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Bocquier A, Erkilic B, Babinet M, Pulcini C, Agrinier N. Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies. Antimicrob Resist Infect Control 2024; 13:29. [PMID: 38448955 PMCID: PMC10918961 DOI: 10.1186/s13756-024-01385-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes. METHOD We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings. RESULTS Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1). CONCLUSIONS Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.
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Affiliation(s)
- Aurélie Bocquier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France.
| | - Berkehan Erkilic
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
| | - Martin Babinet
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
| | - Céline Pulcini
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, F-54000, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
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Taylor LN, Wilson BM, Singh M, Irvine J, Jolles SA, Kowal C, Bej TA, Crnich CJ, Jump RLP. Syndromic Antibiograms and Nursing Home Clinicians' Antibiotic Choices for Urinary Tract Infections. JAMA Netw Open 2023; 6:e2349544. [PMID: 38150250 PMCID: PMC10753399 DOI: 10.1001/jamanetworkopen.2023.49544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/12/2023] [Indexed: 12/28/2023] Open
Abstract
Importance Empirical antibiotic prescribing in nursing homes (NHs) is often suboptimal. The potential for antibiograms to improve empirical antibiotic decision-making in NHs remains poorly understood. Objective To determine whether providing NH clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections (UTIs). Design, Setting, and Participants This was a survey study using clinical vignettes. Participants were recruited via convenience sampling of professional organization listservs of NH clinicians practicing in the US from December 2021 through April 2022. Data were analyzed from July 2022 to June 2023. Interventions Respondents were randomized to complete vignettes using a traditional antibiogram (TA), a weighted-incidence syndromic combination antibiogram (WISCA), or no tool. Participants randomized to antibiogram groups were asked to use the antibiogram to empirically prescribe an antibiotic. Participants randomized to the no tool group functioned as controls. Main Outcomes and Measures Empirical antibiotic selections were characterized as microbiologically (1) active and (2) optimal according to route of administration and spectrum of activity. Results Of 317 responses, 298 (95%) were included in the analysis. Duplicate responses (15 participants), location outside the US (2 participants), and uninterpretable responses (2 participants) were excluded. Most respondents were physicians (217 respondents [73%]) and had over 10 years of NH practice experience (155 respondents [52%]). A mixed-effects logistic model found that use of the TA (odds ratio [OR], 1.41; 95% CI, 1.19-1.68; P < .001) and WISCA (OR, 1.54; 95% CI, 1.30-1.84; P < .001) were statistically superior to no tool when choosing an active empirical antibiotic. A similarly constructed model found that use of the TA (OR, 1.94; 95% CI, 1.42-2.66; P < .001) and WISCA (OR, 1.7; 95% CI, 1.24-2.33; P = .003) were statistically superior to no tool when selecting an optimal empirical antibiotic. Although there were differences between tools within specific vignettes, when compared across all vignettes, the TA and WISCA performed similarly for active (OR, 1.09; 95% CI, 0.92-1.30; P = .59) and optimal (OR, 0.87; 95% CI, 0.64-1.20; P = .69) antibiotics. Conclusions and Relevance Providing NH clinicians with a urinary antibiogram was associated with selection of active and optimal antibiotics when empirically treating UTIs under simulated conditions. Although the antibiogram format was not associated with decision-making in aggregate, context-specific effects may have been present, supporting further study of syndromic antibiograms in clinical practice.
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Affiliation(s)
- Lindsay N. Taylor
- University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Veterans Affairs Medical Center, Madison
- University of Wisconsin Hospital and Clinics, Madison
| | - Brigid M. Wilson
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mriganka Singh
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Jessica Irvine
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Sally A. Jolles
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Taissa A. Bej
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases and HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher J. Crnich
- University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Veterans Affairs Medical Center, Madison
- University of Wisconsin Hospital and Clinics, Madison
| | - Robin L. P. Jump
- TECH-GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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3
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Grey B, Upton M, Joshi LT. Urinary tract infections: a review of the current diagnostics landscape. J Med Microbiol 2023; 72. [PMID: 37966174 DOI: 10.1099/jmm.0.001780] [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: 11/16/2023] Open
Abstract
Urinary tract infections are the most common bacterial infections worldwide. Infections can range from mild, recurrent (rUTI) to complicated (cUTIs), and are predominantly caused by uropathogenic Escherichia coli (UPEC). Antibiotic therapy is important to tackle infection; however, with the continued emergence of antibiotic resistance there is an urgent need to monitor the use of effective antibiotics through better stewardship measures. Currently, clinical diagnosis of UTIs relies on empiric methods supported by laboratory testing including cellular analysis (of both human and bacterial cells), dipstick analysis and phenotypic culture. Therefore, development of novel, sensitive and specific diagnostics is an important means to rationalise antibiotic therapy in patients. This review discusses the current diagnostic landscape and highlights promising novel diagnostic technologies in development that could aid in treatment and management of antibiotic-resistant UTIs.
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Affiliation(s)
- Braith Grey
- Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth, Devon, UK
| | - Mathew Upton
- School of Biomedical Sciences, Faculty of Health, University of Plymouth, Plymouth, Devon, UK
| | - Lovleen Tina Joshi
- Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth, Devon, UK
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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [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: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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Vaughn VM, Gupta A, Petty LA, Malani AN, Osterholzer D, Patel PK, Younas M, Bernstein SJ, Burdick S, Ratz D, Szymczak JE, McLaughlin E, Czilok T, Basu T, Horowitz JK, Flanders SA, Gandhi TN. A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria. JAMA Intern Med 2023; 183:933-941. [PMID: 37428491 PMCID: PMC10334295 DOI: 10.1001/jamainternmed.2023.2749] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/23/2023] [Indexed: 07/11/2023]
Abstract
Importance Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. Objective To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. Design, Setting, and Participants This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Exposure Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Main Outcomes and Measures Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Results Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). Conclusions and Relevance This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.
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Affiliation(s)
- Valerie M. Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Ashwin Gupta
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lindsay A. Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Anurag N. Malani
- Division of Infectious Diseases, Department of Internal Medicine, Trinity Health, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan
| | - Danielle Osterholzer
- Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
- Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing
| | - Payal K. Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Mariam Younas
- Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
| | - Steven J. Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Stephanie Burdick
- Division of Hospital Medicine, Corewell Health, Grand Rapids, Michigan
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Julia E. Szymczak
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tanima Basu
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Jennifer K. Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Scott A. Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tejal N. Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
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Ingalls EM, Veillette JJ, Olson J, May SS, Dustin Waters C, Gelman SS, Vargyas G, Hutton M, Tinker N, Fontaine GV, Foster RA, Stallsmith J, Earl A, Buckel WR, Vento TJ. Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments. Hosp Pharm 2023; 58:401-407. [PMID: 37360208 PMCID: PMC10288455 DOI: 10.1177/00185787231159578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.
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Affiliation(s)
| | - John J. Veillette
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
| | - Jared Olson
- Primary Children’s Hospital, Salt Lake City, UT, USA
- University of Utah, Salt Lake City, UT, USA
| | - Stephanie S. May
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
| | | | - Stephanie S. Gelman
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
| | - George Vargyas
- Intermountain Medical Center Emergency Department, Murray, UT, USA
| | | | - Nick Tinker
- Intermountain Medical Center, Murray, UT, USA
| | | | | | - Jena Stallsmith
- Primary Children’s Hospital, Salt Lake City, UT, USA
- University of Utah, Salt Lake City, UT, USA
| | - Ali Earl
- St. George Regional Hospital, St. George, UT, USA
| | | | - Todd J. Vento
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
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Wretman CJ, Boynton MH, Preisser JS, Zimmerman S, Kistler CE. Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: A discrete choice experiment. Infect Control Hosp Epidemiol 2023; 44:1151-1154. [PMID: 36073169 DOI: 10.1017/ice.2022.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The overdiagnosis of urinary tract infections (UTIs) in nursing home residents is a significant public health threat. Using a discrete choice experiment and a diagnostic guideline, we examined which patient-level information was associated with the overdiagnosis of UTIs and found that urinalysis results and lower urinary tract status were most associated.
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Affiliation(s)
| | - Marcella H Boynton
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Christine E Kistler
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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Kabbani S, Wang SW, Ditz LL, Gouin KA, Palms D, Rowe TA, Hyun DY, Chi NW, Stone ND, Hicks LA. Description of antibiotic use variability among US nursing homes using electronic health record data. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2021; 1:e58. [PMID: 36168476 PMCID: PMC9495428 DOI: 10.1017/ash.2021.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022]
Abstract
Background Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders. Methods A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models. Results In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5-10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software). Conclusions Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.
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Affiliation(s)
- Sarah Kabbani
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | | | | | - Katryna A. Gouin
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Danielle Palms
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Theresa A. Rowe
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - David Y. Hyun
- The Pew Charitable Trusts, Washington, DC, United States
| | | | - Nimalie D. Stone
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Lauri A. Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
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10
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Barman R, Emtman R, Bruno-Murtha LA. Deceptive Urine Studies and Inappropriate Antibiotic Use in Geriatric Psychiatry: The Impact of Bundled Interventions. Int J Appl Basic Med Res 2021; 11:166-170. [PMID: 34458119 PMCID: PMC8360214 DOI: 10.4103/ijabmr.ijabmr_599_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/27/2020] [Accepted: 06/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Indiscriminate orders for urinalysis and urine cultures (UC) drive inappropriate antibiotic treatment (Abx), especially in older adults with mental health disorders. Lack of data regarding the prevalence of and treatment for infections in acute geriatric psychiatric units (GPU) motivated us to initiate this project. Aim: Our goal was to improve urine test utilization and reduce unnecessary Abx for asymptomatic bacteriuria (ASB) and contaminated UC. Methods: This retrospective review and prospective evaluation of bundled interventions was conducted in a 22- bed GPU in a community-based teaching hospital. Four hundred twenty-seven (427) patient records were reviewed for Abx and indication and 157 patients were assessed for the impact of bundled interventions. Results: Near 27% received Abx, primarily for a misdiagnosed urinary tract infection. Only 20% met clinical criteria; 80% were unnecessarily treated for ASB or contaminated cultures. Over two-thirds of the Abx consisted of fluoroquinolones or trimethoprim-sulfamethoxazole, neither of which are recommended due to adverse events and/or resistance. The impact of bundled interventions was marginally effective. Conclusion: Urinalysis and UC are indiscriminately ordered in older adults, resulting in inappropriate Abx with non-recommended agents. Urinalysis should not be a requirement for admission in asymptomatic patients given the high prevalence of ASB and pyuria in older adults. There is an opportunity for more collaboration within referring networks to standardize best practice.
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Affiliation(s)
| | - Reiko Emtman
- Veterans Affairs Medical Center, Boise, Idaho, USA
| | - Lou Ann Bruno-Murtha
- Division Chief of Infectious Disease, Harvard Medical School, Cambridge Health Alliance, Cambridge, Massachusetts, USA
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11
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Patel R, Polage CR, Bard JD, May L, Lee FM, Fabre V, Hayden MK, Doernberg SDB, Haake DA, Trautner BW, Grigoryan L, Tsalik EL, Hanson KE. Envisioning Future UTI Diagnostics. Clin Infect Dis 2021; 74:1284-1292. [PMID: 34463708 DOI: 10.1093/cid/ciab749] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Urinary tract infections (UTIs) are among the most common bacterial infections in the United States and are a major driver of antibiotic use - both appropriate and inappropriate - across healthcare settings. UTI treatment has become complex due to antibacterial resistance; one quarter of urinary tract isolates of Escherichia coli in the United States in 2017 were resistant to fluoroquinolones and one third to trimethoprimsulfamethoxazole (1), agents with historically predictable activity against E. coli. As a result, more broad-spectrum antibiotics are being used to treat UTIs, contributing to selection of further antibiotic resistance.
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Affiliation(s)
- Robin Patel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA. Division of Clinical Microbiology, Mayo Clinic, Rochester, MN, USA
| | | | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Larissa May
- Department of Emergency Medicine, University of California-Davis Health, Sacramento, CA, USA
| | - Francesca M Lee
- Division of Infectious Diseases, Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA
| | - Sarah D B Doernberg
- Division of Infectious Disease, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David A Haake
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, and the Division of Infectious Diseases, Department of Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Larissa Grigoryan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Ephraim L Tsalik
- Duke University Center for Applied Genomics and Precision Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Kimberly E Hanson
- Department of Internal Medicine and Department of Pathology, University of Utah, Salt Lake City, UT, USA
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12
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Wang J, Cao Y, Zhang L, Liu G, Li C. Pathogen distribution and risk factors for urinary tract infection in infants and young children with retained double-J catheters. J Int Med Res 2021; 49:3000605211012379. [PMID: 33947257 PMCID: PMC8113964 DOI: 10.1177/03000605211012379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objectives To investigate the pathogens and potential risk factors for urinary tract
infection (UTI) in patients with retained double-J catheters (DJCs). Methods In total, 107 infants and young children with DJCs were included in this
retrospective analysis. Patients were included in the infection group
(n = 30) or non-infection group (n = 77), according to UTI presence or
absence. The species and characteristics of pathogens were investigated, and
the clinical features of the patients were recorded for further
analysis. Results Gram-negative bacilli were the most common causative pathogens (69.2%), among
which Escherichia coli was most frequent (38.5%). The
second most common causative pathogens were Gram-positive cocci (28.2%),
among which Enterococcus faecalis was most frequent
(10.3%). UTIs among patients in this study were associated with the
following factors: catheter retention (long-term) (odds ratio [OR] = 2.514,
95% confidence interval [CI] = 1.176–5.373), sex (male) (OR = 2.966, 95%
CI = 1.032–8.529), DJC retention (long-term) (OR = 1.869, 95%
CI = 1.194–2.926), and DJC number (unilateral) (OR = 0.309, 95%
CI = 0.103–0.922). Conclusions Infants and young children with DJCs were likely to experience UTIs, mainly
caused by Gram-negative bacilli. Long-term catheter retention or DJC
retention, male sex, and bilateral DJC retention were risk factors for
UTI.
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Affiliation(s)
- Jianfeng Wang
- Affiliated Foshan Maternal and Child Healthcare Hospital, Southern Medical University, Foshan, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yu Cao
- Ningxiang Hospital, Hunan University of Traditional Chinese Medicine, Ningxiang, China
| | - Li Zhang
- Affiliated Foshan Maternal and Child Healthcare Hospital, Southern Medical University, Foshan, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Guoqing Liu
- Affiliated Foshan Maternal and Child Healthcare Hospital, Southern Medical University, Foshan, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Chunjing Li
- Affiliated Foshan Maternal and Child Healthcare Hospital, Southern Medical University, Foshan, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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13
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Felsen CB, Dodds Ashley ES, Barney GR, Nelson DL, Nicholas JA, Yang H, Aydelotte ME, Karlic A, Nicholas NC, Petrone KK, Pine RD, Schabel SL, Medina-Walpole A, Dumyati GK. Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration. J Am Med Dir Assoc 2021; 21:55-61.e2. [PMID: 31888865 DOI: 10.1016/j.jamda.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS Six NHs in Monroe County, NY. METHODS A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.
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Affiliation(s)
- Christina B Felsen
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC
| | - Grant R Barney
- Emerging Infections Program, New York State Department of Health, Albany, NY
| | - Dallas L Nelson
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Joseph A Nicholas
- Department of Medicine and Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | | | - Alexander Karlic
- Unity Living Center and Unity Hospital, Rochester Regional Health, Rochester, NY
| | - Nirmala C Nicholas
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | | | | | - Scott L Schabel
- Division of Long Term Care, Rochester Regional Health, Rochester, NY
| | - Annette Medina-Walpole
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Ghinwa K Dumyati
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY; Department of Medicine, Division of Infectious Disease, University of Rochester Medical Center, Rochester, NY.
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14
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Sommer-Larsen SD, Arnold SH, Holm A, Aamand Olesen J, Cordoba G. Quality of the Diagnostic Process, Treatment Decision, and Predictors for Antibiotic Use in General Practice for Nursing Home Residents with Suspected Urinary Tract Infection. Antibiotics (Basel) 2021; 10:antibiotics10030316. [PMID: 33803831 PMCID: PMC8003235 DOI: 10.3390/antibiotics10030316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
Urinary tract infections (UTIs) are common in nursing home (NH) residents and Denmark is one of the countries with the highest antibiotic use in NHs. The aim of this study was to assess the quality of the diagnostic process and treatment decision on the day of the first contact from NHs to general practice and assess predictors for prescription of antibiotics in NH residents without an indwelling urinary catheter. The study was a prospective observational study in general practice in the Capital Region of Denmark; 490 patients were included; 158 out of 394 (40.1%, 95% CI 35; 45) patients with suspected UTI had urinary tract symptoms; 270 out of 296 (91.2%, 95% CI 87; 94) patients without urinary tract symptoms had a urine culture performed. Performing urine culture in the general practice was inversely associated to prescription of antibiotics on day one (OR 0.27, 95% CI 0.13; 0.56). It is imperative to support the implementation of interventions aimed at improving the quality of the diagnostic process on day one, as less than half of the patients given the diagnosis "suspected UTI" had urinary tract symptoms, and most patients without urinary tract symptoms had a urine culture performed.
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15
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Valmadrid LC, Schwei RJ, Maginot E, Pulia MS. The impact of health care provider relationships and communication dynamics on urinary tract infection management and antibiotic utilization for long-term care facility residents treated in the emergency department: A qualitative study. Am J Infect Control 2021; 49:198-205. [PMID: 32653562 PMCID: PMC7348612 DOI: 10.1016/j.ajic.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND For older adults, over diagnosis of urinary tract infections (UTI) is a primary driver of inappropriate antibiotic use. This risk is increased for patients in long-term care facilities (LTCF), especially as they transition back and forth to emergency departments (ED). In this study, we aimed to understand how health care provider communication and relationship dynamics affect LTCF residents treated in the ED to identify barriers to antibiotic stewardship for UTIs. METHODS We conducted semi-structured interviews with nurses and physicians from LTCFs and EDs, guided by the Systems Engineering Initiative for Patient Safety framework. Data were systematically coded and underwent iterative, conventional, content analysis. RESULTS We interviewed 16 LTCF and 16 ED providers across Wisconsin. ED and LTCF nurses have a critical role in both intrafacility and interfacility communication. Fragmented communication and interprofessional power dynamics were identified barriers to optimal antibiotic prescribing for UTIs. Identified strategies to overcome these issues included using objective diagnostic criteria, development of communication scripts, and nurse-to-nurse education. CONCLUSIONS Our qualitative approach revealed important insights about how communication and relationship dynamics influence UTI diagnosis and optimal antibiotic stewardship for LTCF residents evaluated in the ED. Future interventions should strengthen communications between settings and across provider types, and address standardization of diagnostic and treatment communication pathways for LTCF residents with suspected infections transitioning between EDs and LTCFs.
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Affiliation(s)
- Luke Carmichael Valmadrid
- University of North Carolina at Chapel Hill, Chapel Hill, NC; University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Rebecca J Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Elizabeth Maginot
- University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI.
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16
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Brown KA, Daneman N, Schwartz KL, Langford B, McGeer A, Quirk J, Diong C, Garber G. The Urine-culturing Cascade: Variation in Nursing Home Urine Culturing and Association With Antibiotic Use and Clostridiodes difficile Infection. Clin Infect Dis 2021; 70:1620-1627. [PMID: 31197362 DOI: 10.1093/cid/ciz482] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use. METHODS We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates. RESULTS A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18-1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28-1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07-1.31). CONCLUSIONS Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection.
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Affiliation(s)
- Kevin Antoine Brown
- Public Health Ontario, Canada.,Institute for Clinical Evaluative Sciences, Canada.,Dalla Lana School of Public Health, University of Toronto, Canada
| | - Nick Daneman
- Public Health Ontario, Canada.,Institute for Clinical Evaluative Sciences, Canada.,Sunnybrook Research Institute, Division of Infectious Diseases, Canada.,The Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Canada.,Institute for Clinical Evaluative Sciences, Canada.,Dalla Lana School of Public Health, University of Toronto, Canada.,St Joseph's Health Centre, Canada
| | | | - Allison McGeer
- Dalla Lana School of Public Health, University of Toronto, Canada.,Mount Sinai Hospital, Toronto, Canada
| | | | | | - Gary Garber
- Public Health Ontario, Canada.,Ottawa Research Institute, Canada
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17
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"There is no one to pick up the pieces": Sustainability of antibiotic stewardship programs in nursing homes. Infect Control Hosp Epidemiol 2020; 42:440-447. [PMID: 33100251 DOI: 10.1017/ice.2020.1217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe nursing home staff experiences and perceptions of the factors that impact the sustainability of an antibiotic stewardship program (ASP). METHODS Using a qualitative descriptive design, semistructured interviews with staff at 9 not-for-profit nursing homes with an established ASP were conducted and audio recorded. De-identified transcriptions of the interviews were coded using a sustainability framework and were analyzed to identify themes. RESULTS Interviews were conducted with 48 clinical and administrative staff to elicit their perceptions of the ASPs, and 7 themes were identified. ASPs were perceived to be resource intensive and "data driven," requiring access to and interpretation of data that are not readily available at many nursing homes. Though motivated and committed, ASP champions felt that they could not single-handedly sustain the program. Attending to daily clinical needs (ie, "fires") made it hard to progress beyond implementation and to reach step 2 of sustainability. Longstanding treatment habits by external prescribers and regulations were believed to impede ASP efforts. Partnerships with an external consultant with antibiotic stewardship expertise were considered important, as was the need for internal leadership support and collaboration across disciplinary boundaries. Participants felt that consistent and ongoing education on antibiotic stewardship at all staff levels was important. CONCLUSIONS Although many interconnected factors impact the sustainability of an ASP, nursing homes may be able to sustain an ASP by focusing on 3 critical areas: (1) explicit support by nursing home leadership, (2) external partnerships with professionals with antibiotic stewardship expertise and internal interprofessional collaborations, and (3) consistent education and training for all staff.
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18
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Peng Z, Hayen A, Hall J, Liu B. Microbiology testing and antibiotic treatment for urinary tract infections in general practice: a nationwide observational study. Infection 2020; 49:249-255. [PMID: 32862305 DOI: 10.1007/s15010-020-01512-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Routine urine testing is recommended prior to antibiotic treatment for urinary tract infections (UTIs) among high-risk groups for complicated UTIs. This study aims to examine whether the proportion of UTI encounters where antibiotics are prescribed that have accompanying urine testing differs by patient groups. METHODS A retrospective analysis was conducted using records of general practice encounters for UTIs occurring between January 2013 and July 2018 in an Australian national database. We calculated the proportion of UTI encounters with antibiotics prescribed that had accompanying urine microbiology testing and the odds ratios for the likelihood of testing by patient groups using generalised estimating equations. RESULTS Of 132,688 UTI encounters with antibiotics prescribed, 95,800 (72.2%) were accompanied by urine testing. Among high-risk groups for complicated UTIs and expected to have a high likelihood of testing, we found pregnant women [82.6% vs. non-pregnant 72.3%, adjusted odds ratio (aOR) 1.82, 95% confidence intervals (CI) 1.55-2.12] and children aged 5-9 years (77.6% vs. 20-44 years 72.0%, aOR 1.33, 95% CI 1.22-1.45) had relatively high odds of testing. However, children aged < 5 years (68.7% vs. 20-44 years 72.0%, aOR 0.83, 95% CI 0.76-0.90), patients with recurrent UTIs (69.0% compared to first-onset UTIs 73.6%, aOR 0.81, 95% CI 0.79-0.83), and patients in residential aged care facilities (67.3% vs. not 72.3%, aOR 0.80, 95% CI 0.72-0.90) had relatively low odds of testing. CONCLUSION Our results suggest inconsistencies and potential underuse of urine testing when antibiotics were prescribed for high-risk groups in UTI management. Further antibiotic stewardship is needed to improve guideline-based antibiotic prescribing for UTIs.
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Affiliation(s)
- Zhuoxin Peng
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia.
| | - Andrew Hayen
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - John Hall
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Bette Liu
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
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19
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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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20
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Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, Eckert LO, Geerlings SE, Köves B, Hooton TM, Juthani-Mehta M, Knight SL, Saint S, Schaeffer AJ, Trautner B, Wullt B, Siemieniuk R. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis 2020; 68:e83-e110. [PMID: 30895288 DOI: 10.1093/cid/ciy1121] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/27/2018] [Indexed: 12/22/2022] Open
Abstract
Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.
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Affiliation(s)
- Lindsay E Nicolle
- Department of Internal Medicine, School of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Kalpana Gupta
- Division of Infectious Diseases, Veterans Affairs Boston Healthcare System and Boston University School of Medicine, West Roxbury, Massachusetts
| | | | - Richard Colgan
- Department of Family and Community Medicine, University of Maryland, Baltimore
| | - Gregory P DeMuri
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Dimitri Drekonja
- Division of Infectious Diseases, University of Minnesota, Minneapolis
| | - Linda O Eckert
- Department of Obstetrics and Gynecology and Department of Global Health, University of Washington, Seattle
| | - Suzanne E Geerlings
- Department of Internal Medicine, Amsterdam University Medical Center, The Netherlands
| | - Béla Köves
- Department of Urology, South Pest Teaching Hospital, Budapest, Hungary
| | - Thomas M Hooton
- Division of Infectious Diseases, University of Miami, Florida
| | | | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Sanjay Saint
- Department of Internal Medicine, Veterans Affairs Ann Arbor and University of Michigan, Ann Arbor
| | | | - Barbara Trautner
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Bjorn Wullt
- Division of Microbiology, Immunology and Glycobiology, Lund, Sweden
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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21
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Godbole GP, Cerruto N, Chavada R. Principles of assessment and management of urinary tract infections in older adults. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gauri P. Godbole
- Pharmacy Department Gosford Hospital, NSW Health Gosford Australia
| | - Nicole Cerruto
- Pharmacy Department Gosford Hospital, NSW Health Gosford Australia
| | - Ruchir Chavada
- Department of Microbiology and Infectious Diseases NSW Health Pathology Central Coast Newcastle Australia
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Arnold SH, Jensen JN, Kousgaard MB, Siersma V, Bjerrum L, Holm A. Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e17710. [PMID: 32383679 PMCID: PMC7244999 DOI: 10.2196/17710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Urinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis. OBJECTIVE The objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality. METHODS The study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period. RESULTS The trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020. CONCLUSIONS The greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI. TRIAL REGISTRATION ClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17710.
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Affiliation(s)
- Sif Helene Arnold
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jette Nygaard Jensen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Marius Brostrøm Kousgaard
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anne Holm
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Treatment of urinary tract infections in the old and fragile. World J Urol 2020; 38:2709-2720. [PMID: 32221713 DOI: 10.1007/s00345-020-03159-2] [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: 10/27/2019] [Accepted: 03/04/2020] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Urinary tract infection (UTI) is highly prevalent in the frail elderly population. This review aimed to outline the diagnostic, treatment, and prevention of UTI in the frail aging population. METHODS Pubmed and Web of Science search to identify publications until March 2019 relating to the management of UTI in the elderly population was performed. A narrative review of the available literature was performed. RESULTS 64 publications were considered as relevant and included in this review. The diagnosis of symptomatic UTI in the old and fragile could be challenging. Routine screening and antimicrobial therapy for asymptomatic bacteriuria should not be recommended for frail elderly patients. Cautious choice of antibiotics should be guided by uropathogen identified by culture and sensitivity. Understanding local antibiotic resistance rates plays a fundamental part in selecting appropriate antimicrobial treatment. Impact of associated adverse effect, in particular those with effects on cognitive function, should be considered when deciding choice of antibiotics for symptomatic UTI in the elderlies. Optimal management of comorbidities such as diabetes mellitus, adequate treatment of urinary incontinence, and judicious use of urinary catheter is essential to reduce the development of UTI. CONCLUSION UTI is a significant but common problem in elderly population. Physicians who care for frail elderly patients must be aware of the challenges in the management of asymptomatic UTI, and identifying symptomatic UTI in this population, and their appropriate management strategies. There is strong need in studies to evaluate nonantimicrobial therapies in the prevention of UTI for the frail elderly population.
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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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25
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Sloane PD, Zimmerman S, Nace DA. Progress and Challenges in the Management of Nursing Home Infections. J Am Med Dir Assoc 2020; 21:1-4. [DOI: 10.1016/j.jamda.2019.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 11/27/2019] [Indexed: 01/08/2023]
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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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27
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Biggel M, Heytens S, Latour K, Bruyndonckx R, Goossens H, Moons P. Asymptomatic bacteriuria in older adults: the most fragile women are prone to long-term colonization. BMC Geriatr 2019; 19:170. [PMID: 31226945 PMCID: PMC6588879 DOI: 10.1186/s12877-019-1181-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/04/2019] [Indexed: 12/31/2022] Open
Abstract
Background The diagnosis of urinary tract infections (UTIs) in institutionalized older adults is often based on vague symptoms and a positive culture. The high prevalence of asymptomatic bacteriuria (ABU), which cannot be easily discriminated from an acute infection in this population, is frequently neglected, leading to a vast over-prescription of antibiotics. This study aimed to identify subpopulations predisposed to transient or long-term ABU. Methods Residents in a long-term care facility were screened for ABU. Mid-stream urine samples were collected during two sampling rounds, separated by 10 weeks, each consisting of an initial and a confirmative follow-up sample. Results ABU occurred in approximately 40% of the participants and was mostly caused by Escherichia coli. Long-term ABU (> 3 months) was found in 30% of the subjects. The frailest women with urinary incontinence and dementia had drastically increased rates of ABU and especially long-term ABU. ABU was best predicted by a scale describing the functional independence of older adults. Conclusions Institutionalized women with incontinence have ABU prevalence rates of about 80% and are often persistent carriers. Such prevalence rates should be considered in clinical decision making as they devalue the meaning of a positive urine culture as a criterion to diagnose UTIs. Diagnostic strategies are urgently needed to avoid antibiotic overuse and to identify patients at risk to develop upper UTI. Electronic supplementary material The online version of this article (10.1186/s12877-019-1181-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael Biggel
- Laboratory of Medical Microbiology, University of Antwerp, Universiteitsplein 1, building S, 2610 Wilrijk, Antwerp, Belgium
| | - Stefan Heytens
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Katrien Latour
- Operational Directorate Epidemiology & Public Health, Sciensano, Brussels, Belgium.,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Hasselt University, Hasselt, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Universiteitsplein 1, building S, 2610 Wilrijk, Antwerp, Belgium
| | - Pieter Moons
- Laboratory of Medical Microbiology, University of Antwerp, Universiteitsplein 1, building S, 2610 Wilrijk, Antwerp, Belgium.
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Antimicrobial resistance patterns of urine culture specimens from 27 nursing homes: Impact of a two-year antimicrobial stewardship intervention. Infect Control Hosp Epidemiol 2019; 40:780-786. [DOI: 10.1017/ice.2019.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractObjective:Identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures during a 2-year antimicrobial stewardship intervention program in nursing homes (NHs).Design:Before-and-after intervention study.Setting:The study included 27 NHs in North Carolina.Methods:We audited all urine cultures ordered before and during an antimicrobial stewardship intervention. Analyses compared culture rates, culture positive rates, and pathogen antimicrobial resistance patterns.Results:Of 6,718 total urine cultures collected, 68% were positive for potentially pathogenic bacteria. During the intervention, significant reductions in the urine culture and positive culture rates were observed (P= .014). Most of the identified potentially uropathogenic isolates wereEscherichia coli(38%),Proteusspp (13%), andKlebsiella pneumoniae(12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance amongE. coli(P≤ .001) and ciprofloxacin resistance amongProteusspp (P≤ .001); however carbapenem resistance increased forProteusspp (P≤ .001). Multidrug resistance also increased forProteusspp compared to the baseline. The high baseline resistance ofE. colito the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.Conclusions:The antimicrobial stewardship intervention program significantly reduced urine culture and culture-positive rates. Overall, very high proportions of antimicrobial resistance were observed among common pathogens; however, antimicrobial resistance trended downward but reductions were too small and scattered to conclude that the intervention significantly changed antimicrobial resistance. Longer intervention periods may be needed to effect change in resistance patterns.
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29
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Rousham E, Cooper M, Petherick E, Saukko P, Oppenheim B. Overprescribing antibiotics for asymptomatic bacteriuria in older adults: a case series review of admissions in two UK hospitals. Antimicrob Resist Infect Control 2019; 8:71. [PMID: 31073402 PMCID: PMC6498584 DOI: 10.1186/s13756-019-0519-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Overdiagnosis and overtreatment of urinary tract infection (UTI) with antibiotics is a concern. In older adults, diagnosis of UTI using near-patient urine tests (reagent strip tests, dipsticks) is advised against because the age-related increase in asymptomatic bacteriuria can cause false-positive results. Instead, UTI diagnosis should be based on a full clinical assessment. Previous research lacks systematic information on urine dipstick use in hospitals. The aim of this study was to examine the use of urine dipstick tests and microbiology among older adult hospital admissions in relation to recommended UTI diagnostic criteria. A further aim was to assess factors associated with the use of dipsticks. Methods A case series review of patients aged ≥70 years admitted to two NHS Trust hospitals in England. Records from 312 patients admitted in 2015 meeting inclusion criteria were selected at random. Results Of 298 complete patient records, 54% had at least one urine dipstick test recorded. 13% (21/161) of patients who received a urine dipstick test were diagnosed as having a UTI, only 2 out of these 21 cases had two or more clinical signs and symptoms. 60 patients received a second dipstick test, leading to 13 additional cases of UTI diagnosis. Dipstick tests were more likely to be performed on patients with a history of falls (OR 1.93, 95% CI:1.21, 3.07, p < 0.01), and less likely on those with dementia (OR 0.44, 95% CI: 0.22, 0.87, p < 0.05). The most common reason for testing was routine admissions policy (49.1% of cases), but these cases were predominantly in one hospital. Conclusions Use of urine dipstick tests was high among older adults admitted to hospitals. Most cases were asymptomatic and therefore received inappropriate antibiotic therapy. This paper highlights the need to implement new Public Health England diagnostic guidelines to hospital admission and emergency departments.
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Affiliation(s)
- Emily Rousham
- 1School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, LE11 3TU UK
| | - Michael Cooper
- 2Department of Microbiology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Emily Petherick
- 1School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, LE11 3TU UK
| | - Paula Saukko
- 3School of Social Sciences, Loughborough University, Loughborough, UK
| | - Beryl Oppenheim
- 4NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham and Birmingham Community Healthcare Trust, Birmingham, UK
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30
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Emberger J, Tassone D, Stevens MP, Markley JD. The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions. Curr Infect Dis Rep 2018; 20:31. [PMID: 29959545 DOI: 10.1007/s11908-018-0637-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions. RECENT FINDINGS AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.
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Affiliation(s)
- Jennifer Emberger
- Virginia Commonwealth University Medical Center, VMI Building, 2nd Floor, Room 204, Richmond, VA, 23298, USA.
| | - Dan Tassone
- Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Michael P Stevens
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - J Daniel Markley
- Department of Internal Medicine, Division of Infectious Diseases, Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Abstract
Urinary tract infections (UTIs) are a significant cause of morbidity among older adults. However, antibiotic prescriptions for clinically suspected UTIs are often inappropriate. Health care providers frequently struggle to differentiate UTI from asymptomatic bacteriuria, particularly in patients presenting with nonspecific symptoms. Patients with baseline cognitive impairments that limit history-taking can be particularly challenging. This article reviews the epidemiology and pathogenesis of UTI in older adults. It discusses an approach to diagnosis and treatment focused on recognizing patients who would likely benefit from antibiotic treatment and on identifying patients for whom empiric antibiotic therapy should not be given.
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32
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Applying the Horizontal and Vertical Paradigm to Antimicrobial Stewardship. Infect Control Hosp Epidemiol 2017; 38:532-533. [PMID: 28421979 DOI: 10.1017/ice.2017.44] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Leis JA. Advancing infection prevention and antimicrobial stewardship through improvement science. BMJ Qual Saf 2017; 27:163-165. [PMID: 28615344 DOI: 10.1136/bmjqs-2017-006793] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Jerome A Leis
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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