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

The rate, causes and predictors of ambulance call outs to residential aged care in the Australian Capital Territory: A retrospective observational cohort study

Older people in residential aged care are susceptible to acute illness or injury which may necessitate an ambulance call out, assessment/treatment by a paramedic and transfer to a hospital emergency department. Understanding the case mix of residential aged care ambulance attendances is important for prevention strategies and for planning services. A retrospective observational closed cohort study was designed to investigate the characteristics of emergency ambulance call outs to 15 residential aged care sites in the Australian Capital Territory over a 12-month period. Data were collected from the local ambulance service and the aged care sites. Case load data were analysed to determine rates, clinical characteristics, ambulance attendance outcomes and the temporal distribution of call outs. A Poisson regression model was developed to investigate demographic, morbidity and medication-related risk factors associated with the number of ambulance call outs per resident. Annual ambulance call out costs were estimated. There were 1,275 residents, with 396 (31.1%) requiring at least one ambulance call out over 12 months. Of 669 ambulance attendances, the majority (87.0%) were transported to emergency departments. Trauma (23.9%), pain (16.9%) and infections (9.4%) were the most common primary assessments by the ambulance attendees. Cases/day were similar throughout the year and on weekdays compared to weekends/public holidays. The main predictors of ambulance call out were multi-morbidity, taking regular anticholinergic medicines, being male and younger age. Estimated costs of ambulance call outs/year were $475/resident and $40,375/residential aged care site. The most frequent primary assessments (trauma, pain, infections) may constitute priorities for developing prevention strategies and for treatment initiatives within residential aged care. Strategies to reduce anticholinergic medication prescribing may also be a potential intervention to decrease ambulance call outs and hospital emergency department demand. The ambulance usage data from this study may be useful to compare with future datasets to measure the impact of the introduction of new services.

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

BACKGROUND

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

METHODS AND ANALYSIS

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

DISCUSSION

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

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

OBJECTIVES

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

DESIGN

Observational prospective study.

SETTING AND PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review

BACKGROUND

The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context.

OBJECTIVES

This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness.

DATA SOURCES

Electronic databases until April 2022.

STUDY ELIGIBILITY CRITERIA

Articles covering implementation of AMS interventions in LTCFs.

ASSESSMENT OF RISK OF BIAS

Mixed Methods Appraisal Tool for empirical studies.

METHODS OF DATA SYNTHESIS

Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study.

RESULTS

Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation.

CONCLUSIONS

The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

BACKGROUND

The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents.

OBJECTIVES

Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care.

MAIN RESULTS

We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Characterizing infection prevention programs and urinary tract infection prevention practices in nursing homes: A mixed-methods study

OBJECTIVE

US policies require robust nursing home (NH) infection prevention and control (IPC) programs to ensure safe care. We assessed IPC resources and practices related to catheter and non-catheter-associated urinary tract infection (CAUTI and UTI) prevention among NHs.

METHODS

We conducted a mixed-methods study from April 2018 through November 2019. Quantitative surveys assessed NH IPC program resources, practices, and communication during resident transfer. Semistructured qualitative interviews focused on IPC programs, CAUTI and UTI prevention practices, and resident transfer processes. Using a matrix as an analytic tool, findings from the quantitative survey data were combined with the qualitative data in the form of a joint display.

RESULTS

Representatives from 51 NHs completed surveys; interviews were conducted with 13 participants from 7 NHs. Infection preventionists (IPs) had limited experience and/or additional roles, and in 36.7% of NHs, IPs had no specific IPC training. IP turnover was often mentioned during interviews. Most facilities were aware of their CAUTI and UTI rates and reported using prevention practices, such as hydration (85.7%) or nurse-initiated catheter discontinuation (65.3%). Qualitative interviewees confirmed use of these practices and expressed additional concerns about overuse of urine testing and antibiotics. Although transfer sheets were used by 84% to communicate about infections, the information received was described as suboptimal.

CONCLUSIONS

NHs identified IP challenges related to turnover, limited education, and serving multiple roles. However, most NHs reported awareness of their CAUTI and UTI rates as well as their use of prevention practices. Importantly, we identified opportunities to enhance communication between NHs and hospitals to improve resident care and safety.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

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

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov NCT03970356.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Feasibility of Algorithm-Based Clinical Decision Support for Suspected Urinary Tract Infections in Nursing Home Residents

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.

Antibiotic postprescribing modification opportunities among nursing home residents treated for urinary tract infection

Objective:

To characterize opportunities to postprescriptively modify antibiotic prescriptions initiated for treatment of suspected urinary tract infection (UTI) in nursing homes.

Design:

Cross-sectional cohort study.

Methods:

Data from the health records of residents treated for UTI between 2013 and 2014 in 5 Wisconsin nursing homes were abstracted using a structured approach. Explicit definitions were used to identify whether the prescribed antibiotic could have been stopped, shortened, or changed to a nonfluoroquinolone alternative. Antibiotic treatments appropriately modified by study nursing home providers in real time were not considered modifiable. Identification of >1 potential modification opportunity (eg, stop and shorten) per antibiotic treatment event was permitted.

Results:

In total, 356 eligible antibiotic treatment courses among 249 unique residents were identified. Only 59 antibiotic courses prescribed for treatment of suspected UTI (16.6%) were not amenable to any modification. Discontinuation of treatment due to lack of signs or symptoms of infection was the most frequently identified potential modification opportunity (66.2%). Although less common, substantial numbers of antibiotic treatment courses were potentially amenable to shortening (34%) or agent change (19%) modifications. If applied in concert at 72 hours after antibiotic initiation, stop and shorten modifications could eradicate up to 1,326 avoidable antibiotic days, and change modifications could remove a 32 remaining avoidable fluoroquinolone days.

Conclusions:

Substantial opportunity exists to enhance the quality of antibiotic prescribing for treatment of suspected UTI in nursing homes through postprescriptive review interventions. Additional studies examining how to best design and implement postprescriptive review interventions in nursing homes are needed.