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Werneburg GT, Wagenlehner F, Clemens JQ, Harding C, Drake MJ. Towards a Reference Standard Definition of Urinary Tract Infection for Research. Eur Urol Focus 2024:S2405-4569(24)00178-0. [PMID: 39322455 DOI: 10.1016/j.euf.2024.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 09/17/2024] [Indexed: 09/27/2024]
Abstract
Urinary tract infection (UTI) is among the most common human bacterial infections. In the context of increasing antibiotic resistance, there are many research efforts to improve the pathophysiological understanding, diagnosis, and treatment of UTI. Despite the high clinical relevance of UTI, there is high variability in definitions in the literature, making interpretation and comparison of research studies difficult, and even impossible in some cases. A recent Delphi consensus study generated a new reference standard definition for UTI that incorporates symptoms, pyuria, and urine culture results. This definition allows for designation of systemic involvement, and no longer categorizes UTIs as complicated or uncomplicated. The definition aligns with guidance from regulatory bodies for approval of UTI drugs. Implementation of a reference standard definition in the design and reporting of future investigations will allow better research design and interpretability within and outside the urology field. The new reference standard resolves some issues and offers a suitable way to unify methodology, and hence increase the potential strength of research in this area. There are some limitations and challenges for implementation, such as difficulties in establishing sensitivity and specificity values for the various settings in which the definition will be used. The inclusion of "probable" and "possible" UTI categories could be a problem in studies that require dichotomous outcomes. Nonetheless, the reference standard should be recommended until new developments become available, notably a more specific UTI biomarker than pyuria. Approaches to standardized diagnosis of catheter-associated UTIs remain unresolved. PATIENT SUMMARY: A new research definition for urinary tract infection (UTI) has been developed. Use of a single standardized definition in research will help in better design of research studies and comparison of results. Although the new definition will help in reducing the variability in UTI research reports, it has some limitations and there may be challenges to overcome before it is widely used.
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Affiliation(s)
- Glenn T Werneburg
- Department of Urology, University of Michigan, Ann Arbor, MI, USA; Department of Urology, Glickman Urological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Florian Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
| | | | - Chris Harding
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Marcus J Drake
- Department of Surgery and Cancer, Imperial College, London, UK
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Bausch K, Stangl FP, Prieto J, Bonkat G, Kranz J. Urinary Infection Management in Frail or Comorbid Older Individuals. Eur Urol Focus 2024:S2405-4569(24)00164-0. [PMID: 39217017 DOI: 10.1016/j.euf.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/01/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
Urinary tract infection (UTI) is common among older individuals, especially those with frailty and comorbidity. Asymptomatic bacteriuria is also common in this group and does not require treatment. UTI diagnosis is complicated by atypical signs and symptoms such as confusion or functional decline. This necessitates a more holistic assessment according to a diagnostic algorithm that includes nonspecific symptoms to avoid overdiagnosis or underdiagnosis. Treatment strategies for UTI in older people generally align with those for younger people, with some exceptions. Prophylaxis is similar to that for postmenopausal women. However, it is crucial to carefully consider comorbidities, polypharmacy, and the risk of potential adverse events. PATIENT SUMMARY: We provide recommendations for the management of urinary tract infection (UTI) in older individuals who are frail and have multiple medical conditions. These patients may have signs and symptoms that are not typical for UTI. Treatment plans for these vulnerable patients should take interactions with other drugs and possible side effects into account.
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Affiliation(s)
- Kathrin Bausch
- Department of Urology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Fabian P Stangl
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacqui Prieto
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Gernot Bonkat
- alta Uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland
| | - Jennifer Kranz
- Department of Urology and Pediatric Urology, RWTH Aachen University, Aachen, Germany; Department of Urology and Kidney Transplantation, Martin-Luther-University, Halle, Germany
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3
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Llor C, Moragas A, Ruppe G, Lykkegaard J, Hansen MP, Antsupova VS, Jensen JN, Theut AM, Petek D, Sodja N, Kowalczyk A, Bjerrum L. Diagnosing probable urinary tract infections in nursing home residents without indwelling catheters: a narrative review. Clin Microbiol Infect 2024:S1198-743X(24)00419-1. [PMID: 39209268 DOI: 10.1016/j.cmi.2024.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/18/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
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.
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Affiliation(s)
- Carl Llor
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark; Primary Care Research Institute Jordi Gol, Institut d'Investigació en Atenció Primària (IDIAP), Barcelona, Spain; CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Moragas
- Primary Care Research Institute Jordi Gol, Institut d'Investigació en Atenció Primària (IDIAP), Barcelona, Spain; CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Department of General Pathology. University Rovira i Virgili, Tarragona, Spain
| | - Georg Ruppe
- Austrian Interdisciplinary Platform on Ageing/Österreichische Plattform für Interdisziplinäre Alternsfragen (OEPIA), Vienna, Austria
| | - Jesper Lykkegaard
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Malene Plejdrup Hansen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark; Center for General Practice, Aalborg University, Aalborg, Denmark
| | - Valeria S Antsupova
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Jette Nygaard Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Anna Marie Theut
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Davorina Petek
- Department of Family Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Nina Sodja
- Department of Family Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Lars Bjerrum
- Department of Public Health, Section and Research Unit of General Practice, University of Copenhagen, Copenhagen, Denmark
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Wang RC, Van Buul LW, Geerlings SE, De Greeff SC, Haenen A, Halonen K, Notermans DW, Reuland EA, Smalbrugge M, Twisk JWR, Schneeberger C. YELLOW RoUTIne prospective cohort study protocol: insight in the dynamics of bacteria in the elderly bladder. BMC Infect Dis 2024; 24:890. [PMID: 39215213 PMCID: PMC11363575 DOI: 10.1186/s12879-024-09727-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024] Open
Abstract
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.
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Affiliation(s)
- Ruo Chen Wang
- Department of Medicine for Older People, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Laura W Van Buul
- Department of Medicine for Older People, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Suzanne E Geerlings
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Internal Medicine, Infectious Diseases Division, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam, The Netherlands
| | - Sabine C De Greeff
- Centre for Infectious Disease Research, Epidemiology and Surveillance, National Institute for Public Health and Environment, Bilthoven, The Netherlands
| | - Anja Haenen
- Centre for Infectious Disease Research, Epidemiology and Surveillance, National Institute for Public Health and Environment, Bilthoven, The Netherlands
| | - Kati Halonen
- Centre for Infectious Disease Research, Epidemiology and Surveillance, National Institute for Public Health and Environment, Bilthoven, The Netherlands
| | - Daan W Notermans
- Centre for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and Environment, Bilthoven, The Netherlands
| | - E Ascelijn Reuland
- Department of Medical Microbiology, Central Bacteriology and Serology Laboratory, Tergooi Medical Centre, Hilversum, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Caroline Schneeberger
- Department of Medicine for Older People, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Infectious Diseases in Primary Care, Nivel, Utrecht, The Netherlands
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5
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Langford BJ, Amoah S, Hansen J, Hudd L, Almohri H, Wright J. BLADDER score: evaluating a tool to support urinary diagnostic and antibiotic stewardship in hospitalized adults. Infect Control Hosp Epidemiol 2024:1-5. [PMID: 39192746 DOI: 10.1017/ice.2024.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
OBJECTIVE Antibiotic overuse for asymptomatic bacteriuria is common in older adults and can lead to harmful outcomes including antimicrobial resistance. Our objective was to evaluate the impact of a simple scoring tool on urine culturing and antibiotic prescribing for adults with presumed urinary tract infections (UTI). DESIGN Quasi-experimental study using interrupted time series with segmented regression to evaluate urine culturing and urinary antibiotic use and length of stay (LOS), acute care transfers, and mortality 18 months before and 16 months after the intervention. SETTING 134-bed complex continuing care and rehabilitation hospital in Ontario, Canada. PARTICIPANTS Nurses, nurse practitioners, physicians, and other healthcare professionals. INTERVENTION A multifaceted intervention focusing on a 6-item mnemonic scoring tool called the BLADDER score was developed based on existing minimum criteria for prescribing antibiotics in patients with presumed UTI. The BLADDER score was combined with ward- and prescriber-level feedback and education. RESULTS Before the intervention, the mean rate of urine culturing was 12.47 cultures per 1,000 patient days; after the intervention, the rate was 7.92 cultures per 1,000 patient days (IRR 0.87; 95% CI, 0.67-1.12). Urinary antibiotic use declined after the intervention from a mean of 40.55 DDD per 1,000 patient days before and 25.96 DDD per 1,000 patient days after the intervention (IRR 0.68; 95% CI, 0.59-0.79). There was no change in mean patient LOS, acute care transfers, or mortality. CONCLUSIONS The BLADDER score may be a safe and effective tool to support improved diagnostic and antimicrobial stewardship to reduce unnecessary treatment for asymptomatic bacteriuria.
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Affiliation(s)
- Bradley J Langford
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Stephanie Amoah
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada
- Brock University, St. Catharines, ON, Canada
| | - Jennifer Hansen
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada
| | - Lorraine Hudd
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada
| | - Huda Almohri
- LifeLabs Medical Laboratories, Toronto, ON, Canada
| | - Janice Wright
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada
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6
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Smithson A. Asymptomatic bacteriuria or symptomatic urinary tract infection? That is the question. Acad Emerg Med 2024; 31:837. [PMID: 38881344 DOI: 10.1111/acem.14966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/30/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Alejandro Smithson
- Emergency Department, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet, Barcelona, Spain
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7
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Biebelberg B, Kehoe IE, Filbin MR, Heldt T, Reisner AT. Response to: "Asymptomatic bacteriuria or symptomatic urinary tract infection? That is the question". Acad Emerg Med 2024; 31:838-839. [PMID: 38881314 DOI: 10.1111/acem.14967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 05/30/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Brett Biebelberg
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Iain E Kehoe
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas Heldt
- Institute for Medical Engineering and Science and Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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8
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Bilsen MP, Conroy SP, Schneeberger C, Platteel TN, van Nieuwkoop C, Mody L, Caterino JM, Geerlings SE, Köves B, Wagenlehner F, Kunneman M, Visser LG, Lambregts MMC. A reference standard for urinary tract infection research: a multidisciplinary Delphi consensus study. THE LANCET. INFECTIOUS DISEASES 2024; 24:e513-e521. [PMID: 38458204 DOI: 10.1016/s1473-3099(23)00778-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/15/2023] [Accepted: 12/07/2023] [Indexed: 03/10/2024]
Abstract
The absence of a consensus-based reference standard for urinary tract infection (UTI) research adversely affects the internal and external validity of diagnostic and therapeutic studies. This omission hinders the accumulation of evidence for a disease that imposes a substantial burden on patients and society, particularly in an era of increasing antimicrobial resistance. We did a three-round Delphi study involving an international, multidisciplinary panel of UTI experts (n=46) and achieved a high degree of consensus (94%) on the final reference standard. New-onset dysuria, urinary frequency, and urinary urgency were considered major symptoms, and non-specific symptoms in older patients were not deemed indicative of UTI. The reference standard distinguishes between UTI with and without systemic involvement, abandoning the term complicated UTI. Moreover, different levels of pyuria were incorporated in the reference standard, encouraging quantification of pyuria in studies done in all health-care settings. The traditional bacteriuria threshold (105 colony-forming units per mL) was lowered to 104 colony-forming units per mL. This new reference standard can be used for UTI research across many patient populations and has the potential to increase homogeneity between studies.
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Affiliation(s)
- Manu P Bilsen
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands.
| | - Simon P Conroy
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Caroline Schneeberger
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, Netherlands; Department of Public Health and Primary Care, The Hague Health Campus, Leiden University Medical Center, The Hague, Netherlands
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Geriatrics Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Suzanne E Geerlings
- Amsterdam UMC, Department of Internal Medicine, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Bela Köves
- Department of Urology, University of Szeged, Szeged, Hungary
| | - Florian Wagenlehner
- Clinic for Urology, Paediatric Urology and Andrology, Justus Liebig University, Giessen, Germany
| | - Marleen Kunneman
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands; Knowledge and Evaluation Research Unit, Mayo Clinic Rochester, Rochester, MN, USA
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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Kranz J, Bartoletti R, Bruyère F, Cai T, Geerlings S, Köves B, Schubert S, Pilatz A, Veeratterapillay R, Wagenlehner FME, Bausch K, Devlies W, Horváth J, Leitner L, Mantica G, Mezei T, Smith EJ, Bonkat G. European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines. Eur Urol 2024; 86:27-41. [PMID: 38714379 DOI: 10.1016/j.eururo.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND AND OBJECTIVE Urological infections significantly impact the wellbeing and quality of life of individuals owing to their widespread occurrence and diverse clinical manifestations. The objective of the guidelines panel was to provide evidence-based guidance on the diagnosis, treatment, and prevention of urinary tract infections (UTIs) and male accessory-gland infections, while addressing crucial public health aspects related to infection control and antimicrobial stewardship. METHODS For the 2024 guidelines on urological infections, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS Key recommendations emphasise the importance of a thorough medical history and physical examination for patients with urological infections. The guidelines stress the role of antimicrobial stewardship to combat the rising threat of antimicrobial resistance, providing recommendations for antibiotic selection, dosing, and duration on the basis of the latest evidence. CONCLUSIONS AND CLINICAL IMPLICATIONS This overview of the 2024 EAU guidelines offers valuable insights into managing urological infections and are designed for effective integration into clinical practice. PATIENT SUMMARY The European Association of Urology has issued an updated guideline on urological infections. The guidelines provide recommendations for diagnosis, treatment, and prevention, with a particular focus on minimising antibiotic use because of the increasing global threat of antimicrobial resistance.
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Affiliation(s)
- Jennifer Kranz
- Department of Urology and Pediatric Urology, RWTH Aachen University, Aachen, Germany; Department of Urology and Kidney Transplantation, Martin-Luther-University, Halle, Germany.
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies, University of Pisa, Pisa, Italy
| | - Franck Bruyère
- Department of Urology, CHRU Bretonneau, Tours, France; Université Francois Rabelais, PRES Centre Val de Loire, Tours, France
| | - Tommaso Cai
- Department of Urology, Santa Chiara, Regional Hospital, Trento, Italy
| | - Suzanne Geerlings
- Department of Internal Medicine, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Bela Köves
- Department of Urology, University of Szeged, Szeged, Hungary
| | - Sören Schubert
- Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | - Florian M E Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Kathrin Bausch
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wout Devlies
- Department of Urology, UZ Leuven, Leuven, Belgium
| | - József Horváth
- BKMK SZTE ÁOK Okt. Kh. Urológiai Osztálya, Kecskemét, Hungary
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Tunde Mezei
- Department of Urology, Telemark Hospital, Skien, Norway
| | - Emma J Smith
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Gernot Bonkat
- alta Uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel, Basel, Switzerland
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10
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Yeung GYC, Smalbrugge M, van Buul LW, Rutten JJS, van Houten P, Gerridzen IJ, de Bruijne MC, Joling KJ, Hertogh CMPM. Urinary Tract Infection Guideline Adherence in a Dutch Sentinel Nursing Home Surveillance Network. J Am Med Dir Assoc 2024; 25:105037. [PMID: 38796171 DOI: 10.1016/j.jamda.2024.105037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 05/28/2024]
Abstract
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.
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Affiliation(s)
- Gary Y C Yeung
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Paul van Houten
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; ABR Zorgnetwerken Noord-Holland en Flevoland, Amsterdam, the Netherlands
| | - Ineke J Gerridzen
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Atlant, Korsakoff Centre of Expertise, Beekbergen, the Netherlands
| | - Martine C de Bruijne
- Department of Public and Occupational Health, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Quality of Care, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Karlijn J Joling
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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11
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Schmiemann G, Kranz J, Mandraka F, Schubert S, Wagenlehner F, Gágyor I. The Diagnosis, Treatment, and Prevention of Recurrent Urinary Tract Infection. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:373-382. [PMID: 38686602 DOI: 10.3238/arztebl.m2024.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Urinary tract infection has a one-year prevalence of 11% in women and ranges among the most common reasons for consulting a primary care physician and for receiving a prescription for antibiotics. In the case of recurrent urinary tract infection (rUTI), there are questions about the further work-up, treatment, and preventive measures. METHODS The systematic literature search performed for the update of the German clinical practice guideline on uncomplicated urinary tract infection (043-044) (up to February 2022) was supplemented with a selective search for clinical trials (up to August 2023). RESULTS Urine culture and ultrasonography are reasonable steps in the diagnostic evaluation of rUTI. Further invasive testing is suggested for men but is not routinely indicated for women. Antibiotics are among the most effective preventive measures (risk ratio [RR] 0.15, 95% confidence interval [0.1; 0.3]) but carry a high risk of side effects. Non-antibiotic preparations such as cranberry juice (RR 0.74 [0.5; 0.99]), mannose (RR 0.23 [0.14; 0.37]), and vaginal estrogen (RR, 0.42 [0.30; 0.59]) can also reduce the infection rate, with a low risk of side effects. Increased daily fluid intake has been shown to lower infection rates in the short term (odds ratio [OR] 0.13 [0.07; 0.25]); the use of hygienically advisable wiping techniques after passing stool or urine has been little studied but can be implemented with no risk. CONCLUSION rUTI poses a challenge for the treating physician. The measures to be taken must be considered on an individual basis. Vulnerable groups, such as older patients, need special attention.
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Affiliation(s)
- Guido Schmiemann
- Institute of Public Health and Nursing Research, Department for Health Services Research, University of Bremen; Clinic of Urology and Pediatric Urology, University Hospital Aachen; University Hospital and Department of Urology, University Hospital of Halle (Saale); Laboratory Dr. Wisplinghoff, Specialist in Internal Medicine and Infectiology, ABS-Expert (DGI), Köln; Max von Pettenkofer-Institute, Chair of Medical Microbiology and Hospital Hygiene, Ludwig-Maximilians-University (LMU) Munich; Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen; Departement of General Practice, Julius-Maximilians-Universität of Würzburg
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12
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Mendoza De la Garza MD, Mohammad NF, DiTommaso MJ, Bicknese AL, Kaffine KB, Verdoorn BP. A Nurse-Led Algorithm for Diagnosing Urinary Tract Infection in Homebound Older Adults. Res Gerontol Nurs 2024; 17:92-97. [PMID: 38351581 DOI: 10.3928/19404921-20240206-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
PURPOSE We designed a nurse-led algorithm to standardize urinary tract infection (UTI) diagnosis for older adults receiving home-based medical care. Aims of this pilot quality improvement study were to reduce the frequency of empiric antibiotic therapy initiated without a urinalysis and urine culture (UA/UC) first being obtained, reduce antibiotic use without a concomitant increase in emergency department (ED) visits or hospital admissions, and ensure stakeholders' satisfaction with algorithm use. METHOD A nurse-led diagnostic algorithm was designed and pilot-tested to address challenges and standardize diagnosis of UTI in a population of homebound older adults. RESULTS In pre/post data analysis, algorithm implementation was associated with improved frequency of obtaining UA/UC before empiric antibiotic therapy was initiated, but the overall rate of antibiotic use for UTI did not decrease. No increase in ED or hospital admissions was identified. CONCLUSION Use of a diagnostic algorithm for UTI among homebound older adults was associated with reduced frequency of empiric antibiotic initiation for suspected UTI without a UA/UC first being obtained. More rigorous study is needed to confirm and expand on these findings. [Research in Gerontological Nursing, 17(2), 92-97.].
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13
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Young J, Allan GM, Thomas B, Pasay D. A tale of two bladders: Understanding common bladder issues in primary care. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2024; 70:103-106. [PMID: 38383012 PMCID: PMC11271834 DOI: 10.46747/cfp.7002103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
| | - G Michael Allan
- Director of Programs and Practice Support at the College of Family Physicians of Canada
| | - Betsy Thomas
- Clinical Evidence Expert at the College of Family Physicians of Canada
| | - Darren Pasay
- Drug stewardship pharmacist for Alberta Health Services in Vegreville, Alta
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14
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Rutten JJS, Smalbrugge M, van Buul LW, van Eijk J, Geerlings SE, Natsch S, Sloane PD, van der Wouden JC, Hertogh CMPM, Gerritsen DL. A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes. J Am Med Dir Assoc 2024; 25:146-154.e9. [PMID: 38173264 DOI: 10.1016/j.jamda.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention. DESIGN Mixed-methods process evaluation study. SETTING AND PARTICIPANTS Physicians, nursing staff, client council members, and residents of Dutch NHs. METHODS We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members. RESULTS Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture. CONCLUSIONS AND IMPLICATIONS Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
| | - Jorna van Eijk
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of General Practice, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community care, Radboudumc Alzheimer Center, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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15
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Taylor LN, Wilson BM, Singh M, Irvine J, Jolles SA, Kowal C, Bej TA, Crnich CJ, Jump RLP. Syndromic Antibiograms and Nursing Home Clinicians' Antibiotic Choices for Urinary Tract Infections. JAMA Netw Open 2023; 6:e2349544. [PMID: 38150250 PMCID: PMC10753399 DOI: 10.1001/jamanetworkopen.2023.49544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/12/2023] [Indexed: 12/28/2023] Open
Abstract
Importance Empirical antibiotic prescribing in nursing homes (NHs) is often suboptimal. The potential for antibiograms to improve empirical antibiotic decision-making in NHs remains poorly understood. Objective To determine whether providing NH clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections (UTIs). Design, Setting, and Participants This was a survey study using clinical vignettes. Participants were recruited via convenience sampling of professional organization listservs of NH clinicians practicing in the US from December 2021 through April 2022. Data were analyzed from July 2022 to June 2023. Interventions Respondents were randomized to complete vignettes using a traditional antibiogram (TA), a weighted-incidence syndromic combination antibiogram (WISCA), or no tool. Participants randomized to antibiogram groups were asked to use the antibiogram to empirically prescribe an antibiotic. Participants randomized to the no tool group functioned as controls. Main Outcomes and Measures Empirical antibiotic selections were characterized as microbiologically (1) active and (2) optimal according to route of administration and spectrum of activity. Results Of 317 responses, 298 (95%) were included in the analysis. Duplicate responses (15 participants), location outside the US (2 participants), and uninterpretable responses (2 participants) were excluded. Most respondents were physicians (217 respondents [73%]) and had over 10 years of NH practice experience (155 respondents [52%]). A mixed-effects logistic model found that use of the TA (odds ratio [OR], 1.41; 95% CI, 1.19-1.68; P < .001) and WISCA (OR, 1.54; 95% CI, 1.30-1.84; P < .001) were statistically superior to no tool when choosing an active empirical antibiotic. A similarly constructed model found that use of the TA (OR, 1.94; 95% CI, 1.42-2.66; P < .001) and WISCA (OR, 1.7; 95% CI, 1.24-2.33; P = .003) were statistically superior to no tool when selecting an optimal empirical antibiotic. Although there were differences between tools within specific vignettes, when compared across all vignettes, the TA and WISCA performed similarly for active (OR, 1.09; 95% CI, 0.92-1.30; P = .59) and optimal (OR, 0.87; 95% CI, 0.64-1.20; P = .69) antibiotics. Conclusions and Relevance Providing NH clinicians with a urinary antibiogram was associated with selection of active and optimal antibiotics when empirically treating UTIs under simulated conditions. Although the antibiogram format was not associated with decision-making in aggregate, context-specific effects may have been present, supporting further study of syndromic antibiograms in clinical practice.
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Affiliation(s)
- Lindsay N. Taylor
- University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Veterans Affairs Medical Center, Madison
- University of Wisconsin Hospital and Clinics, Madison
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mriganka Singh
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Jessica Irvine
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Sally A. Jolles
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Taissa A. Bej
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher J. Crnich
- University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Veterans Affairs Medical Center, Madison
- University of Wisconsin Hospital and Clinics, Madison
| | - Robin L. P. Jump
- TECH-GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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16
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van Eijk J, Rutten JJS, Hertogh CMPM, Smalbrugge M, van Buul LW. 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. Int J Older People Nurs 2023; 18:e12560. [PMID: 37563799 DOI: 10.1111/opn.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/24/2023] [Accepted: 07/08/2023] [Indexed: 08/12/2023]
Abstract
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.
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Affiliation(s)
- Jorna van Eijk
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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17
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Wretman CJ, Boynton MH, Preisser JS, Zimmerman S, Kistler CE. Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: A discrete choice experiment. Infect Control Hosp Epidemiol 2023; 44:1151-1154. [PMID: 36073169 DOI: 10.1017/ice.2022.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The overdiagnosis of urinary tract infections (UTIs) in nursing home residents is a significant public health threat. Using a discrete choice experiment and a diagnostic guideline, we examined which patient-level information was associated with the overdiagnosis of UTIs and found that urinalysis results and lower urinary tract status were most associated.
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Affiliation(s)
| | - Marcella H Boynton
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Christine E Kistler
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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18
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Mancuso G, Midiri A, Gerace E, Marra M, Zummo S, Biondo C. Urinary Tract Infections: The Current Scenario and Future Prospects. Pathogens 2023; 12:pathogens12040623. [PMID: 37111509 PMCID: PMC10145414 DOI: 10.3390/pathogens12040623] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Urinary tract infections (UTIs) are among the most common bacterial infections worldwide, occurring in both community and healthcare settings. Although the clinical symptoms of UTIs are heterogeneous and range from uncomplicated (uUTIs) to complicated (cUTIs), most UTIs are usually treated empirically. Bacteria are the main causative agents of these infections, although more rarely, other microorganisms, such as fungi and some viruses, have been reported to be responsible for UTIs. Uropathogenic Escherichia coli (UPEC) is the most common causative agent for both uUTIs and cUTIs, followed by other pathogenic microorganisms, such as Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis, and Staphylococcus spp. In addition, the incidence of UTIs caused by multidrug resistance (MDR) is increasing, resulting in a significant increase in the spread of antibiotic resistance and the economic burden of these infections. Here, we discuss the various factors associated with UTIs, including the mechanisms of pathogenicity related to the bacteria that cause UTIs and the emergence of increasing resistance in UTI pathogens.
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Affiliation(s)
- Giuseppe Mancuso
- Department of Human Pathology, University of Messina, 98125 Messina, Italy
| | - Angelina Midiri
- Department of Human Pathology, University of Messina, 98125 Messina, Italy
| | | | - Maria Marra
- Department of Human Pathology, University of Messina, 98125 Messina, Italy
| | - Sebastiana Zummo
- Department of Human Pathology, University of Messina, 98125 Messina, Italy
| | - Carmelo Biondo
- Department of Human Pathology, University of Messina, 98125 Messina, Italy
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19
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Hartman EAR, van de Pol AC, Heltveit-Olsen SR, Lindbæk M, Høye S, Lithén SS, Sundvall PD, Sundvall S, Arnljots ES, Gunnarsson R, Kowalczyk A, Godycki-Cwirko M, Platteel TN, Groen WG, Monnier AA, Zuithoff NP, Verheij TJM, Hertogh CMPM. 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. BMJ 2023; 380:e072319. [PMID: 36813284 PMCID: PMC9943914 DOI: 10.1136/bmj-2022-072319] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
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.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Silje Rebekka Heltveit-Olsen
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Høye
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sara Sofia Lithén
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Sofia Sundvall
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Egill Snaebjörnsson Arnljots
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
| | - Nicolaas P Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
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20
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Bacteriuria in older adults triggers confusion in healthcare providers: A mindful pause to treat the worry. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e4. [PMID: 36714291 PMCID: PMC9879885 DOI: 10.1017/ash.2022.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 01/11/2023]
Abstract
The evidence base for refraining from screening for or treating asymptomatic bacteriuria (ASB) in older adults is strong, but both practices remain prevalent. Clinical confusion over how to respond to a change from baseline, when to order a urinalysis and urine culture, and what to do with a positive urine culture fuels unnecessary antibiotic use for ASB. If the provider can take a mindful pause to apply evidenced-based assessment tools, the resulting increased clarity in how to manage the situation can reduce overtreatment of ASB.
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21
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How Are Older Adults Different Than Other Adults for Infections? INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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22
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Hidad S, Kuil SD, Fischer JC, Visser CE, Geerlings SE, Leeflang MMG, Schneeberger C. C‐reactive protein, procalcitonin, and erythrocyte sedimentation rate for the diagnosis of lower urinary tract infection in older people. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022. [PMCID: PMC9761663 DOI: 10.1002/14651858.cd014521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:
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Affiliation(s)
| | - Soemeja Hidad
- Department of Medical MicrobiologyAmsterdam University Medical CentersAmsterdamNetherlands
| | - Sacha D Kuil
- Department of Medical MicrobiologyAmsterdam University Medical CentersAmsterdamNetherlands
| | - Johan C Fischer
- Department of Clinical ChemistryAmsterdam University Medical CentersAmsterdamNetherlands
| | - Caroline E Visser
- Department of Medical MicrobiologyAmsterdam University Medical CentersAmsterdamNetherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Center for Infection and ImmunityAmsterdam University Medical CentersAmsterdamNetherlands
| | - Mariska MG Leeflang
- Department of Clinical Epidemiology, Biostatistics and BioinformaticsAmsterdam University Medical CentersAmsterdamNetherlands
| | - Caroline Schneeberger
- Center for Infectious Disease ControlNational Institute for Public Health and the Environment (RIVM)BilthovenNetherlands
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23
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Eecen C, Vreeswijk R, Souverein D, Euser SM, Kalisvaart KJ. 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. Eur Geriatr Med 2022; 13:1391-1401. [PMID: 36309951 DOI: 10.1007/s41999-022-00708-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- C Eecen
- Department of Geriatrics, Spaarne Gasthuis, Location Haarlem-Zuid, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands.
| | - R Vreeswijk
- Department of Geriatrics, Spaarne Gasthuis, Location Haarlem-Zuid, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - D Souverein
- Department of Epidemiology, Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035 RC, Haarlem, The Netherlands
| | - S M Euser
- Department of Epidemiology, Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035 RC, Haarlem, The Netherlands
| | - K J Kalisvaart
- Department of Geriatrics, Spaarne Gasthuis, Location Haarlem-Zuid, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
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24
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Feasibility of Algorithm-Based Clinical Decision Support for Suspected Urinary Tract Infections in Nursing Home Residents. Antibiotics (Basel) 2022; 11:antibiotics11101276. [PMID: 36289934 PMCID: PMC9599012 DOI: 10.3390/antibiotics11101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022] Open
Abstract
Urinary tract infections (UTIs) are commonly suspected in nursing home (NH) residents, commonly resulting in antimicrobial prescriptions, even when symptoms are non-specific. To improve the diagnosis and management of suspected UTIs in NH residents, we conducted a pilot test of a paper-based clinical algorithm across NHs in the southern U.S. with ten advanced practice providers (APPs). The paper-based algorithm was modified based on the clinical care needs of our APPs and included antimicrobial treatment recommendations. The APPs found the UTI antimicrobial stewardship and clinical decision support acceptable. The educational sessions and algorithm improved baseline confidence toward UTI diagnosing and treatment. The APPs thought the algorithm was useful and did not negatively impact workload. Feedback from the pilot study will be used to improve the next iteration of the algorithm as we assess its impact on prescribing outcomes.
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25
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Masot O, Cox A, Mold F, Sund-Levander M, Tingström P, Boersema GC, Botigué T, Daltrey J, Hughes K, Mayhorn CB, Montgomery A, Mullan J, Carey N. Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review. BMC Geriatr 2022; 22:552. [PMID: 35778707 PMCID: PMC9247966 DOI: 10.1186/s12877-022-03218-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care. Objective To identify and analyse decision support tools available to support detection of infection in older people (> 65 years). Methods A scoping review of the literature 2010–2021 following Arksey and O’Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches. Results Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection. Conclusions DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03218-w.
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Affiliation(s)
- Olga Masot
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain. .,Health Care Research Group (GRECS), [Lleida Institute for Biomedical Research Dr. Pifarré Foundation], IRBLleida, 25198, Lleida, Spain.
| | - Anna Cox
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Freda Mold
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Märtha Sund-Levander
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Pia Tingström
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Teresa Botigué
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain.,Health Care Research Group (GRECS), [Lleida Institute for Biomedical Research Dr. Pifarré Foundation], IRBLleida, 25198, Lleida, Spain
| | - Julie Daltrey
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Karen Hughes
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Christopher B Mayhorn
- Department of Psychology, North Carolina State University, Raleigh, NC, 27695-7801, USA
| | - Amy Montgomery
- School of Nursing, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Judy Mullan
- School of Medicine, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Nicola Carey
- Department of Nursing and Midwifery, University of the Highlands and Islands, Inverness, IV2 3JH, UK
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26
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The Ambiguous Reality of Prescribing in Geriatric Practice. J Am Med Dir Assoc 2022; 23:976-979. [PMID: 35659943 DOI: 10.1016/j.jamda.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
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27
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Hartman EAR, Groen WG, Heltveit-Olsen SR, Lindbæk M, Høye S, Sundvall PD, Skoglund I, Snaebjörnsson Arnljots E, Gunnarsson R, Kowalczyk A, Godycki-Cwirko M, Kosiek K, Platteel TN, van de Pol AC, Verheij TJM, Monnier AA, Hertogh CMPM. Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries. Age Ageing 2022; 51:afac134. [PMID: 35697352 PMCID: PMC9191618 DOI: 10.1093/ageing/afac134] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
| | - Silje Rebekka Heltveit-Olsen
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Høye
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Egill Snaebjörnsson Arnljots
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- Primary Health Care Clinic for Homeless People, Närhälsan, Region Västra Götaland, Sweden
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, The Medical University of Lodz, Lodz, Poland
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, the Faculty of Health Sciences, The Medical University of Lodz, Lodz, Poland
| | | | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
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28
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Delgado KF, Roberson D, Haberstroh A, Wei H. Nursing Staff's Role in Detecting Urinary Tract Infections in Nursing Homes: An Integrative Review. J Gerontol Nurs 2022; 48:43-50. [PMID: 35511064 DOI: 10.3928/00989134-20220405-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite evidence-based protocols, inappropriate antibiotic use still presents a systemic global threat to health care in nursing homes (NHs). Nursing staff are responsible for recognizing signs and symptoms that may indicate urinary tract infections (UTIs). The current integrative review was designed to examine the state of the literature related to the role of nursing staff in UTI identification and care in NHs. This review, which includes 19 articles published between 2011 and 2020, identified that, although prescribers are the experts in UTI management, nursing staff in NHs were the individuals who recognized changes and communicated residents' needs to prescribers. Further research is required to understand nursing staff's decision making and unique perspectives and determine if evidence-based protocols align with current practice in the NH setting. [Journal of Gerontological Nursing, 48(5), 43-50.].
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29
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Goedemans T, Verberk JDM, van den Munckhof P, Buis DR, Vandertop WP, de Korte AM. Neurological update: consult the neurosurgical oracle for a standard operating procedure. J Neurol 2022; 269:5179-5186. [PMID: 35381880 PMCID: PMC9363322 DOI: 10.1007/s00415-022-11090-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/24/2022]
Abstract
Standard operating procedures (SOPs) contain general instructions and principles to standardize care, to improve effective and safe healthcare. Developing new, or updating current, SOPs is, however, challenging in fields where high-level evidence is limited. Still, SOPs alone have been shown to result in less complications. In this narrative review, we describe the process of creating a consensus-based SOP that is pragmatic for clinical practice since it can be created regardless of the current level of evidence. Through live audience engagement platforms, a group of experts will be able to both anonymously respond to a created questionnaire, and (subsequently) discuss the results within the same meeting. This modified Digital Delphi method as described here can be used as a tool toward consensus-based healthcare.
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Affiliation(s)
- Taco Goedemans
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Janneke D M Verberk
- Department of Medical Microbiology and Infection Prevention, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Dennis R Buis
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Antonius M de Korte
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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30
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Gombash A, Pergola M. Guidelines for Acute Urinary Tract Infections. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-021-00241-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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Kolodziej LM, Kuil SD, de Jong MD, Schneeberger C. Resident-Related Factors Influencing Antibiotic Treatment Decisions for Urinary Tract Infections in Dutch Nursing Homes. Antibiotics (Basel) 2022; 11:antibiotics11020140. [PMID: 35203742 PMCID: PMC8868192 DOI: 10.3390/antibiotics11020140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/15/2022] [Accepted: 01/18/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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32
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Kistler CE, Wretman CJ, Zimmerman S, Enyioha C, Ward K, Farel CE, Sloane PD, Boynton MH, Beeber AS, Preisser JS. Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. J Am Geriatr Soc 2022; 70:1070-1081. [PMID: 35014024 DOI: 10.1111/jgs.17638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. METHODS We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. RESULTS One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). CONCLUSIONS Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of North Carolina, Chapel Hill, NC, USA.,Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Chineme Enyioha
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Claire E Farel
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Marcella H Boynton
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Anna S Beeber
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Rutten JJS, van Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, Sloane PD, van der Wouden JC, Twisk JWR, Hertogh CMPM. 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. J Am Med Dir Assoc 2021; 23:387-393. [PMID: 34896069 DOI: 10.1016/j.jamda.2021.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Radboud Institute for Health Sciences, Radboudumc Alzheimer Center, Department of Primary and Community care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Kuil SD, van Leth F, Schneeberger C, de Jong MD, Harting J. Clinical Reasoning Underlying Guideline Nonadherence in Urinary Tract Infections in Nursing Homes. J Am Med Dir Assoc 2021; 23:896-898. [PMID: 34687606 DOI: 10.1016/j.jamda.2021.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Sacha Daniëlle Kuil
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank van Leth
- Department of Health Sciences, Vrije Universiteit, Amsterdam, the Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Caroline Schneeberger
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Menno Douwe de Jong
- Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Janneke Harting
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Hartman EAR, Groen WG, Heltveit-Olsen SR, Lindbaek M, Hoye S, Sundvall PD, Gunnarsson R, Skoglund I, Snaebjörnsson Arnljots E, Godycki-Cwirko M, Kowalczyk A, Platteel TN, Zuithoff NPA, Monnier AA, Verheij TJM, Hertogh CMPM, van de Pol AC. 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. BMJ Open 2021; 11:e052552. [PMID: 34620666 PMCID: PMC8499316 DOI: 10.1136/bmjopen-2021-052552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Silje Rebekka Heltveit-Olsen
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbaek
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Hoye
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Egill Snaebjörnsson Arnljots
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Maciej Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee. J Am Med Dir Assoc 2021; 21:12-24.e2. [PMID: 31888862 DOI: 10.1016/j.jamda.2019.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 02/04/2023]
Abstract
The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.
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Sommer-Larsen SD, Arnold SH, Holm A, Aamand Olesen J, Cordoba G. Quality of the Diagnostic Process, Treatment Decision, and Predictors for Antibiotic Use in General Practice for Nursing Home Residents with Suspected Urinary Tract Infection. Antibiotics (Basel) 2021; 10:antibiotics10030316. [PMID: 33803831 PMCID: PMC8003235 DOI: 10.3390/antibiotics10030316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Risk adjustment for benchmarking nursing home infection surveillance data: A narrative review. Am J Infect Control 2021; 49:366-374. [PMID: 32791257 DOI: 10.1016/j.ajic.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/20/2022]
Abstract
Until recently, there was no national surveillance system for monitoring infection occurrence in long-term care facilities (LTCF) in the United States. As a result, there are no national benchmarks for LTCF infection rates that can be utilized for quality improvement at the facility level. One of the major challenges in the reporting of health care-related infection data is accounting for nonmodifiable facility and patient characteristics that influence benchmarks for infection. The objectives of this paper are to review: (a) published infection rates in LTCF in the United States to assess the level of variability; (b) studies describing facility- and resident-level risk factors for infection that can be used in risk adjustment models; (c) published attempts to risk-adjust LTCF infection rates; and (d) efforts to develop models specifically for risk adjustment of infection rates in LTCF for benchmarking. It is anticipated that this review will stimulate further study of methods to risk-adjust LTCF infection rates for benchmarking that will facilitate research and public reporting.
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Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review. Drugs Aging 2020; 38:29-41. [PMID: 33174126 DOI: 10.1007/s40266-020-00814-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.
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Rutten JJS, van Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, Sloane PD, Veenhuizen RB, van der Wouden JC, Hertogh CMPM. 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. BMC Geriatr 2020; 20:341. [PMID: 32912192 PMCID: PMC7488520 DOI: 10.1186/s12877-020-01662-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
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 .
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Infectious Diseases division, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community care, Radboud Institute for Health Sciences, Radboudumc Alzheimer Center, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Ruth B Veenhuizen
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Johannes C van der Wouden
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
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Beeber AS, Kistler CE, Zimmerman S, Dictus C, Ward K, Farel C, Chrzan K, Wretman CJ, Boyton-Hansen M, Pignone M, Sloane PD. Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse. J Am Med Dir Assoc 2020; 22:156-163. [PMID: 32839125 DOI: 10.1016/j.jamda.2020.06.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Anna Song Beeber
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA; The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA.
| | - Christine E Kistler
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA; School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | - Cassandra Dictus
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Claire Farel
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Arnold SH, Olesen JA, Jensen JN, Bjerrum L, Holm A, Kousgaard MB. Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents. Antibiotics (Basel) 2020; 9:E360. [PMID: 32630549 PMCID: PMC7345997 DOI: 10.3390/antibiotics9060360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Sif H. Arnold
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark;
| | - Julie A. Olesen
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
| | - Jette N. Jensen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark;
| | - Lars Bjerrum
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
| | - Anne Holm
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
| | - Marius B. Kousgaard
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
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Hughes C, Ellard DR, Campbell A, Potter R, Shaw C, Gardner E, Agus A, O'Reilly D, Underwood M, Loeb M, Stafford B, Tunney M. Developing evidence-based guidance for assessment of suspected infections in care home residents. BMC Geriatr 2020; 20:59. [PMID: 32059649 PMCID: PMC7023778 DOI: 10.1186/s12877-020-1467-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to update and refine an algorithm, originally developed in Canada, to assist care home staff to manage residents with suspected infection in the United Kingdom care home setting. The infections of interest were urinary tract infections, respiratory tract infections and skin and soft tissue infection. METHOD We used a multi-faceted process involving a literature review, consensus meeting [nominal group technique involving general practitioners (GPs) and specialists in geriatric medicine and clinical microbiology], focus groups (care home staff and resident family members) and interviews (GPs), alongside continual iterative internal review and analysis within the research team. RESULTS Six publications were identified in the literature which met inclusion criteria. These were used to update the algorithm which was presented to a consensus meeting (four participants all with a medical background) which discussed and agreed to inclusion of signs and symptoms, and the algorithm format. Focus groups and interview participants could see the value in the algorithm, and staff often reported that it reflected their usual practice. There were also interesting contrasts between evidence and usual practice informed by experience. Through continual iterative review and analysis, the final algorithm was finally presented in a format which described management of the three infections in terms of initial assessment of the resident, observation of the resident and action by the care home staff. CONCLUSIONS This study has resulted in an updated algorithm targeting key infections in care home residents which should be considered for implementation into everyday practice.
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Affiliation(s)
- Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK.
| | - David R Ellard
- Warwick Clinical Trials Unit, The University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Anne Campbell
- Faculty of Medicine, Department of Infectious Diseases, Imperial College London, London, UK
| | - Rachel Potter
- Warwick Clinical Trials Unit, The University of Warwick, Coventry, UK
| | - Catherine Shaw
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Evie Gardner
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, The University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | | | - Michael Tunney
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Kistler CE, Beeber AS, Zimmerman S, Ward K, Farel CE, Chrzan K, Wretman CJ, Boynton MH, Pignone M, Sloane PD. Nursing Home Clinicians' Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment. J Am Med Dir Assoc 2020; 21:675-682.e1. [PMID: 31974065 DOI: 10.1016/j.jamda.2019.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine which nursing home (NH) resident characteristics were most important to clinicians' decision to prescribe antibiotics for a suspected urinary tract infection (UTI), including both evidence-based and non-evidence-based characteristics. DESIGN Web-based discrete choice experiment with 19 clinical scenarios. For each scenario, clinicians were asked whether they would prescribe an antibiotic for a suspected UTI. SETTING Online survey. PARTICIPANTS Convenience sample of 876 NH physicians and advanced practice providers who practiced primary care for NH residents in the United States. METHODS Each scenario varied information about 10 resident characteristics regarding urinalysis results, resident temperature, lower urinary tract symptoms, physical examination, antibiotic request, mental status, UTI risk, functional status, goals of care, and resident type. We derived importance scores for the characteristics and odds ratios (ORs) for specific information related to each characteristic from a multinomial logistic regression. RESULTS Approximately half of the participants were male (56%) with a mean age of 49 years. Resident characteristics differed in their importance (ie, part-worth utility) when deciding whether to prescribe for a suspected UTI: urinalysis results (32%), body temperature (17%), lower urinary tract symptoms (17%), physical examination (15%), antibiotic request (7%), mental status (4%), UTI risk (4%), functional status (3%), goals of care (2%), and resident type (1%). Information about "positive leukocyte esterase, positive nitrates" was associated with highest odds of prescribing [OR 19.6, 95% confidence interval (CI) 16.9, 22.7], followed by "positive leukocyte esterase, negative nitrates" (OR 6.7, 95% CI 5.8, 7.6), and "painful or difficult urination" (OR 4.8, 95% CI 4.2, 5.5). CONCLUSIONS AND IMPLICATIONS Although guidelines focus on lower urinary tract symptoms, body temperature, and physical examination for diagnosing a UTI requiring antibiotics, these characteristics were considered less important than urinalysis results, which have inconsistent clinical utility in NH residents. Point-of-care clinical decision support offers an evidence-based prescribing process.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC; The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC.
| | - Anna S Beeber
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC; School of Nursing, University of North Carolina, Chapel Hill, NC
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC; School of Social Work, University of North Carolina, Chapel Hill, NC
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Claire E Farel
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | | | | | - Philip D Sloane
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC; The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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Van Buul LW, Monnier AA, Sundvall PD, Ulleryd P, Godycki-Cwirko M, Kowalczyk A, Lindbaek M, Hertogh CMPM. Antibiotic Stewardship in European Nursing Homes: Experiences From the Netherlands, Norway, Poland, and Sweden. J Am Med Dir Assoc 2019; 21:34-40.e1. [PMID: 31791900 DOI: 10.1016/j.jamda.2019.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/07/2019] [Accepted: 10/07/2019] [Indexed: 11/18/2022]
Abstract
Antibiotics are among the most widely prescribed drugs in long-term care facilities, which highlights the importance of antibiotic stewardship (ABS) in this setting. In this article, we describe the experiences with ABS in nursing homes (NHs) from the perspective of 4 European countries: the Netherlands, Norway, Poland, and Sweden. In these countries, a large variety of initiatives to develop and implement ABS in NHs have been introduced in recent years. Among these initiatives are national antibiotic prescribing surveillance systems, NH-specific prescribing guidelines, and national networks of healthcare institutions that exchange information and develop ABS policy. Several initiatives evolved as a result of political prioritization of antibiotic resistance, translated into national action plans. Experiences of the 4 countries with the presented initiatives may inspire other countries that aim to develop or improve ABS in the long-term care setting.
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Affiliation(s)
- Laura W Van Buul
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Annelie A Monnier
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Pär-Daniel Sundvall
- Region Västra Götaland, Research and Development Primary Health Care, Research and Development Center Södra Älvsborg, Borås, Sweden; Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Regional Strama, Region Västra Götaland, Sweden
| | - Peter Ulleryd
- Regional Strama, Region Västra Götaland, Sweden; Department of Communicable Disease Control and Prevention, Region Västra Götaland, Sweden
| | - Maciek Godycki-Cwirko
- Center for Family and Community Medicine, Medical University of Lodz, Lodz, Poland; Division of Public Health, Faculty of Medical Sciences, Medical University of Lodz, Lodz, Poland
| | - Anna Kowalczyk
- Center for Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Morten Lindbaek
- Antibiotic Center for Primary Care, Department of General Practice, Institute for Health and Society, University of Oslo, Oslo, Norway
| | - Cees M P M Hertogh
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Smithson A, Ramos J, Niño E, Culla A, Pertierra U, Friscia M, Bastida MT. Characteristics of febrile urinary tract infections in older male adults. BMC Geriatr 2019; 19:334. [PMID: 31783801 PMCID: PMC6884897 DOI: 10.1186/s12877-019-1360-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/19/2019] [Indexed: 12/26/2022] Open
Abstract
Background Urinary tract infections (UTI) are among the most frequent bacterial infections in older adults. The aim of the study was to analyse the existence of differences in clinical features, microbiological data and risk of infection by multidrug-resistant organisms (MDRO) between older and non-older men with febrile UTI (FUTI). Methods This was an ambispective observational study involving older males with a FUTI attended in the Emergency Department. Variables collected included age, comorbidity, diagnostic of healthcare-associated (HCA)-FUTI, clinical manifestations, hospitalization, mortality, and microbiological data. Results Five hundred fifty-two males with a FUTI, 329 (59.6%) of whom were older adults, were included. Older males had a higher frequency of HCA-FUTI (p < 0.001), increased Charlson scores (p < 0.001), had received previous antimicrobial treatment more frequently (p < 0.001) and had less lower urinary tract symptoms (p < 0.001). Older patients showed a lower frequency of FUTI caused by E. coli (p < 0.001) and a higher rate of those due to Enterobacter spp. (p = 0.003) and P. aeruginosa (p = 0.033). Resistance rates to cefuroxime (p = 0.038), gentamicin (p = 0.043), and fluoroquinolones (p < 0.001) in E. coli isolates and the prevalence of extended-spectrum beta-lactamase and AmpC producing E. coli and Klebsiella spp. strains (p = 0.041) and MDRO (p < 0.001) were increased in older males. Inadequate empirical antimicrobial treatment (p = 0.004), frequency of hospitalization (p < 0.001), and all cause in-hospital mortality (p = 0.007) were higher among older patients. In the multivariate analysis, being admitted from an long term care facility (OR 2.4; 95% CI: 1.06–5.9), having a urinary tract abnormality (OR 2.2; 95% CI: 1.2–3.8) and previous antimicrobial treatment (OR 3.2; 95% CI: 1.9–5.4) were associated to FUTI caused by MDRO. Conclusions Older male adults with a FUTI have different clinical characteristics, present specific microbiological features, and antimicrobial resistance rates. In the multivariate analysis being an older male was not associated with an increased risk of FUTI caused by MDRO.
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Affiliation(s)
- Alex Smithson
- Infectious Diseases Unit, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain.
| | - Javier Ramos
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Esther Niño
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Alex Culla
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Ubaldo Pertierra
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Michele Friscia
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Maria Teresa Bastida
- Microbiology Laboratory, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
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Kuil SD, Hidad S, Fischer JC, Harting J, Hertogh CM, Prins JM, van Leth F, de Jong MD, Schneeberger C. Sensitivity of point-of-care testing C reactive protein and procalcitonin to diagnose urinary tract infections in Dutch nursing homes: PROGRESS study protocol. BMJ Open 2019; 9:e031269. [PMID: 31401614 PMCID: PMC6701568 DOI: 10.1136/bmjopen-2019-031269] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Suspected urinary tract infection (UTI) ranks among the most common reasons for antibiotic use in nursing homes. However, diagnosing UTI in this setting is challenging because UTI often presents with non-specific symptomatology. Moreover asymptomatic bacteriuria is common in elderly, which complicates attribution of causality to detection of bacteria in urine. These diagnostic challenges contribute to overuse of antibiotics and emergence of antimicrobial resistance in nursing homes. Given the diagnostic challenges, there is a need for point-of-care (POC) diagnostic tests to support clinical rules for diagnosing UTI. Procalcitonin (PCT) and C reactive protein (CRP) are inflammatory blood markers that have been proven useful to support diagnosis and monitoring of (bacterial) respiratory tract infections and sepsis. While limited studies suggest their usefulness in supporting UTI diagnosis, their utility has not been studied in elderly populations for this purpose. METHODS AND ANALYSIS In a 24-month matched prospective study, 'PROGRESS' will assess and compare the sensitivity of rapid POC measurements of blood CRP and PCT levels to support clinical rules for diagnosing UTI in nursing home residents. The primary outcome measure is sensitivity of the POC tests to identify patients with true UTI based on the predefined definition, as derived from receiver operating curves. ETHICS AND DISSEMINATION This study will be conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. The study protocol is approved by the Medical Ethical Committee of Amsterdam UMC location VUmc with reference number 2017.350 and National Central Committee on Research involving Human Subjects with reference number NL62067.029.17. TRIAL REGISTRATION NUMBER NTR6467.
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Affiliation(s)
- Sacha D Kuil
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Soemeja Hidad
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Johan C Fischer
- Clinical Chemistry, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke Harting
- Public Health, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Cees Mpm Hertogh
- General Practice and Elderly Care Medicine, Amsterdam UMC Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Internal Medicine, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Frank van Leth
- Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Menno D de Jong
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Caroline Schneeberger
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
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Sloane PD, Zimmerman S, Ward K, Kistler CE, Paone D, Weber DJ, Wretman CJ, Preisser JS. A 2-Year Pragmatic Trial of Antibiotic Stewardship in 27 Community Nursing Homes. J Am Geriatr Soc 2019; 68:46-54. [PMID: 31317534 DOI: 10.1111/jgs.16059] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/19/2019] [Accepted: 04/22/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN Two-year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS Nursing staff and medical care providers in the participating NHs. INTERVENTION Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) infections. RESULTS Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69-0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65-0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92-0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2-year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46-54, 2019.
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Affiliation(s)
- Philip D Sloane
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Service Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Service Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kimberly Ward
- Cecil G. Sheps Center for Health Service Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christine E Kistler
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Service Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - David J Weber
- Division of Infectious Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christopher J Wretman
- Cecil G. Sheps Center for Health Service Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John S Preisser
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Abstract
PURPOSE OF REVIEW We review non-pharmacological and pharmacological approaches to managing behavioral and psychological symptoms of dementia (BPSD). We examine methods for assessment and evidence for interventions, focusing on recent findings and innovations. Finally, we recommend an algorithm for management of BPSD. RECENT FINDINGS Training of formal caregivers is the most effective intervention for BPSD; other non-pharmacological interventions are also beneficial. Antidepressants and antipsychotics remain a mainstay of pharmacological treatment for BPSD. There is limited evidence supporting the use of stimulants, cognitive enhancers, dextromethorphan/quinidine, benzodiazepines, anticonvulsants, and pimavanserin. The management of BPSD is highly individualized. Following thorough assessment, the initial step is addressing contributing medical problems. Non-pharmacological interventions should be tried prior to pharmacological interventions. Antipsychotics should be prescribed only when behaviors pose a significant safety risk or if the person with dementia is very distressed. New approaches will be needed to address an increasing population of people with dementia.
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