1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Resistência microbiana a medicamentos em uma Instituição de Longa Permanência para Idosos. ACTA PAUL ENFERM 2022. [DOI: 10.37689/acta-ape/2022ao03751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
3
|
Cassone M, Mody L. Measuring the outsized impact of COVID-19 in the evolving setting of aged care facilities. EClinicalMedicine 2021; 34:100825. [PMID: 33880439 PMCID: PMC8050616 DOI: 10.1016/j.eclinm.2021.100825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 01/24/2023] Open
Affiliation(s)
- Marco Cassone
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Lona Mody
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
- Geriatric Research and Education Clinical Center, VA Ann Arbor, MI, USA
- Corresponding author. Present address: Division of Geriatric and Palliative Medicine, University of Michigan Medical School, 300 N Ingalls Rd, Room 905, Ann Arbor, MI 48109, USA.
| |
Collapse
|
4
|
Hashan MR, Smoll N, King C, Ockenden-Muldoon H, Walker J, Wattiaux A, Graham J, Booy R, Khandaker G. Epidemiology and clinical features of COVID-19 outbreaks in aged care facilities: A systematic review and meta-analysis. EClinicalMedicine 2021; 33:100771. [PMID: 33681730 PMCID: PMC7917447 DOI: 10.1016/j.eclinm.2021.100771] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19 outbreaks in aged care facilities (ACFs) often have devastating consequences. However, epidemiologically these outbreaks are not well defined. We aimed to define such outbreaks in ACFs by systematically reviewing literature published during the current COVID-19 pandemic. METHODS We searched 11 bibliographic databases for literature published on COVID-19 in ACFs between December 2019 and September 2020. Original studies reporting extractable epidemiological data as part of outbreak investigations or non-outbreak surveillance of ACFs were included in this systematic review and meta-analysis. PROSPERO registration: CRD42020211424. FINDINGS We identified 5,148 publications and selected 49 studies from four continents reporting data on 214,380 residents in 8,502 ACFs with 25,567 confirmed cases of COVID-19. Aged care residents form a distinct vulnerable population with single-facility attack rates of 45% [95% CI 32-58%] and case fatality rates of 23% [95% CI 18-28%]. Of the cases, 31% [95% CI 28-34%] were asymptomatic. The rate of hospitalization amongst residents was 37% [95% CI 35-39%]. Data from 21 outbreaks identified a resident as the index case in 58% of outbreaks and a staff member in 42%. Findings from the included studies were heterogeneous and of low to moderate quality in risk of bias assessment. INTERPRETATION The clinical presentation of COVID-19 varies widely in ACFs residents, from asymptomatic to highly serious cases. Preventing the introduction of COVID-19 into ACFs is key, and both residents and staff are a priority group for COVID-19 vaccination. Rapid diagnosis, identification of primary and secondary cases and close contacts plus their isolation and quarantine are of paramount importance. FUNDING Queensland Advancing Clinical Research Fellowship awarded to Prof. Gulam Khandaker by Queensland Health's Health Innovation, Investment and Research Office (HIRO), Office of the Director-General.
Collapse
Affiliation(s)
- Mohammad Rashidul Hashan
- Central Queensland University, Rockhampton, Australia
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Nicolas Smoll
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Catherine King
- National Centre for Immunisation Research and Surveillance (NCIRS), The Children's Hospital at Westmead, Westmead, Australia
- The Children's Hospital at Westmead Clinical School, The faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Hannah Ockenden-Muldoon
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Jacina Walker
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Andre Wattiaux
- Gold Coast Public Health Unit, Gold Coast Hospital and Health Service, Gold Coast, Australia
| | - Julieanne Graham
- Medical Services Team, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Robert Booy
- National Centre for Immunisation Research and Surveillance (NCIRS), The Children's Hospital at Westmead, Westmead, Australia
- The Children's Hospital at Westmead Clinical School, The faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Gulam Khandaker
- Central Queensland University, Rockhampton, Australia
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
- The Children's Hospital at Westmead Clinical School, The faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
5
|
Kistler CE, Jump RLP, Sloane PD, Zimmerman S. The Winter Respiratory Viral Season During the COVID-19 Pandemic. J Am Med Dir Assoc 2020; 21:1741-1745. [PMID: 33256954 PMCID: PMC7586921 DOI: 10.1016/j.jamda.2020.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 02/07/2023]
Abstract
The winter respiratory virus season always poses challenges for long-term care settings; this winter, severe acute respiratory syndrome coronavirus 2 will compound the usual viral infection challenges. This special article discusses unique considerations that Coronavirus Disease 2019 (COVID-19) brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. Specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. Policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a COVID-19 vaccine when it becomes available. Research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. If there is a positive side to this year's winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection.
Collapse
Affiliation(s)
- Christine E Kistler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, NC, USA.
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
6
|
Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review. Drugs Aging 2020; 38:29-41. [PMID: 33174126 DOI: 10.1007/s40266-020-00814-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.
Collapse
|
7
|
Furuno JP, Mody L. Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes. J Am Geriatr Soc 2019; 68:11-14. [PMID: 31825520 DOI: 10.1111/jgs.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Detroit, Michigan.,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Detroit, Michigan
| |
Collapse
|
8
|
Nursing Home-Associated Pneumonia, Part I: Diagnosis. J Am Med Dir Assoc 2019; 21:308-314. [PMID: 31178286 DOI: 10.1016/j.jamda.2019.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/21/2019] [Indexed: 11/20/2022]
Abstract
Pneumonia is 1 of the 3 most common infections identified in nursing home residents and is associated with the highest mortality of any infection in this setting. In regard to pneumonia in the nursing home setting, practitioners are focused primarily on identifying residents with this infection and choosing a treatment regimen. In this article, the diagnosis of this infection is addressed. Based on published studies and clinical experience, "bedside criteria" for the diagnosis of nursing home-associated pneumonia (NHAP) are proposed that are based primarily on objective respiratory signs and symptoms that can be readily identified by staff. It is also stressed that factors predisposing to aspiration should be identified because there is a risk for aspiration pneumonitis. A previously published decision tool to distinguish between aspiration pneumonia and aspiration pneumonitis is discussed. Because providers are often not present when there is a change in status of a resident, nursing staff are crucial to the diagnosis of NHAP. However, there is variability in staff experience and the ability to obtain and communicate clinical findings to assist providers in making decisions about diagnosis. To deal with this issue, templates have been developed to help staff collect the appropriate information before contacting the provider. The most important diagnostic test in a resident with suspected pneumonia is a chest radiograph. However, studies done more than a decade ago demonstrated considerable variability in radiologists' interpretation of chest radiographs of residents performed in the nursing home. Radiologic techniques have improved considerably with utilization of digital technology, but there have been no recent studies to determine if interpretation of these radiographs is more consistent. An alternative to radiographs is lung ultrasonography, which has been found to be more accurate than chest radiographs in identifying pneumonia in adults; however, this method has not been studied in the nursing home setting. Host biomarkers such as serum C-reactive protein and procalcitonin levels have been studied in adults with pneumonia to distinguish between bacterial and nonbacterial infection, but there has been limited study in NHAP and the findings are conflicting. Lastly, it is stressed that the provider should carefully document the clinical findings and testing that result in a diagnosis of pneumonia to enhance surveillance for infection as well as antimicrobial stewardship activities.
Collapse
|
9
|
van Buul LW, Vreeken HL, Bradley SF, Crnich CJ, Drinka PJ, Geerlings SE, Jump RLP, Mody L, Mylotte JJ, Loeb M, Nace DA, Nicolle LE, Sloane PD, Stuart RL, Sundvall PD, Ulleryd P, Veenhuizen RB, Hertogh CMPM. The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure. J Am Med Dir Assoc 2018; 19:757-764. [PMID: 29910137 DOI: 10.1016/j.jamda.2018.05.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/11/2018] [Accepted: 05/01/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population. DESIGN A Delphi consensus procedure. SETTING AND PARTICIPANTS An international panel of practitioners recognized as experts in the field of UTI in frail older patients. MEASURES In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool. RESULTS Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter. CONCLUSIONS A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.
Collapse
Affiliation(s)
- Laura W van Buul
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.
| | - Hilde L Vreeken
- Dutch Association of Elderly Care Physicians, Utrecht, The Netherlands
| | - Suzanne F Bradley
- Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Medical School, Ann Arbor, MI
| | - Christopher J Crnich
- University of Wisconsin School of Medicine and Public Health, Madison, WI; Medical Service, William S. Middleton VA Hospital, Madison, WI
| | - Paul J Drinka
- Department of Internal Medicine, Geriatrics University of Wisconsin, Madison, WI
| | - Suzanne E Geerlings
- Division Infectious Diseases, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Robin L P Jump
- Geriatric Research, Education and Clinical Center and Specialty Care Center of Innovation at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC), Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Epidemiology and Biostatistics at Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lona Mody
- University of Michigan and Geriatrics Research Education and Clinical Care, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Joseph J Mylotte
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY
| | - Mark Loeb
- Department of Pathology and Molecular Medicine and Institute for Infectious Diseases Research, McMaster University, Hamilton, Canada
| | - David A Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Philip D Sloane
- Department of Family Medicine and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rhonda L Stuart
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia; Monash University, Victoria, Australia; National Centre for Antimicrobial Stewardship, Victoria, Australia
| | - Pär-Daniel Sundvall
- Närhälsan, Research and Development Primary Health Care Region Västra Götaland, R&D Center Södra Älvsborg, Sweden; The Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Peter Ulleryd
- Department of Communicable Disease Control, Region Västra Götaland, Sweden
| | - Ruth B Veenhuizen
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice and Old Age Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Feldstein D, Sloane PD, Feltner C. Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review. J Am Med Dir Assoc 2017; 19:110-116. [PMID: 28797590 DOI: 10.1016/j.jamda.2017.06.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/22/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance. These programs are now mandated in nursing homes (NHs) but it is unclear if these programs improve resident outcomes. This systematic review evaluated the current evidence regarding outcomes of ASPs in the NH. METHODS PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for intervention trials of ASPs performed in NHs that evaluated final health outcomes (mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence to recommended guidelines). RESULTS A total of 14 studies rated good or fair quality were included. Eight studies reported a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines proposed by the studied ASP. None reported a statistically significant change in NH mortality rates, C. difficile infection rates, or hospitalizations. DISCUSSION The limited research to date suggests that NH ASPs can affect intermediate health outcomes, but not key health outcomes or health care utilization. CONCLUSION Larger trials evaluating more intensive interventions over longer durations may be needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.
Collapse
Affiliation(s)
- Diana Feldstein
- Division of Geriatric Medicine, Center for Aging and Health, University of North Carolina, Chapel Hill, NC.
| | - Philip D Sloane
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Cynthia Feltner
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
11
|
Urine Culture Testing in Community Nursing Homes: Gateway to Antibiotic Overprescribing. Infect Control Hosp Epidemiol 2017; 38:524-531. [PMID: 28137327 DOI: 10.1017/ice.2016.326] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs) DESIGN Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period SETTING 31 NHs in North Carolina PARTICIPANTS 254 NH residents who had a urine culture ordered within the 1-month study period METHODS We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs. RESULTS Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000-99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%). CONCLUSIONS Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available. Infect Control Hosp Epidemiol 2017;38:524-531.
Collapse
|