Prevention of urinary tract infections in nursing homes: lack of evidence-based prescription?

Real-World Data about Commonly Used Antibiotics in Long-Term Care Homes in Australia from 2016 to 2019

In this study, we use real-world data to explore trends in antibiotic use in a dynamic cohort of long-term care (LTC) residents. A cross-sectional retrospective analysis of pharmacy medication supply records of 3459 LTC residents was conducted from 31 May 2016 to 31 May 2019. The primary outcome was the monthly prevalence of residents with an antibiotic episode. Secondary outcomes were the type of antibiotic used and duration of use. Over the three-year study period, residents were supplied 10460 antibiotics. On average, 18.9% of residents received an antibiotic monthly. Antibiotic use decreased slightly over time with a mean of 168/1000 (95% CI 146-177) residents using at least one antibiotic per month in June 2016 to 148/1000 (95% CI 127-156) in May 2019. The total number of antibiotic days per 100 resident days remained relatively constant over the study period: 8.8 days in 2016-2017, 8.4 in 2017-2018 and 6.4 in 2018-2019. Prolonged durations exceeding 100 days were seen for a small percentage of residents. We found extensive antibiotic use, which is a recognized contributor to antimicrobial resistance development, underscoring the necessity for quality treatment guidelines in this vulnerable population.

Nursing Effect Analysis of Urinary Tract Infections in Urology Surgery Patients: a Systematic Review and Meta-analysis

This meta-analysis aims to identify urinary tract infections (UTIs) in patients with different levels of age groups. For both diagnosis and treatment of UTIs, antibiotics have been widely used in nursing home settings. We also aimed to evaluate the duration of catheterization in UTI patients to reduce catheter-associated complications. We conducted a systematic review that was performed following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines and recommendations from Cochrane Collaboration. We performed a comprehensive search for published literature in PubMed, ScienceDirect, Taylor & Francis Online, Springer, and Wiley Online databases from 2010 to June 25, 2021. We performed two meta-analysis: the first meta-analysis (meta-analysis I) was performed on data obtained from included studies that compared patients with UTIs (experimental group) and without UTIs (control group); the second meta-analysis (meta-analysis II) was performed to assess the appropriate use of a catheter in UTI patients. All statistical analyses were conducted using the Review Manager 5.4 tool. A total of 15 research articles were included in this systematic review and meta-analysis. Of these, results showed the identification of critical patients with UTIs and without UTIs from nursing resident homes (risk ratio [RR] = 0.80 95% confidence interval CI = 0.69-0.93 p < 0.0001). Risk ratio results with random effects (RE) were obtained as RR = 0.69 95% CI = 0.26-1.83, p = 0.45, along with heterogeneity I ² (96%) values. No appropriate prescription of antibiotics in UTIs is practiced among nursing home residents. In addition, pooled results between two groups (short-duration vs. long-duration catheterization) showed RR 0.66 95% CI 0.46-0.93 p = 0.02, I ² = 56, that reduced complications associated with CAUTIs. This systematic review and meta-analysis suggested an appropriate use of agents and catheter insertion for a short duration at nursing homes.

Oral and parenteral antibiotic use in Norwegian nursing homes: are primary care institutions becoming our new local hospitals?

Background

Norwegian nursing homes (NHs) have over the last 10 years increasingly applied the use of parenteral treatment, which in turn allows more broad-spectrum use of antibiotics. Previous studies from Norwegian NHs have for the most part not described parenteral formulations.

Objectives

To describe systemic antibiotic use in Norwegian NHs.

Methods

Thirty-seven NHs in the county of Østfold, Norway, were invited to participate in this retrospective cross-sectional study. Associated pharmacies provided sales data for systemic antibiotic use for the participating NHs for 1 year (October 2015 to October 2016). General institutional characteristics were collected through a questionnaire.

Results

Thirty-four NHs participated in the study. Mean use of antibiotics was 9.5 DDD/100 bed days (range 0.6–30.9 DDD/100 bed days). Oral antibiotics accounted for 83% and parenteral antibiotics for 17% of the total antibiotic use. Of parenteral antibiotics, ampicillin was most used (31.1%) followed by cefotaxime (17.7%) and penicillin G (16.6%). The proportion of antibiotics compliant with guideline recommendations was 60%. Being a short-term NH was associated with increased antibiotic use, with an unstandardized coefficient of 13.1 (95% CI 4.2–21.9; P = 0.005).

Conclusions

We found a high level of total and parenteral antibiotic use compared with previous studies from Norwegian NHs. Data showed wide variations in total antibiotic use and that only a moderate proportion of the antibiotic use was considered guideline compliant. This highlights the necessity of further implementation strategies regarding the national guidelines for antibiotic use in NHs.

A Review of Nonantibiotic Agents to Prevent Urinary Tract Infections in Older Women

OBJECTIVE

This article provides a comprehensive literature review on nonantibiotic agents used for the prevention of urinary tract infections (UTIs) in women ≥45 years of age.

DESIGN

A structured review was performed by conducting a literature search to identify relevant studies pertaining to the use of nonantibiotic agents to prevent UTIs in women who were perimenopausal through postmenopausal. Recommendations were made for or against the use of each nonantibiotic agent, unless data were unavailable. Levels of evidence were assigned to each recommendation made.

SETTING AND PARTICIPANTS

Studies on the prevention of UTIs with women subjects ≥45 years of age in the community, inpatient, and long-term care settings were considered for inclusion.

MEASURE

The efficacy and safety of using ascorbic acid, cranberry products, d-mannose, estrogens, lactobacilli, and methenamine hippurate for prevention of UTIs was assessed.

RESULTS

There is evidence to support use of estrogens (A-I) in postmenopausal women, and cranberry capsules (C-I) in women ≥45 years of age for the prevention of UTIs. There was a lack of evidence to make recommendations for or against the use of ascorbic acid, cranberry juice, cranberry capsules with high proanthocyanidin (PAC) content, d-mannose, lactobacillus, and methenamine hippurate in this population.

CONCLUSIONS/IMPLICATIONS

Current studies support that estrogens and cranberry capsules may have a role in preventing UTIs in women ≥45 years of age. Further research is needed to elucidate the role of these nonantibiotic agents and how they may be used to decrease antibiotic use.

To check or not to check. Rectal ESBL colonization in hospitalized elderly patients

BACKGROUND

The worldwide spread of extended-spectrum-beta-lactamase (ESBL) producing bacteria has affected health care. ESBL confers resistance to the majority of beta-lactam antibiotics.

MATERIALS AND METHODS

We intended to quantify the rates of rectal ESBL-positive and negative patients that eventually developed fever and urinary tract infection (UTI). All rectal ESBL-positive patients were to be initially treated with the conventional antibiotics that have anti-ESBL activity (amikacin or ertapenem), while ESBL-negative patients were given ceftriaxone.

RESULTS

Most patients were rectal ESBL-positive (60.7%). Fever was in 51% patients; 67.8% of them developed signs and symptoms of UTI. Most patients with UTI were urinary ESBL-positive (79%), most rectal ESBL-negative patients were urinary ESBL-negative (75%), (χ² = 18.5, df = 1, P < .001). Overall mortality was higher in the febrile group (39, 34.8%) versus the afebrile (1, 0.9%) (χ² = 42, df = 1, P < .001). The mortality rate in the febrile group was significantly higher in the rectal ESBL-positive patients (χ2 = 7.5, df = 1, P = .006).

DISCUSSION

The direct correlation of rectal ESBL-positive and negative and respectively urinary ESBL-positive and negative patients' advocate for the use of antibiotics with anti-ESBL activity as an empiric treatment of rectal ESBL-positive patients with suspected UTI.

CONCLUSION

In our opinion, it is worthwhile to identify rectal ESBL-positivity on hospital admission.

Variation in antibiotic use among and within different settings: a systematic review

Objectives

Variation in antibiotic use may reflect inappropriate use. We aimed to systematically describe the variation in measures for antibiotic use among settings or providers. This study was conducted as part of the innovative medicines initiative (IMI)-funded international project DRIVE-AB.

Methods

We searched for studies published in MEDLINE from January 2004 to January 2015 reporting variation in measures for systemic antibiotic use (e.g. DDDs) in inpatient and outpatient settings. The ratio between a study's reported maximum and minimum values of a given measure [maximum:minimum ratio (MMR)] was calculated as a measure of variation. Similar measures were grouped into categories and when possible the overall median ratio and IQR were calculated.

Results

One hundred and forty-three studies were included, of which 85 (59.4%) were conducted in Europe and 12 (8.4%) in low- to middle-income countries. Most studies described the variation in the quantity of antibiotic use in the inpatient setting (81/143, 56.6%), especially among hospitals (41/81, 50.6%). The most frequent measure was DDDs with different denominators, reported in 23/81 (28.4%) inpatient studies and in 28/62 (45.2%) outpatient studies. For this measure, we found a median MMR of 3.7 (IQR 2.6-5.0) in 4 studies reporting antibiotic use in ICUs in DDDs/1000 patient-days and a median MMR of 2.3 (IQR 1.5-3.2) in 18 studies reporting outpatient antibiotic use in DDDs/1000 inhabitant-days. Substantial variation was also identified in other measures.

Conclusions

Our review confirms the large variation in antibiotic use even across similar settings and providers. Data from low- and middle-income countries are under-represented. Further studies should try to better elucidate reasons for the observed variation to facilitate interventions that reduce unwarranted practice variation. In addition, the heterogeneity of reported measures clearly shows that there is need for standardization.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set

Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

[Healthcare-associated infections and antimicrobial use in long term care facilities (HALT-2): German results of the second European prevalence survey]

Prevention of infections and strategies for the prudent use of antimicrobials in long-term care facilities have gained importance in view of the demographic changes, not only in Germany. To generate appropriate data and to identify relevant aspects of infection prevention in this field, the European Centre for Disease Prevention and Control (ECDC) launched the second point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities in 2013 (HALT-2). Despite methodical adjustments in the collection of data on healthcare-associated infections, in this second survey healthcare workers in the participating facilities were intensively trained in methodology and data collection. Overall, 221 German facilities participated and collected data from 17,208 residents. Well-established structures of regional networks facilitated the recruitment of participants as well as the preparations for training and survey. The median prevalence of residents receiving at least one antimicrobial agent was 1.1% (95 %-CI 0,7-1,6)), which is remarkably low. However, the most frequently used antimicrobials in German facilities beside beta-lactams (penicillins 18.2%, other beta-lactams 17.2%) were quinolones (28.2%). Data collection of infections was performed based on signs and symptoms in detailed decision algorithms according to the recently updated McGeer surveillance criteria and yielded a median prevalence of 1.7% (95 %-CI 1,1-2,2). Symptomatic urinary tract infections (28.4%), skin and soft tissue infection (27.9%), and respiratory tract infections (24.7%) were identified both as the most common types of infections and the most common indications for the use of systemic antimicrobials. Clinical implications evolve mainly from the high use of quinolones. In terms of infection prevention measures, compliance of health care workers with a hand hygiene regimen revealed further potential for improvement.

Prevention of infections in nursing homes: antibiotic prophylaxis versus infection control and antimicrobial stewardship measures

Because of the lack of structural and human resources for implementing more effective and safe preventive procedures, antimicrobial prophylaxis is often used to prevent infections in nursing homes. However, if data on the efficacy of antibiotic prophylaxis in nursing homes are null, there is a plenty of evidence that the inappropriate use of antimicrobials in this setting is associated with a high rate of colonization and infection with multi-drug-resistant organisms (MDROs), and of Clostridium difficile infection (CDI). Here, we have reviewed the infection epidemiology, the burden of MDROs and CDI, the antibiotic use and some potential infection preventive measures in nursing homes, pointing up the peculiarities of this setting and the absolute need of a more prudential use of antimicrobials.

Effectiveness of cranberry capsules to prevent urinary tract infections in vulnerable older persons: a double-blind randomized placebo-controlled trial in long-term care facilities

OBJECTIVES

To determine whether cranberry capsules prevent urinary tract infection (UTI) in long-term care facility (LTCF) residents.

DESIGN

Double-blind randomized placebo-controlled multicenter trial.

SETTING

Long-term care facilities (LTCFs).

PARTICIPANTS

LTCF residents (N = 928; 703 women, median age 84).

MEASUREMENTS

Cranberry and placebo capsules were taken twice daily for 12 months. Participants were stratified according to UTI risk (risk factors included long-term catheterization, diabetes mellitus, ≥ 1 UTI in preceding year). Main outcomes were incidence of UTI according to a clinical definition and a strict definition.

RESULTS

In participants with high UTI risk at baseline (n = 516), the incidence of clinically defined UTI was lower with cranberry capsules than with placebo (62.8 vs 84.8 per 100 person-years at risk, P = .04); the treatment effect was 0.74 (95% confidence interval (CI) = 0.57-0.97). For the strict definition, the treatment effect was 1.02 (95% CI = 0.68-1.55). No difference in UTI incidence between cranberry and placebo was found in participants with low UTI risk (n = 412).

CONCLUSION

In LTCF residents with high UTI risk at baseline, taking cranberry capsules twice daily reduces the incidence of clinically defined UTI, although it does not reduce the incidence of strictly defined UTI. No difference in incidence of UTI was found in residents with low UTI risk.

Different patterns in use of antibiotics for lower urinary tract infection in institutionalized and home-dwelling elderly: a register-based study

PURPOSE

We compared the quality and pattern of use of antibiotics to treat urinary tract infection (UTI) between institutionalized and home-dwelling elderly.

METHODS

We analyzed the quality of use of UTI antibiotics in Swedish people aged ≥ 65 years at 30 September 2008 (1,260,843 home-dwelling and 86,721 institutionalized elderly). Data regarding drug use, age and sex were retrieved from the Swedish Prescribed Drug Register and information about type of housing from the Social Services Register. In women, we assessed: (1) the proportion who use quinolones (should be as low as possible); (2) the proportion treated with the recommended drugs (pivmecillinam, nitrofurantoin, or trimethoprim) (proportions should be about 40 %, 40 % and 15-20 %, respectively); In men, we assessed: (1) the proportion who used quinolones or trimethoprim (should be as high as possible).

RESULTS

The 1-day point prevalence for antibiotic use for UTI was 1.6 % among institutionalized and 0.9 % among home-dwelling elderly. Of these, about 15 % of institutionalized and 19 % of home-dwelling women used quinolones. The proportion of women treated with the recommended drugs pivmecillinam, nitrofurantoin or trimethoprim was 29 %, 27 % and 45 % in institutions and 40 %, 28 % and 34 % for home-dwellers. In men treated with antibiotics for UTI, quinolones or trimethoprim were used by about 76 % in institutions and 85 % in home-dwellers.

CONCLUSIONS

Our results indicate that recommendations for UTI treatment with antibiotics are not adequately followed. The high use of trimethoprim amongst institutionalized women and the low use of quinolones or trimethoprim among institutionalized men need further investigation.