterias. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a LTCF, to characterise antibiotic therapy and assess the appropriateness of antibiotic prescriptions. A prospective quasi-experimental study to implement an ASP in a LTCF. Antibiotic prescriptions for suspected infections initiated in any setting for LTCF residents were included. We assessed appropriateness and prospective audits and feedback of each inappropriate antimicrobial prescription were carried out. Associations of variables with appropriate antibiotic prescribing were estimated using logistic regression. A total of 416 antibiotic prescriptions were included. The mean consumption of antibiotics was reduced from 63.2 defined daily doses per 1000 residents-days (DRD) in the preintervention period to 22.8 in the intervention period (- 63.8%), with a signifcant drop in fluoroquinolones (81.4%). Overall, 46.6% of antibiotic prescriptions were judged inappropriate, mainly because of a use not recommended in treatment guidelines (63.2%). Multivariable analysis showed that empirical therapy, some classes of antibiotics (cephalosporins, fluoroquinolones, fosfomycin calcium, macrolides) and prescription initiation in the emergency department were independent predictors of antimicrobial inappropriateness. Pharmacist-led ASP in a LTCF has being effective in reducing consumption of antibiotics by improving appropriateness of treatment decisions. However, ASP should include interventions in the emergency department because of the high inappropriate use in this setting.

Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: cluster randomised controlled trial

OBJECTIVE

To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents.

DESIGN

Pragmatic, cluster randomised controlled trial.

SETTING

The UPCARE study included 11 nursing home organisations in the Netherlands.

PARTICIPANTS

84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020.

INTERVENTIONS

Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections.

MAIN OUTCOME MEASURES

The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks).

RESULTS

Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups.

CONCLUSIONS

CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance.

TRIAL REGISTRATION

Netherlands Trial Register NL5054.

Healthcare-associated infections and antibiotic use in long-term care residents from two geographical regions in Switzerland

BACKGROUND

The burden of healthcare-associated infections (HAIs) and antimicrobial use in Swiss long-term care facilities (LTCFs) is currently unknown. This study assessed the prevalence of HAIs and antibiotic use among LTCF residents in Switzerland.

METHODS

A point-prevalence study was undertaken in LTCFs in eastern and western Switzerland from August to October 2019 according to the 'Healthcare-associated infections in long-term care facilities' (HALT) protocol. Characteristics of residents (age, sex, wounds, dementia, indwelling catheters) and institutions (specific factors, geographic region) were assessed. LTCF residents were screened for HAIs and current antibiotic treatment. Personal and institutional factors associated with HAIs were assessed.

RESULTS

In total, 1185 residents from 16 LTCFs (eight per geographic region) were screened for HAIs and antibiotic treatment. Median age was 87 years (interquartile range 79-91) and 71% were female. The prevalence of HAIs was 4.2% (west 4.3% vs east 4.2%; P=0.93), with mucocutaneous skin infections (36%) and respiratory tract infections (30%) being the most common. Independent risk factors for the presence of HAIs were presence of a chronic wound [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1-5.0; P=0.02] and being immobile (OR 1.8, 95% CI 1.0-3.3; P=0.04). Antibiotics were given to 2.9% of residents (west 3.9% vs east 1.8%; P=0.05) on the day of the survey. The most commonly prescribed antibiotics were amoxicillin-clavulanic acid and quinolones.

CONCLUSIONS

The prevalence of HAIs in Swiss LTCFs is similar to that in other European countries, whereas antibiotic consumption is lower. Further point-prevalence surveys on a broader scale are recommended to improve understanding of the burden of HAIs and antibiotic consumption in this setting.

Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial

BACKGROUND

When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI.

METHODS

This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062.

FINDINGS

Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33).

INTERPRETATION

The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality.

FUNDING

Danish Ministry of Health and the Velux Foundation.

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes

Aim:

The aim was to determine the association between healthcare workers’ (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention.

Background:

Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important.

Methods:

This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ² test and a linear mixed regression model were applied.

Findings:

Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (−7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (−5.64, P < 0.01). Native HCWs’ mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs’ mean change in knowledge-of-antibiotic score.

Conclusion:

Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Quality of the Diagnostic Process, Treatment Decision, and Predictors for Antibiotic Use in General Practice for Nursing Home Residents with Suspected Urinary Tract Infection

Urinary tract infections (UTIs) are common in nursing home (NH) residents and Denmark is one of the countries with the highest antibiotic use in NHs. The aim of this study was to assess the quality of the diagnostic process and treatment decision on the day of the first contact from NHs to general practice and assess predictors for prescription of antibiotics in NH residents without an indwelling urinary catheter. The study was a prospective observational study in general practice in the Capital Region of Denmark; 490 patients were included; 158 out of 394 (40.1%, 95% CI 35; 45) patients with suspected UTI had urinary tract symptoms; 270 out of 296 (91.2%, 95% CI 87; 94) patients without urinary tract symptoms had a urine culture performed. Performing urine culture in the general practice was inversely associated to prescription of antibiotics on day one (OR 0.27, 95% CI 0.13; 0.56). It is imperative to support the implementation of interventions aimed at improving the quality of the diagnostic process on day one, as less than half of the patients given the diagnosis "suspected UTI" had urinary tract symptoms, and most patients without urinary tract symptoms had a urine culture performed.

Development of a core outcome set for clinical trials aimed at improving antimicrobial stewardship in care homes

Background

Diverse outcomes reported in clinical trials of antimicrobial stewardship (AMS) interventions in care homes have hindered evidence synthesis. Our main objective was to develop a core outcome set (COS) for use in trials aimed at improving AMS in care homes.

Methods

A refined inventory of outcomes for AMS interventions in care homes, compiled from a previous study, was rated in a three-round international Delphi survey with 82 participants, using a nine-point Likert scale (from 1, unimportant, to 9, critical). This was followed by an online consensus exercise with 12 participants from Northern Ireland to finalise the COS content. Subsequently, a suitable outcome measurement instrument (OMI) was selected for each outcome in the COS by: identifying existing OMIs through a literature search and experts’ suggestions, assessing the quality of OMIs, and selecting one OMI for each core outcome via a two-round international Delphi survey with 59 participants.

Results

Of 14 outcomes initially presented, consensus was reached for inclusion of five outcomes in the COS after the three-round Delphi survey and the online consensus exercise, comprising the total number of antimicrobial courses prescribed, appropriateness of antimicrobial prescribing, days of therapy per 1000 resident-days, rate of antimicrobial resistance, and mortality related to infection. Of 17 potential OMIs identified, three were selected for the two-round Delphi exercise after the quality assessment. Consensus was reached for selection of two OMIs for the COS.

Conclusion

This COS is recommended to be used in clinical trials aimed at improving AMS in care homes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00925-8.

Deimplementation strategy to reduce overtreatment of asymptomatic bacteriuria: a study protocol for a stepped-wedge cluster randomised trial

INTRODUCTION

Antimicrobial treatment of asymptomatic bacteriuria (ASB) is one of the most common unnecessary uses of antimicrobials. Earlier studies have shown that the prevalence of this inappropriate treatment ranges from 45% to 83%. Multifaceted interventions based on international guidelines and antimicrobial stewardship can decrease overtreatment of ASB. We have designed a study protocol with the main objective of reducing overtreatment of ASB by 50% through use of a deimplementation strategy.

METHODS AND ANALYSIS

We will use a stepped-wedge cluster randomised design, comparing outcomes before and after introduction of our intervention in the emergency department (ED) of five hospitals (clusters) in the Netherlands. All patients (≥18 years old) who have a urine test performed in the ED will be screened for eligibility. The deimplementation strategy consists of a combination of interventions, including education, audit and feedback. The primary endpoint is overtreatment of ASB in patients without risk factors (eg, pregnancy, planned invasive urological procedures and neutropenia). Secondary endpoints are the duration of antimicrobial treatment for ASB, the number of urine cultures and urinalysis per 1000 patients, and overtreatment of positive urinalysis in asymptomatic patients.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the medical ethics research committee of the Academic Medical Centre (Amsterdam, the Netherlands) with a waiver for informed consent. Local feasibility was obtained by the local institutional review boards of all participating hospitals. Our study aims to reduce inappropriate screening and treatment of ASB in EDs, improve healthcare quality, lower the increase in antimicrobial resistance and save costs. If proven (cost)-effective, this study provides a well-suited strategy for a nationwide approach to reduce overtreatment of ASB. Relevant results of our study will be disseminated through publications in peer-reviewed journals and presentations at relevant (scientific) conferences.

TRIAL REGISTRATION NUMBER

NL8242; Pre-results.

Sensitivity of C-reactive protein and procalcitonin measured by Point-of-Care tests to diagnose urinary tract infections in nursing home residents: a cross-sectional study

Background

Diagnosing urinary tract infections (UTIs) in nursing home residents is complex, as specific urinary symptoms are often absent and asymptomatic bacteriuria (ASB) is prevalent. The aim of this study was to assess the sensitivity of blood C-reactive protein (CRP) and procalcitonin (PCT), measured by point-of-care tests (PoCTs), to diagnose UTIs in this setting.

Methods

Elderly residents (≥65 years old) with a suspected UTI were recruited from psychogeriatric, somatic, or rehabilitation wards across 13 participating nursing homes. CRP and PCT were tested simultaneously in the same study participants. To assess the tests’ sensitivities, a stringent definition of “true” UTI was used that included the presence of symptoms, urinary leucocytes, a positive urine culture, and symptom resolution during antibiotic treatment covering isolated uropathogen(s). The original sample size was 440 suspected UTI episodes, in order to detect a clinically relevant sensitivity of at least 65% when calculated using the matched analysis approach to compare both PoCTs.

Results

After enrollment of 302 episodes (68.6% of the planned sample size), an unplanned and funder-mandated interim analysis was done, resulting in premature discontinuation of the study for futility. For 247 of 266 eligible episodes, all mandatory items required for the true UTI definition (92.9%) were available. In total, 49 episodes fulfilled our stringent UTI definition (19.8%). The sensitivities of CRP (cut-off, 6.5 mg/L) and PCT (cut-off, 0.025 ng/mL) were 52.3% (95% confidence interval [CI], 36.7–67.5%) and 37.0% (95% CI, 23.2–52.5%), respectively.

Conclusions

Our results indicate that CRP and PCT are not suitable tests for distinguishing UTI and ASB in nursing home residents.

Clinical Trials Registration

Netherlands Trial Registry NL6293.

"A false sense of confidence" The perceived role of inflammatory point-of-care testing in managing urinary tract infections in Dutch nursing homes: a qualitative study

BACKGROUND

Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent non-specific symptomatology and asymptomatic bacteriuria. The objective of this study was to explore health care professionals' perceptions of the proposed use of inflammatory marker Point-Of-Care Testing (POCT) in this respect.

METHODS

We conducted a qualitative inquiry (2018-2019) alongside the multicenter PROGRESS study (NL6293), which assessed the sensitivity of C-reactive protein and procalcitonin POCT in UTI. We used semi-structured face-to-face interviews. The participants were physicians (n = 12) and nurses (n = 6) from 13 nursing homes in the Netherlands. Most respondents were not familiar with inflammatory marker POCT, while some used POCT for respiratory tract infections. Both the interview guide and the analysis of the interview transcripts were based on the Consolidated Framework for Implementation Research.

RESULTS

All respondents acknowledged that sufficiently sensitive POCT could decrease diagnostic uncertainty to some extent in residents presenting with non-specific symptoms. They primarily thought that negative test results would rule out UTI and justify withholding antibiotic treatment. Secondly, they described how positive test results could rule in UTI and justify antimicrobial treatment. However, most respondents also expected new diagnostic uncertainties to arise. Firstly, in case of negative test results, they were not sure how to deal with residents' persisting non-specific symptoms. Secondly, in case of positive test results, they feared overlooking infections other than UTI. These new uncertainties could lead to inappropriate antibiotics use. Therefore, POCT was thought to create a false sense of confidence.

CONCLUSIONS

Our study suggests that inflammatory marker POCT will only improve UTI management in nursing homes to some extent. To realize the expected added value, any implementation of POCT requires thorough guidance to ensure appropriate use. Developing UTI markers with high negative and positive predictive values may offer greater potential to improve UTI management in nursing homes.

Oral and parenteral antibiotic use in Norwegian nursing homes: are primary care institutions becoming our new local hospitals?

Background

Norwegian nursing homes (NHs) have over the last 10 years increasingly applied the use of parenteral treatment, which in turn allows more broad-spectrum use of antibiotics. Previous studies from Norwegian NHs have for the most part not described parenteral formulations.

Objectives

To describe systemic antibiotic use in Norwegian NHs.

Methods

Thirty-seven NHs in the county of Østfold, Norway, were invited to participate in this retrospective cross-sectional study. Associated pharmacies provided sales data for systemic antibiotic use for the participating NHs for 1 year (October 2015 to October 2016). General institutional characteristics were collected through a questionnaire.

Results

Thirty-four NHs participated in the study. Mean use of antibiotics was 9.5 DDD/100 bed days (range 0.6–30.9 DDD/100 bed days). Oral antibiotics accounted for 83% and parenteral antibiotics for 17% of the total antibiotic use. Of parenteral antibiotics, ampicillin was most used (31.1%) followed by cefotaxime (17.7%) and penicillin G (16.6%). The proportion of antibiotics compliant with guideline recommendations was 60%. Being a short-term NH was associated with increased antibiotic use, with an unstandardized coefficient of 13.1 (95% CI 4.2–21.9; P = 0.005).

Conclusions

We found a high level of total and parenteral antibiotic use compared with previous studies from Norwegian NHs. Data showed wide variations in total antibiotic use and that only a moderate proportion of the antibiotic use was considered guideline compliant. This highlights the necessity of further implementation strategies regarding the national guidelines for antibiotic use in NHs.

Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial

BACKGROUND

Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process.

METHODS

A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals.

DISCUSSION

This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care.

TRIAL REGISTRATION

The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555 .

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

OBJECTIVES

To determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.

DESIGN

Web-based discrete choice experiment with 19 clinical scenarios.

SETTING AND PARTICIPANTS

Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.

METHODS

Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non-evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.

RESULTS

For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16-5.65], obvious blood in urine (OR 4.66, 95% CI 3.99-5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28-4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53-7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53-5.47) had highest odds for the forced-deliberation group.

CONCLUSIONS AND IMPLICATIONS

This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.

Risk Factors for Unnecessary Antibiotic Therapy: A Major Role for Clinical Management

BACKGROUND

Assessment of antimicrobial use places an emphasis on therapeutic aspects of infected patients. Our aim was to determine the risk factors for unnecessary antibiotic therapy (UAT).

METHODS

This was a prospective, multicenter study evaluating all curative antibiotic therapies prescribed over 2 consecutive days through the same electronic medical records. Each item that could participate in these prescriptions was collected from the computerized file (reason for hospitalization, comorbid conditions, suspected or definitive diagnosis of infection, microbial analyses). UAT was defined as the recognition of noninfectious sydromes (NIS), nonbacterial infections, use of redundant antimicrobials, and continuation of empirical broad-spectrum antimicrobials.

RESULTS

Four hundred fifty-three antibiotic therapies were analyzed at 17 institutions. An infectious disease was the reason for hospitalization in 201 cases (44%). An unspecified diagnosis of infection was observed in 104 cases (23%). Microbial samples were taken in 296 cases (65%), allowing isolation of a pathogen in 156 cases (53%). Unspecified diagnosis was associated with the absence of a microbial sample compared to patients with a diagnosis: (56/104 [54%] vs 240/349 [69%]; P = .005). A total of 158 NIS were observed (35%). UAT was observed in 169 cases (37%), due to NIS in 106 cases. In multivariate analysis, the modifiable risk factors for UAT were unspecified diagnosis (adjusted odds ratio [AOR], 1.83; 95% confidence interval [CI], 1.04-3.20) and absence of a blood culture (AOR, 5.26; 95% CI, 2.56-10.00).

CONCLUSIONS

UAT is associated with an unspecified diagnosis and the absence of microbial testing. Antimicrobial stewardship programs should focus on diagnostic difficulties and microbial testing, the latter facilitating antibiotic reassessment and therapeutic interruption.

Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents

BACKGROUND

Inappropriate antibiotic treatments for urinary tract infections (UTIs) in nursing homes cause the development of resistant bacteria. Nonspecific symptoms and asymptomatic bacteriuria are drivers of overtreatment. Nursing home staff provide general practice with information about ailing residents; therefore, their knowledge and communication skills influence prescribing. This paper describes the development of a tailored, complex intervention for a cluster-randomised trial that targets the knowledge of UTI and communication skills in nursing home staff to reduce antibiotic prescriptions.

METHODS

A dialogue tool was drafted, drawing on participatory observations in nursing homes, interviews with stakeholders, and a survey in general practice. The tool was tailored through a five-phase process that included stakeholders. Finally, the tool and a case-based educational session were tested in a pilot study.

RESULTS

The main barriers were that complex patients were evaluated by healthcare staff with limited knowledge about disease and clinical reasoning; findings reported to general practice were insignificant and included vague descriptions; there was evidence of previous opinion bias; nonspecific symptoms were interpreted as UTI; intuitive reasoning led to the inappropriate suspicion of UTI.

CONCLUSION

Sustainable change in antibiotic-prescribing behaviour in nursing homes requires a change in nursing home staff's beliefs about and management of UTIs.

Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Urinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis.

OBJECTIVE

The objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality.

METHODS

The study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period.

RESULTS

The trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020.

CONCLUSIONS

The greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17710.

Microbiology testing associated with antibiotic dispensing in older community-dwelling adults

Background

It is commonly recommended that microbiological assessment should accompany the use of antibiotics prone to resistance. We sought to estimate the rate of microbiology testing and compare this to dispensing of the World Health Organization classified “watch” group antibiotics in primary care.

Methods

Data from a cohort of older adults (mean age 69 years) were linked to Australian national health insurance (Pharmaceutical Benefits Scheme & Medicare Benefits Schedule) records of community-based antibiotic dispensing and microbiology testing in 2015. Participant characteristics associated with greater watch group antibiotic dispensing and microbiology testing were estimated using adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) in multivariable zero-inflated negative binomial regression models.

Results

In 2015, among 244,299 participants, there were 63,306 watch group antibiotic prescriptions dispensed and 149,182 microbiology tests conducted; the incidence rate was 0.26 per person-year for watch group antibiotic dispensing and 0.62 for microbiology testing. Of those antibiotic prescriptions, only 19% were accompanied by microbiology testing within − 14 to + 7 days. After adjusting for socio-demographic factors and co-morbidities, individuals with chronic respiratory diseases were more likely to receive watch group antibiotics than those without, e.g. asthma (aIRR:1.59, 95%CI:1.52–1.66) and chronic obstructive pulmonary disease (COPD) (aIRR:2.71, 95%CI:2.48–2.95). However, the rate of microbiology testing was not comparably higher among them (with asthma aIRR:1.03, 95%CI:1.00–1.05; with COPD aIRR:1.00, 95%CI:0.94–1.06).

Conclusions

Priority antibiotics with high resistance risk are commonly dispensed among community-dwelling older adults. The discord between the rate of microbiology testing and antibiotic dispensing in adults with chronic respiratory diseases suggests the potential for excessive empirical prescribing.

Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial

Background

Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting.

Methods/design

A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no).

Discussion

This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results.

Trial registration

Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.