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Plasencia JT, Ashraf MS. Management of Bacteriuria and Urinary Tract Infections in the Older Adult. Urol Clin North Am 2024; 51:585-594. [PMID: 39349025 DOI: 10.1016/j.ucl.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
Urinary tract infection (UTI) is one of the most frequent bacterial infections diagnosed in older adults and the most common reason for antibiotic prescriptions in nursing homes. Distinguishing between asymptomatic bacteriuria and UTI in older adults can be challenging and implementing a systematic approach to diagnosis using standard toolkits or algorithms is recommended for patients residing in post-acute and long-term care settings. This article reviews the pathophysiology, microbiology, diagnostic approach, treatment, and approaches to prophylaxis in the older adult.
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Affiliation(s)
- Juan Teran Plasencia
- Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA.
| | - Muhammad Salman Ashraf
- Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA; Division of Public Health, Nebraska Department of Health and Human Services, 301 Centennial Mall South, PO Box 95026, Lincoln, NE 68509, USA
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AlHabil Y, Owda AN, Zaid BJ, Hameedi S, Saadeddin L, Awad MAA. Concurrent acute cystitis, pancolitis, and tubo-ovarian abscess following laparoscopic ovarian cystectomy: a case report. BMC Womens Health 2024; 24:489. [PMID: 39232767 PMCID: PMC11373178 DOI: 10.1186/s12905-024-03341-3] [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: 07/05/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Inadequate surgical interventions can lead to serious complications such as tubo-ovarian abscesses in the upper female genital system, often resulting from untreated pelvic inflammatory disease. Pelvic inflammatory disease, caused by infections like Chlamydia trachomatis and Neisseria gonorrhoeae, leads to scarring and adhesions in the reproductive organs, with common risk factors including intrauterine device use and multiple sexual partners. Pelvic inflammatory disease primarily affects sexually active young women and can manifest with varied symptoms, potentially leading to complications like ectopic pregnancy, infertility, and chronic pelvic pain if untreated. CASE PRESENTATION This case report presents a unique scenario involving a 17-year-old sexually inactive female who experienced concurrent tubo-ovarian abscess, acute cystitis, and pancolitis following laparoscopic ovarian cystectomy. Pelvic inflammatory disease and its complications are well-documented, but the simultaneous occurrence of acute cystitis and pancolitis in this context is unprecedented in the medical literature. The patient's presentation, clinical course, and management are detailed, highlighting the importance of considering diverse and severe complications in individuals with a history of gynecological surgeries. CONCLUSIONS Our case report highlights the need for healthcare professionals to remain vigilant for atypical presentations of gynecological complications and emphasizes the value of interdisciplinary collaboration for optimal patient care. We encourage further research and awareness to enhance understanding and recognition of complex clinical scenarios associated with gynecological procedures.
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Affiliation(s)
- Yazan AlHabil
- Faculty of Medicine and Health Sciences, Department of Medicine, An-Najah National University, Nablus, 00970,, Palestine.
| | - Anas N Owda
- General Physician, School of Medicine, An-Najah National University, Nablus, 00970, Palestine
| | - Basil J Zaid
- General Surgery, H-Clinic Specialty Hospital, Ramallah, 00970, Palestine
| | - Seema Hameedi
- Faculty of Medicine and Health Sciences, Department of Medicine, An-Najah National University, Nablus, 00970,, Palestine
| | - Liza Saadeddin
- Faculty of Medicine and Health Sciences, Department of Medicine, An-Najah National University, Nablus, 00970,, Palestine
| | - Mohammad A A Awad
- Head of Radiology Department, H-Clinic Specialty Hospital, Ramallah, 00970, Palestine
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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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Stall NM, Kandel C, Reppas-Rindlisbacher C, Quinn KL, Wiesenfeld L, MacFadden DR, Johnstone J, Fralick M. Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review. J Am Geriatr Soc 2024; 72:2566-2578. [PMID: 38895992 DOI: 10.1111/jgs.18964] [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: 03/06/2024] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND It is unclear whether antibiotics impact delirium outcomes in older adults with pyuria or bacteriuria in the absence of systemic signs of infection or genitourinary symptoms. METHODS We registered our systematic review protocol with PROSPERO (CRD42023418091). We searched the Medline and Embase databases from inception until April 2023 for studies investigating the impact of antimicrobial treatment on the duration and severity of delirium in older adults (≥60 years) with pyuria (white blood cells detected on urinalysis or dipstick) or bacteriuria (bacteria growing on urine culture) and without systemic signs of infection (temperature > 37.9C [>100.2F] or 1.5C [2.4F] increase above baseline temperature, and/or hemodynamic instability) or genitourinary symptoms (acute dysuria or new/worsening urinary symptoms). Two reviewers independently screened search results, abstracted data, and appraised the risk of bias. Full-text randomized controlled trials (RCTs) and observational study designs were included without restriction on study language, duration, or year of publication. RESULTS We screened 984 citations and included 4 studies comprising 652 older adults (mean age was 84.6 years and 63.5% were women). The four studies were published between 1996 and 2022, and included one RCT, two prospective observational cohort studies, and one retrospective chart review. None of the four studies demonstrated a significant effect of antibiotics on delirium outcomes, with two studies reported a worsening of outcomes among adults who received antibiotics. The three observational studies included had a moderate or serious overall risk of bias, while the one RCT had a high overall risk of bias. CONCLUSIONS Our systematic review found no evidence that treatment with antibiotics is associated with improved delirium outcomes in older adults with pyuria or bacteriuria and without systemic signs of infection or genitourinary symptoms. Overall, the evidence was limited, largely observational, and had substantial risk of bias.
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Affiliation(s)
- Nathan M Stall
- Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Canada
- Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Christopher Kandel
- Department of Medicine, University of Toronto, Toronto, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Canada
| | - Christina Reppas-Rindlisbacher
- Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Canada
- Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Kieran L Quinn
- Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Lesley Wiesenfeld
- Division of Psychiatry, Sinai Health, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Derek R MacFadden
- Department of Medicine, University of Ottawa, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jennie Johnstone
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Infection Prevention and Control, Sinai Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Michael Fralick
- Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
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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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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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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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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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Chambers A, Chen C, Brown KA, Daneman N, Langford B, Leung V, Adomako K, Schwartz KL, Moore JE, Quirk J, MacFarlane S, Cronsberry T, Garber GE. Virtual learning collaboratives to improve urine culturing and antibiotic prescribing in long-term care: controlled before-and-after study. BMJ Qual Saf 2021; 31:94-104. [PMID: 33853868 PMCID: PMC8785008 DOI: 10.1136/bmjqs-2020-012226] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/16/2021] [Accepted: 04/05/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urine culturing practices are highly variable in long-term care and contribute to overprescribing of antibiotics for presumed urinary tract infections. The purpose of this study was to evaluate the use of virtual learning collaboratives to support long-term care homes in implementing a quality improvement programme focused on reducing unnecessary urine culturing and antibiotic overprescribing. METHODS Over a 4-month period (May 2018-August 2018), 45 long-term care homes were self-selected from five regions to participate in virtual learning collaborative sessions, which provided an orientation to a quality improvement programme and guidance for implementation. A process evaluation complemented the use of a controlled before-and-after study with a propensity score matched control group (n=127) and a difference-in-difference analysis. Primary outcomes included rates of urine cultures performed and urinary antibiotic prescriptions. Secondary outcomes included rates of emergency department visits, hospital admission and mortality. An 18-month baseline period was compared with a 16-month postimplementation period with the use of administrative data sources. RESULTS Rates of urine culturing and urinary antibiotic prescriptions per 1000 resident days decreased significantly more among long-term care homes that participated in learning collaboratives compared with matched controls (differential reductions of 19% and 13%, respectively, p<0.0001). There was no statistically significant changes to rates of emergency department visits, hospital admissions or mortality. These outcomes were observed with moderate adherence to the programme model. CONCLUSIONS Rates of urine culturing and urinary antibiotic prescriptions declined among long-term care homes that participated in a virtual learning collaborative to support implementation of a quality improvement programme. The results of this study have refined a model to scale this programme in long-term care.
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Affiliation(s)
| | - Cynthia Chen
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Kevin Antoine Brown
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | | | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Gary E Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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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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11
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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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12
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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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Kuil SD, Hidad S, Fischer JC, Harting J, Hertogh CMPM, Prins JM, de Jong MD, van Leth F, Schneeberger C. Sensitivity of C-reactive protein and procalcitonin measured by Point-of-Care tests to diagnose urinary tract infections in nursing home residents: a cross-sectional study. Clin Infect Dis 2020; 73:e3867-e3875. [PMID: 33175147 PMCID: PMC8664473 DOI: 10.1093/cid/ciaa1709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background Diagnosing urinary tract infections (UTIs) in nursing home residents is complex, as specific urinary symptoms are often absent and asymptomatic bacteriuria (ASB) is prevalent. The aim of this study was to assess the sensitivity of blood C-reactive protein (CRP) and procalcitonin (PCT), measured by point-of-care tests (PoCTs), to diagnose UTIs in this setting. Methods Elderly residents (≥65 years old) with a suspected UTI were recruited from psychogeriatric, somatic, or rehabilitation wards across 13 participating nursing homes. CRP and PCT were tested simultaneously in the same study participants. To assess the tests’ sensitivities, a stringent definition of “true” UTI was used that included the presence of symptoms, urinary leucocytes, a positive urine culture, and symptom resolution during antibiotic treatment covering isolated uropathogen(s). The original sample size was 440 suspected UTI episodes, in order to detect a clinically relevant sensitivity of at least 65% when calculated using the matched analysis approach to compare both PoCTs. Results After enrollment of 302 episodes (68.6% of the planned sample size), an unplanned and funder-mandated interim analysis was done, resulting in premature discontinuation of the study for futility. For 247 of 266 eligible episodes, all mandatory items required for the true UTI definition (92.9%) were available. In total, 49 episodes fulfilled our stringent UTI definition (19.8%). The sensitivities of CRP (cut-off, 6.5 mg/L) and PCT (cut-off, 0.025 ng/mL) were 52.3% (95% confidence interval [CI], 36.7–67.5%) and 37.0% (95% CI, 23.2–52.5%), respectively. Conclusions Our results indicate that CRP and PCT are not suitable tests for distinguishing UTI and ASB in nursing home residents. Clinical Trials Registration Netherlands Trial Registry NL6293.
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Affiliation(s)
- S D Kuil
- Amsterdam UMC, University of Amsterdam, Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - S Hidad
- Amsterdam UMC, University of Amsterdam, Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - J C Fischer
- Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Meibergdreef 9, Amsterdam, The Netherlands
| | - J Harting
- Amsterdam UMC, University of Amsterdam, Department of Public Health, Amsterdam Public Health research institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - C M P M Hertogh
- Amsterdam UMC, VU University Medical Center, Department of General Practice and Elderly Care Medicine, Amsterdam Public Health, University Network of Organizations for Elderly Care, Amsterdam, The Netherlands
| | - J M Prins
- Amsterdam UMC, University of Amsterdam, Division of Infectious Diseases, Department of Internal Medicine, Amsterdam Infection & Immunity Institute, Amsterdam, The Netherlands
| | - M D de Jong
- Amsterdam UMC, University of Amsterdam, Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - F van Leth
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - C Schneeberger
- Amsterdam UMC, University of Amsterdam, Department of Medical Microbiology, Amsterdam Infection & Immunity Institute, Meibergdreef 9, Amsterdam, The Netherlands
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Improvements in Antibiotic Appropriateness for Cystitis in Older Nursing Home Residents: A Quality Improvement Study With Randomized Assignment. J Am Med Dir Assoc 2020; 22:173-177. [PMID: 32948472 DOI: 10.1016/j.jamda.2020.07.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the impact of an educational quality improvement initiative on the appropriateness of antibiotic prescribing restricted to uncomplicated cystitis in older noncatheterized nursing home residents. DESIGN Quality improvement study with randomized assignment. SETTINGS AND PARTICIPANTS Twenty-five nursing homes in United States were randomized to the intervention or usual care group by strata that included state, urban/rural status, bed size, and geographic separation. METHODS A 12-month trial of a low-intensity multifaceted antimicrobial stewardship intervention focused on uncomplicated cystitis in nursing home residents vs usual care. The outcome was the modified Medication Appropriateness Index as assessed by a blinded geriatric clinical pharmacist and consisted of an assessment of antibiotic effectiveness, dosage, drug-drug interactions, and duration. RESULTS There were 75 cases (0.15/1000 resident days) in intervention and 92 (0.22/1000 resident days) in control groups with a probable cystitis per consensus guidelines. Compared with controls, there was a statistically nonsignificant 21% reduction in the risk of inappropriate antibiotic prescribing (nonzero Medication Appropriateness Index score rate 0.13 vs 0.21/1000 person days; adjusted incident rate ratio 0.79; 95% confidence interval 0.45‒1.38). There was a favorable comparison in inappropriateness of duration (77% vs 89% for intervention vs control groups, respectively; P = .0394). However, the intervention group had more problems with drug-drug interactions than the control group (8% vs 1%, respectively; P = .0463). Similarly, the intervention group had a nonsignificant trend toward more problems with dosage (primarily because of the lack of adjustment for decreased renal function) than the control group (32% vs 25%, respectively; P = .3170). Both groups had similar rates of problems with choice/effectiveness (44% vs 45%; P = .9417). The most common class of antibiotics prescribed inappropriately was quinolones (25% vs 23% for intervention versus control groups, respectively; P = .7057). CONCLUSIONS AND IMPLICATIONS A low-intensity intervention showed a trend toward improved appropriate antibiotic prescribing in nursing home residents with likely uncomplicated cystitis. Efforts to improve antibiotic prescribing in addition to the low-intensity intervention might include a consultant pharmacist in a nursing home to identify inappropriate prescribing practices.
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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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Ramly E, Tong M, Bondar S, Ford JH, Nace DA, Crnich CJ. Workflow Barriers and Strategies to Reduce Antibiotic Overuse in Nursing Homes. J Am Geriatr Soc 2020; 68:2222-2231. [PMID: 32722847 DOI: 10.1111/jgs.16632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Antibiotic overuse is a significant problem in nursing homes (NHs). Strategies to improve antibiotic prescribing practices in NHs are a critical need. In this study, we analyzed antibiotic prescribing workflows to identify strategies for improving antibiotic prescribing in NHs. DESIGN Qualitative descriptive study using prospective field-based assessment of workflows. SETTING Six NHs in Wisconsin (n = 3) and Pennsylvania (n = 3). PARTICIPANTS A total of 44 interviews with 68 NH professionals, including leadership, nurses, and prescribers. MEASUREMENTS During a 1-day field visit in each NH, we conducted semistructured interviews with NH professionals, collected artifacts (policies, procedures, and documentation and communication tools), and observed clinical meetings. Study participants were interviewed (30-60 minutes) about antibiotic prescribing workflows in their facility. Information collected during site visits was used to create a representative workflow map of NH antibiotic prescribing. The workflow map guided thematic analysis to identify barriers corresponding to workflow steps across multiple NHs. RESULTS The representative antibiotic preprescribing workflow map included 17 steps, beginning with resident change in condition and ending with the decision to prescribe an antibiotic. Thematic analysis identified common step-specific barriers to antibiotic stewardship centering on three themes: (A) information barriers, comprising (A1) inconsistent nurse assessment report and (A2) misalignment between the work and tools of information sharing within the facility, (B) communication barriers, comprising (B1) mismatched perception of prescriber information needs and (B2) difficulty reaching prescribers for direct interaction, and (C) professional barriers, comprising (C1) low prescriber confidence in nurse assessment report and (C2) nurse reluctance to express their professional opinions. CONCLUSION Strategies addressing workflow barriers are important targets for antibiotic stewardship. Such strategies include structured information tools, nurse and prescriber education, and organizational improvement. Future research can build on combinations of existing and new strategies to measure their effects in improving antibiotic prescribing. J Am Geriatr Soc 68:2222-2231, 2020.
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Affiliation(s)
- Edmond Ramly
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Michelle Tong
- Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Svetlana Bondar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - James H Ford
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher J Crnich
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Nace DA, Hanlon JT, Crnich CJ, Drinka PJ, Schweon SJ, Anderson G, Perera S. A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents. JAMA Intern Med 2020; 180:944-951. [PMID: 32391862 PMCID: PMC7215632 DOI: 10.1001/jamainternmed.2020.1256] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections. OBJECTIVE To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents. DESIGN, SETTING, AND PARTICIPANTS A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018. INTERVENTIONS Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death. RESULTS Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]). CONCLUSIONS AND RELEVANCE This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Christopher J Crnich
- Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison.,Medical Service, William S. Middleton Veterans Affairs Hospital, Madison, Wisconsin
| | - Paul J Drinka
- Division of Internal Medicine and Geriatrics, University of Wisconsin, Madison
| | | | - Gulsum Anderson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Maki DG. USPSTF recommends screening for asymptomatic bacteriuria in pregnant women but not nonpregnant adults. Ann Intern Med 2020; 172:JC14. [PMID: 32066147 DOI: 10.7326/acpj202002180-014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dennis G. Maki
- University of Wisconsin School of Medicine and Public HealthMadison, Wisconsin, USADisclosures: The commentator has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3039
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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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Zimmerman S, Sloane PD, Resnick B. Encouraging the Use of Research to Guide Practice and Policy. J Am Med Dir Assoc 2019; 20:1063-1064. [DOI: 10.1016/j.jamda.2019.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 11/28/2022]
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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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23
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Hanlon JT, Perera S, Drinka PJ, Crnich CJ, Schweon SJ, Klein-Fedyshin M, Wessel CB, Saracco S, Anderson G, Mulligan M, Nace DA. The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents. J Am Geriatr Soc 2019; 67:539-545. [PMID: 30584657 PMCID: PMC7980083 DOI: 10.1111/jgs.15726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. DESIGN Two-round modified Delphi survey. PARTICIPANTS Expert panel of 19 clinical pharmacists. MEASUREMENTS Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score. RESULTS The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine). CONCLUSION An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539-545, 2019.
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Affiliation(s)
- Joseph T Hanlon
- Division of Geriatric Medicine, Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), VAPHS, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Division of Geriatric Medicine, Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul J Drinka
- Divisions of Internal Medicine and Geriatric Medicine, University of Wisconsin, Madison, Wisconsin
| | - Christopher J Crnich
- Infectious Disease, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- William S. Middleton Veterans Administration Medical Center, Madison, Wisconsin
| | | | | | - Charles B Wessel
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stacey Saracco
- Division of Geriatric Medicine, Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gulsum Anderson
- Division of Geriatric Medicine, Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Mulligan
- AMDA, The Society of Post-Acute and Long-Term Care Medicine, Columbia, Maryland
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine (Geriatrics), University of Pittsburgh, Pittsburgh, Pennsylvania
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