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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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