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Brierley RCM, Taylor J, Turner N, Rees S, Thorn J, Metcalfe C, Henderson EJ, Clement C, Welsh TJ, Sargent K, Morgan G, Ready D, Mellon D, Wen L, Kipping R, Hay AD. A pragmatic cluster randomised controlled trial of air filtration to prevent symptomatic winter respiratory infections (including COVID-19) in care homes (AFRI-c) in England: Trial protocol. PLoS One 2024; 19:e0304488. [PMID: 39042618 PMCID: PMC11265654 DOI: 10.1371/journal.pone.0304488] [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] [Received: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Respiratory tract infections are readily transmitted in care homes. Airborne transmission of pathogens causing respiratory tract illness is largely unmitigated. Portable high-efficiency-particulate-air (HEPA) filtration units capture microbial particles from the air, but it is unclear whether this is sufficient to reduce infections in care home residents. The Air Filtration to prevent symptomatic winter Respiratory Infections (including COVID-19) in care homes (AFRI-c) randomized controlled trial will determine whether using HEPA filtration units reduces respiratory infection episodes in care home residents. METHODS AFRI-c is a cluster randomized controlled trial that will be delivered in residential care homes for older people in England. Ninety-one care homes will be randomised to take part for one winter period. The intervention care homes will receive HEPA filtration units for use in communal areas and private bedrooms. Normal infection control measures will continue in all care homes. Anonymised daily data on symptoms will be collected for up to 30 residents. Ten to 12 of these residents will be invited to consent to a primary care medical notes review and (in intervention homes) to having an air filter switched on in their private room. The primary outcome will be number of symptomatic winter respiratory infection episodes. Secondary outcomes include specific clinical measures of infection, number of falls / near falls, number of laboratory confirmed infections, hospitalisations, staff sickness and cost-effectiveness. A mixed methods process evaluation will assess intervention acceptability and implementation. DISCUSSION The results of AFRI-c will provide vital information about whether portable HEPA filtration units reduce symptomatic winter respiratory infections in older care home residents. Findings about effectiveness, fidelity, acceptability and cost-effectiveness will support stakeholders to determine the use of HEPA filtration units as part of infection control policies.
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Affiliation(s)
- Rachel C. M. Brierley
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jodi Taylor
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nicholas Turner
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sophie Rees
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Joanna Thorn
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Chris Metcalfe
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Emily J. Henderson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Research Institute for the Care of Older People, Royal United Hospital, Bath, United Kingdom
| | - Clare Clement
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tomas J. Welsh
- Research Institute for the Care of Older People, Royal United Hospital, Bath, United Kingdom
| | - Karen Sargent
- Patient and Public Contributor, Bristol, United Kingdom
| | - Gemma Morgan
- South Gloucestershire Council, Yate, Gloucestershire, United Kingdom
| | - Derren Ready
- United Kingdom Health Security Agency (South West), Bristol, United Kingdom
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, Bristol, United Kingdom University of the West of England, Bristol, United Kingdom
| | - Dominic Mellon
- United Kingdom Health Security Agency (South West), Bristol, United Kingdom
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, Bristol, United Kingdom University of the West of England, Bristol, United Kingdom
- University of the West of England, Bristol, United Kingdom
| | - Liping Wen
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ruth Kipping
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Alastair D. Hay
- Centre of Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Sapula SA, Hart BJ, Siderius NL, Amsalu A, Blaikie JM, Venter H. Multidrug-resistant Stenotrophomonas maltophilia in residential aged care facilities: An emerging threat. Microbiologyopen 2024; 13:e1409. [PMID: 38682784 PMCID: PMC11057060 DOI: 10.1002/mbo3.1409] [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: 11/08/2023] [Revised: 03/20/2024] [Accepted: 04/16/2024] [Indexed: 05/01/2024] Open
Abstract
Stenotrophomonas maltophilia is a multidrug-resistant (MDR), Gram-negative bacterium intrinsically resistant to beta-lactams, including last-resort carbapenems. As an opportunistic pathogen, it can cause serious healthcare-related infections. This study assesses the prevalence, resistance profiles, and genetic diversity of S. maltophilia isolated from residential aged care facilities (RACFs). RACFs are known for their overuse and often inappropriate use of antibiotics, creating a strong selective environment that favors the development of bacterial resistance. The study was conducted on 73 S. maltophilia isolates recovered from wastewater and facility swab samples obtained from three RACFs and a retirement village. Phenotypic and genotypic assessments of the isolates revealed high carbapenem resistance, exemplifying their intrinsic beta-lactam resistance. Alarmingly, 49.3% (36/73) of the isolates were non-wild type for colistin, with minimum inhibitory concentration values of > 4 mg/L, and 11.0% (8/73) were resistant to trimethoprim-sulfamethoxazole. No resistance mechanisms were detected for either antimicrobial. Genotypic assessment of known lineages revealed isolates clustering with Sm17 and Sm18, lineages not previously reported in Australia, suggesting the potential ongoing spread of MDR S. maltophilia. Lastly, although only a few isolates were biocide tolerant (2.7%, 2/73), their ability to grow in high concentrations (64 mg/L) of triclosan is concerning, as it may be selecting for their survival and continued dissemination.
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Affiliation(s)
- Sylvia A. Sapula
- Health and Biomedical Innovation, UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Bradley J. Hart
- Health and Biomedical Innovation, UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Naomi L. Siderius
- Health and Biomedical Innovation, UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Anteneh Amsalu
- Health and Biomedical Innovation, UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- Department of Medical MicrobiologyUniversity of GondarGondarEthiopia
| | - Jack M. Blaikie
- Health and Biomedical Innovation, UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Henrietta Venter
- Health and Biomedical Innovation, UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
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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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Rui L, Lindbaek M, Gjelstad S. Preventive effect of methenamine in women with recurrent urinary tract infections - a case-control study. Scand J Prim Health Care 2022; 40:331-338. [PMID: 36369890 PMCID: PMC9848284 DOI: 10.1080/02813432.2022.2139363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Urinary tract infection (UTI) is the most common bacterial infection in women. In Norwegian general practice, methenamine has been prescribed for many years as long-term prevention and accounted for 20% of the total antibiotic prescribing in 2015, as measured in defined daily dosages (DDDs). The efficacy of methenamine is unknown. If shown to be effective, this drug may become an important preventive against UTI. OBJECTIVE To examine whether methenamine is preventive against recurrent UTI in women. DESIGN Data for all antibiotics used for UTIs dispensed from all pharmacies from 2005 to 2015 were collected from the Norwegian prescription database (NorPD). SUBJECTS Women aged ≥ 40 years with recurrent UTI, defined as ≥3 courses of UTI antibiotic/year, were included. MAIN OUTCOME MEASURES Patients using methenamine (cases) and those not using methenamine (controls) were compared. The numbers of UTI prescriptions during the 2 years before and after inclusion were analysed. Results: The yearly prevalence for recurrent UTI was 2.4% in women ≥ 40 years. The change in antibiotic use from 2 years before to 2 years after inclusion in the study differed significantly between groups: 44.6 and 34.9% reductions in the number of antibiotic prescriptions for UTI in the methenamine and control groups, respectively. The decrease in UTI antibiotic prescriptions (58.9%) was greater in patients with a higher consumption of antibiotics before starting methenamine. CONCLUSIONS Methenamine seems to be effective against recurrent UTI over the time span studied. The effect seems to be greater in patients with the highest number of recurrent UTIs. Key pointsMethenamine has been used for many years for prevention of recurrent UTI, but no studies have demonstrated a significant preventive effect of long time use.This study shows that methenamine seems to be effective for prevention in patients having recurrent UTI over 2 years or more.The effect seems to be larger in patients with a high number of UTIs over 2 years.
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Affiliation(s)
- Linda Rui
- Department of General Practice, Antibiotic Centre for Primary Care, Institute for Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbaek
- Department of General Practice, Antibiotic Centre for Primary Care, Institute for Health and Society, University of Oslo, Oslo, Norway
- CONTACT Morten Lindbaek Department of General Practice, Antibiotic Centre for Primary Care, Institute for Health and Society, University of Oslo, Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice, Antibiotic Centre for Primary Care, Institute for Health and Society, University of Oslo, Oslo, Norway
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5
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Azaizi H, Veimer Jensen ML, Scheel Rasmussen I, Jarloev JO, Nygaard Jensen J. Antibiotic prescribing among elderly living in long-term care facilities versus elderly living at home: a Danish registry-based study. Infect Dis (Lond) 2022; 54:651-655. [PMID: 35587537 DOI: 10.1080/23744235.2022.2076903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The objective of this study was to compare antibiotic prescription rates in Denmark among elderly living in long-term care facilities to elderly living at home, with regards to total antibiotic use and antibiotic use for urinary tract infection. METHODS This is an observational registry-based study. The study population included all elderly Danish residents aged ≥75 years in 2016. Linear regression models were used to examine the difference in antibiotic prescription rates between elderly living in long-term care facilities and elderly living at home. Results were adjusted for age, sex and comorbidity, the latter assessed via the Charlson Comorbidity Index. RESULTS The study population consisted of 416,627 elderly. Regression models showed that elderly living in long-term care facilities were prescribed 1.7 [CI 1.7-1.7] prescriptions/individual/year more than elderly living at home. For urinary tract infections the difference between elderly living in long-term care facilities and elderly living at home was 1.2 [CI 1.2-1.3] prescriptions/individual/year. CONCLUSIONS Elderly living in long-term care facilities have a higher antibiotic prescribing rate than elderly living at home, despite controlling for age, sex and comorbidity. This indicates that long-term care facilities continuously should be a focus for antibiotic stewardship interventions.
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Affiliation(s)
- Hadir Azaizi
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Maria Louise Veimer Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,University of Copenhagen, Faculty of Health and Medical Sciences, Section of General Practice, Copenhagen, Denmark
| | - Ida Scheel Rasmussen
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jens Otto Jarloev
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jette Nygaard Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Capital Region of Denmark, Committee for the Prevention of Hospital Infections, Copenhagen, Denmark
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Hartman EAR, Groen WG, Heltveit-Olsen SR, Lindbaek M, Hoye S, Sundvall PD, Gunnarsson R, Skoglund I, Snaebjörnsson Arnljots E, Godycki-Cwirko M, Kowalczyk A, Platteel TN, Zuithoff NPA, Monnier AA, Verheij TJM, Hertogh CMPM, van de Pol AC. Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial. BMJ Open 2021; 11:e052552. [PMID: 34620666 PMCID: PMC8499316 DOI: 10.1136/bmjopen-2021-052552] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Almost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting. METHODS AND ANALYSIS First, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents ≥70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021. ETHICS AND DISSEMINATION Ethical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03970356.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Silje Rebekka Heltveit-Olsen
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbaek
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Hoye
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Egill Snaebjörnsson Arnljots
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Maciej Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Raban MZ, Gates PJ, Gasparini C, Westbrook JI. Temporal and regional trends of antibiotic use in long-term aged care facilities across 39 countries, 1985-2019: Systematic review and meta-analysis. PLoS One 2021; 16:e0256501. [PMID: 34424939 PMCID: PMC8382177 DOI: 10.1371/journal.pone.0256501] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Antibiotic misuse is a key contributor to antimicrobial resistance and a concern in long-term aged care facilities (LTCFs). Our objectives were to: i) summarise key indicators of systemic antibiotic use and appropriateness of use, and ii) examine temporal and regional variations in antibiotic use, in LTCFs (PROSPERO registration CRD42018107125). METHODS & FINDINGS Medline and EMBASE were searched for studies published between 1990-2021 reporting antibiotic use rates in LTCFs. Random effects meta-analysis provided pooled estimates of antibiotic use rates (percentage of residents on an antibiotic on a single day [point prevalence] and over 12 months [period prevalence]; percentage of appropriate prescriptions). Meta-regression examined associations between antibiotic use, year of measurement and region. A total of 90 articles representing 78 studies from 39 countries with data between 1985-2019 were included. Pooled estimates of point prevalence and 12-month period prevalence were 5.2% (95% CI: 3.3-7.9; n = 523,171) and 62.0% (95% CI: 54.0-69.3; n = 946,127), respectively. Point prevalence varied significantly between regions (Q = 224.1, df = 7, p<0.001), and ranged from 2.4% (95% CI: 1.9-2.7) in Eastern Europe to 9.0% in the British Isles (95% CI: 7.6-10.5) and Northern Europe (95% CI: 7.7-10.5). Twelve-month period prevalence varied significantly between regions (Q = 15.1, df = 3, p = 0.002) and ranged from 53.9% (95% CI: 48.3-59.4) in the British Isles to 68.3% (95% CI: 63.6-72.7) in Australia. Meta-regression found no association between year of measurement and antibiotic use prevalence. The pooled estimate of the percentage of appropriate antibiotic prescriptions was 28.5% (95% CI: 10.3-58.0; n = 17,245) as assessed by the McGeer criteria. Year of measurement was associated with decreasing appropriateness of antibiotic use over time (OR:0.78, 95% CI: 0.67-0.91). The most frequently used antibiotic classes were penicillins (n = 44 studies), cephalosporins (n = 36), sulphonamides/trimethoprim (n = 31), and quinolones (n = 28). CONCLUSIONS Coordinated efforts focusing on LTCFs are required to address antibiotic misuse in LTCFs. Our analysis provides overall baseline and regional estimates for future monitoring of antibiotic use in LTCFs.
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Affiliation(s)
- Magdalena Z. Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Peter J. Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Claudia Gasparini
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I. Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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8
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Appaneal HJ, Shireman TI, Lopes VV, Mor V, Dosa DM, LaPlante KL, Caffrey AR. Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study. BMC Geriatr 2021; 21:436. [PMID: 34301192 PMCID: PMC8299613 DOI: 10.1186/s12877-021-02378-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA. .,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Vincent Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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9
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Granlund D, Zykova YV. Can Private Provision of Primary Care Contribute to the Spread of Antibiotic Resistance? A Study of Antibiotic Prescription in Sweden. PHARMACOECONOMICS - OPEN 2021; 5:187-195. [PMID: 33098069 PMCID: PMC8160061 DOI: 10.1007/s41669-020-00234-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Growing rates of antibiotic resistance, caused by increasing antibiotic use, pose a threat by making antibiotics less effective in treating infections. OBJECTIVE We aimed to study whether physicians working at privately and publicly owned health centres differed in the likelihood of prescribing antibiotics and choosing broad-spectrum over narrow-spectrum antibiotics. METHODS To estimate the effect of ownership on the probability of a prescribed drug being an antibiotic, we analysed all 4.5 million prescriptions issued from 2011 to 2015 at primary health centres in Västerbotten, Sweden. We controlled for patient age, sex, number of prescriptions per patient, and month of prescription, and used a maximum likelihood logit estimator. We then analysed how ownership affected the likelihood of a prescribed antibiotic being broad spectrum. We also used aggregated data to estimate the impact of the number of private health centres on the number of antibiotic prescriptions per inhabitant and the proportion of broad-spectrum antibiotics. RESULTS Holding other factors constant, private physicians were 6% more likely to prescribe antibiotics and 9% more likely to choose broad-spectrum antibiotics. An increase by one additional private health centre was positively associated with an increase in the number of antibiotic prescriptions per inhabitant and a higher proportion, although not significant, of broad-spectrum antibiotic prescriptions. CONCLUSION Our findings suggest that private physicians prescribe more antibiotics, especially broad-spectrum antibiotics, than public physicians. Therefore, it is crucial to provide health centres with incentives to follow guidelines for antibiotic prescription, especially when the level of private provision of primary healthcare is high.
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Affiliation(s)
| | - Yana V Zykova
- School of Business and Economics, The Arctic University of Norway (UiT), Tromsø, Norway.
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10
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Buehrle DJ, Clancy CJ, Decker BK. Suprapubic catheter placement improves antimicrobial stewardship among Veterans Affairs nursing care facility residents. Am J Infect Control 2020; 48:1264-1266. [PMID: 32063396 DOI: 10.1016/j.ajic.2020.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 11/20/2022]
Abstract
In a Veterans Affairs nursing facility, suprapubic catheters were associated with significantly fewer urinary tract infections (catheter-associated urinary tract infection) than were indwelling urinary catheters (mean: 0.95 vs 4.5/1,000 device-days, P = .05) among 18 patients with a history of both catheter types. Suprapubic catheters were associated with significantly shorter antibiotic treatment courses for catheter-associated urinary tract infection or asymptomatic bacteriuria (mean: 28.3 vs 88.8 days, P = .02).
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Affiliation(s)
- Deanna J Buehrle
- Division of Infectious Diseases, Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA.
| | - Cornelius J Clancy
- Division of Infectious Diseases, Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brooke K Decker
- Division of Infectious Diseases, Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA
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11
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Thornley T, Ashiru-Oredope D, Normington A, Beech E, Howard P. Antibiotic prescribing for residents in long-term-care facilities across the UK. J Antimicrob Chemother 2020; 74:1447-1451. [PMID: 30698718 PMCID: PMC6477989 DOI: 10.1093/jac/dkz008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/19/2018] [Accepted: 12/23/2018] [Indexed: 11/17/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is a major public health problem. Elderly residents in long-term-care facilities (LTCFs) are frequently prescribed antibiotics, particularly for urinary tract infections. Optimizing appropriate antibiotic use in this vulnerable population requires close collaboration between NHS healthcare providers and LTCF providers. Objectives Our aim was to identify and quantify antibiotic prescribing in elderly residents in UK LTCFs. This is part of a wider programme of work to understand opportunities for pharmacy teams in the community to support residents and carers. Methods This was a retrospective longitudinal cohort study. Data were extracted from a national pharmacy chain database of prescriptions dispensed for elderly residents in UK LTCFs over 12 months (November 2016–October 2017). Results Data were analysed for 341536 residents in LTCFs across the four UK nations, from which a total of 544796 antibiotic prescriptions were dispensed for 167002 residents. The proportion of residents prescribed at least one antibiotic over the 12 month period varied by LTCF, by month and by country. Conclusions Whilst national data sets on antibiotic prescribing are available for hospitals and primary care, this is the first report on antibiotic prescribing for LTCF residents across all four UK nations, and the largest reported data set in this setting. Half of LTCF residents were prescribed at least one antibiotic over the 12 months, suggesting that there is an opportunity to optimize antibiotic use in this vulnerable population to minimize the risk of AMR and treatment failure. Pharmacy teams are well placed to support prudent antibiotic prescribing and improved antimicrobial stewardship in this population.
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Affiliation(s)
- Tracey Thornley
- University of Nottingham, Nottingham, UK.,Boots UK Ltd, Thane Road, Nottingham, UK
| | - Diane Ashiru-Oredope
- Public Health England, London, UK.,University College London, Bloomsbury, London, UK
| | | | - Elizabeth Beech
- NHS Improvement, Wellington House, Waterloo Road, London, UK
| | - Philip Howard
- NHS Improvement, Wellington House, Waterloo Road, London, UK.,University of Leeds, Leeds, UK
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12
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Smith CM, Williams H, Jhass A, Patel S, Crayton E, Lorencatto F, Michie S, Hayward AC, Shallcross LJ. Antibiotic prescribing in UK care homes 2016-2017: retrospective cohort study of linked data. BMC Health Serv Res 2020; 20:555. [PMID: 32552886 PMCID: PMC7301534 DOI: 10.1186/s12913-020-05422-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older people living in care homes are particularly susceptible to infections and antibiotics are therefore used frequently for this population. However, there is limited information on antibiotic prescribing in this setting. This study aimed to investigate the frequency, patterns and risk factors for antibiotic prescribing in a large chain of UK care homes. METHODS Retrospective cohort study of administrative data from a large chain of UK care homes (resident and care home-level) linked to individual-level pharmacy data. Residents aged 65 years or older between 1 January 2016 and 31 December 2017 were included. Antibiotics were classified by type and as new or repeated prescriptions. Rates of antibiotic prescribing were calculated and modelled using multilevel negative binomial regression. RESULTS 13,487 residents of 135 homes were included. The median age was 85; 63% residents were female. 28,689 antibiotic prescriptions were dispensed, the majority were penicillins (11,327, 39%), sulfonamides and trimethoprim (5818, 20%), or other antibacterials (4665, 16%). 8433 (30%) were repeat prescriptions. The crude rate of antibiotic prescriptions was 2.68 per resident year (95% confidence interval (CI) 2.64-2.71). Increased antibiotic prescribing was associated with residents requiring more medical assistance (adjusted incidence rate ratio for nursing opposed to residential care 1.21, 95% CI 1.13-1.30). Prescribing rates varied widely by care home but there were no significant associations with the care home-level characteristics available in routine data. CONCLUSIONS Rates of antibiotic prescribing in care homes are high and there is substantial variation between homes. Further research is needed to understand the drivers of this variation to enable development of effective stewardship approaches that target the influences of prescribing.
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Affiliation(s)
- Catherine M Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK.
| | - Haydn Williams
- Four Seasons Health Care, Norcliffe House, Station Road, Wilmslow, Cheshire, SK9 1BU, UK
| | - Arnoupe Jhass
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK
| | - Selina Patel
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Elise Crayton
- Centre for Behaviour Change, University College London, WC1E 7HB, London, UK
| | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, WC1E 7HB, London, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, WC1E 7HB, London, UK
| | - Andrew C Hayward
- Institute of Epidemiology and Health Care, University College London, WC1E 7HB, London, UK
| | - Laura J Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
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13
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Smithson A, Ramos J, Niño E, Culla A, Pertierra U, Friscia M, Bastida MT. Characteristics of febrile urinary tract infections in older male adults. BMC Geriatr 2019; 19:334. [PMID: 31783801 PMCID: PMC6884897 DOI: 10.1186/s12877-019-1360-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/19/2019] [Indexed: 12/26/2022] Open
Abstract
Background Urinary tract infections (UTI) are among the most frequent bacterial infections in older adults. The aim of the study was to analyse the existence of differences in clinical features, microbiological data and risk of infection by multidrug-resistant organisms (MDRO) between older and non-older men with febrile UTI (FUTI). Methods This was an ambispective observational study involving older males with a FUTI attended in the Emergency Department. Variables collected included age, comorbidity, diagnostic of healthcare-associated (HCA)-FUTI, clinical manifestations, hospitalization, mortality, and microbiological data. Results Five hundred fifty-two males with a FUTI, 329 (59.6%) of whom were older adults, were included. Older males had a higher frequency of HCA-FUTI (p < 0.001), increased Charlson scores (p < 0.001), had received previous antimicrobial treatment more frequently (p < 0.001) and had less lower urinary tract symptoms (p < 0.001). Older patients showed a lower frequency of FUTI caused by E. coli (p < 0.001) and a higher rate of those due to Enterobacter spp. (p = 0.003) and P. aeruginosa (p = 0.033). Resistance rates to cefuroxime (p = 0.038), gentamicin (p = 0.043), and fluoroquinolones (p < 0.001) in E. coli isolates and the prevalence of extended-spectrum beta-lactamase and AmpC producing E. coli and Klebsiella spp. strains (p = 0.041) and MDRO (p < 0.001) were increased in older males. Inadequate empirical antimicrobial treatment (p = 0.004), frequency of hospitalization (p < 0.001), and all cause in-hospital mortality (p = 0.007) were higher among older patients. In the multivariate analysis, being admitted from an long term care facility (OR 2.4; 95% CI: 1.06–5.9), having a urinary tract abnormality (OR 2.2; 95% CI: 1.2–3.8) and previous antimicrobial treatment (OR 3.2; 95% CI: 1.9–5.4) were associated to FUTI caused by MDRO. Conclusions Older male adults with a FUTI have different clinical characteristics, present specific microbiological features, and antimicrobial resistance rates. In the multivariate analysis being an older male was not associated with an increased risk of FUTI caused by MDRO.
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Affiliation(s)
- Alex Smithson
- Infectious Diseases Unit, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain.
| | - Javier Ramos
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Esther Niño
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Alex Culla
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Ubaldo Pertierra
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Michele Friscia
- Internal Medicine Department, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
| | - Maria Teresa Bastida
- Microbiology Laboratory, Fundació Hospital de l'Esperit Sant, C/Avinguda Mossen Pons i Rabadà s/n, 08923, Santa Coloma Gramenet, Spain
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14
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Thornley T, Ashiru-Oredope D, Beech E, Howard P, Kirkdale CL, Elliott H, Harris C, Roberts A. Antimicrobial use in UK long-term care facilities: results of a point prevalence survey. J Antimicrob Chemother 2019; 74:2083-2090. [PMID: 30993326 PMCID: PMC6587415 DOI: 10.1093/jac/dkz135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/28/2019] [Accepted: 03/06/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The majority of people in long-term care facilities (LTCFs) are aged 65 years and older, and most of their care needs are provided by the LTCF staff. Provision of healthcare services for residents in LTCFs is variable and can result in disjointed care between carers and NHS healthcare professionals. OBJECTIVES Our aim was to understand the use of antibiotics in LTCFs across the UK and to identify potential gaps in knowledge and support for carers and residents when using antibiotics, in order to determine how community pharmacy teams can provide additional support. METHODS A point prevalence survey (PPS) was conducted by community pharmacists (n = 57) when they carried out visits to LTCFs across the UK between 13 November and 12 December 2017. Anonymized data were recorded electronically by the individual pharmacists. RESULTS Data were analysed for 17909 residents in 644 LTCFs across the UK. The mean proportion of residents on antibiotics on the day of the visit was as follows: 6.3% England (536 LTCFs), 7.6% Northern Ireland (35 LTCFs), 8.6% Wales (10 LTCFs) and 9.6% Scotland (63 LTCFs). The percentage of antibiotics prescribed for prophylactic use was 25.3%. Antibiotic-related training was reported as being available for staff in 6.8% of LTCFs and 7.1% of LTCFs reported use of a catheter passport scheme. Pharmacists conducting the PPS intervened during the survey for 9.5% of antibiotic prescription events; 53.4% of interventions were for clinical reasons and 32.2% were for administration reasons. CONCLUSIONS This survey identified high prophylactic use of antibiotics. There are opportunities for community pharmacy teams to improve antimicrobial stewardship in LTCF settings, including workforce education.
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Affiliation(s)
- Tracey Thornley
- University of Nottingham, Nottingham, UK
- Boots UK Ltd, Thane Road, Nottingham, UK
| | - Diane Ashiru-Oredope
- Public Health England, London, UK
- University College London, Bloomsbury, London, UK
| | - Elizabeth Beech
- NHS Improvement, Wellington House, Waterloo Road, London, UK
| | - Philip Howard
- NHS Improvement, Wellington House, Waterloo Road, London, UK
- University of Leeds, Leeds, UK
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15
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Nguyen HQ, Tunney MM, Hughes CM. Interventions to Improve Antimicrobial Stewardship for Older People in Care Homes: A Systematic Review. Drugs Aging 2019; 36:355-369. [PMID: 30675682 DOI: 10.1007/s40266-019-00637-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inappropriate antimicrobial prescribing has been reported in care homes. This may result in serious drug-related adverse events, Clostridium difficile colonization, and the development of antimicrobial resistance among care home residents. Interventions to improve antibiotic prescribing in nursing homes have been reported through clinical trials, but whether antifungal and antiviral prescribing and residential homes have been considered, or how outcomes were measured and reported in such interventions, remains unclear. OBJECTIVES Our aims were to evaluate the effect of interventions to improve antimicrobial stewardship in care homes and to report the outcomes used in these trials. METHODS We searched 11 electronic databases and five trial registries for studies published until 30 November 2018. Inclusion criteria for the review were randomized controlled trials, targeting care home residents and healthcare professionals, providing interventions to improve antimicrobial prescribing compared with usual care or other interventions. The Cochrane tools for assessing risk of bias were used for quality assessment. A narrative approach was taken because of heterogeneity across the studies. RESULTS Five studies met the inclusion criteria. The studies varied in terms of types of infection, key targets, delivery of interventions, and reported outcomes. In total, 27 outcomes were reported across the studies, with seven not prespecified in the methods. The interventions had little impact on adherence to guidelines and prevalence of antimicrobial prescribing; they appeared to decrease total antimicrobial consumption but were unlikely to have affected overall hospital admissions and mortality. The overall quality of evidence was low because the risk of bias was high across the studies. CONCLUSION The interventions had limited effect on improving antimicrobial prescribing but did not appear to cause harm to care home residents. The low quality of evidence and heterogeneity in outcome measurement suggest the need for future well-designed studies and the development of a core outcome set to best evaluate the effectiveness of antimicrobial stewardship in care homes.
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Affiliation(s)
- Hoa Q Nguyen
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Michael M Tunney
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Carmel M Hughes
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
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16
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Perceptions of Antibiotic Therapy Among Nursing Home Residents: Perspectives of Caregivers and Residents in a Mixed Exploratory Study. Antibiotics (Basel) 2019; 8:antibiotics8020066. [PMID: 31137842 PMCID: PMC6627220 DOI: 10.3390/antibiotics8020066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 12/17/2022] Open
Abstract
Antimicrobial resistance is a major public health threat worldwide. Some authors have suggested that end-users of nursing homes have an influence on antibiotic prescribing. The objective of this study is to describe the views of end-users and professionals on residents' behavior towards antibiotic therapy in terms of knowledge, beliefs, and attitudes towards this drug class and its prescribing process. This is a concurrent mixed methodology study using questionnaires and semi-directive individual interviews with nursing homes residents, nurses, and doctors practicing in these facilities. The questionnaires analyzed were collected from 35 residents (24.3%) and 109 nurses (75.7%). The qualitative interview involved 26 of total participants that agreed to be interviewed. We noticed misconceptions being held by the residents regarding the antibiotic resistance phenomenon. Additionally, nurses were not considered as a source of information about antibiotics. Nurses and residents had conflicting opinions about residents requesting antibiotics, and the findings depict a stereotypical view of the nurse profession as a reflection of a cognitive representation. The authors conclude that, despite many campaigns, further efforts are needed to tackle antimicrobial resistance. Initiatives could include raising awareness about antimicrobial resistance, clarifying the role of nurses, and communicating well with residents about their needs in nursing homes.
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17
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Haaijman J, Stobberingh EE, van Buul LW, Hertogh CMPM, Horninge H. Urine cultures in a long-term care facility (LTCF): time for improvement. BMC Geriatr 2018; 18:221. [PMID: 30236062 PMCID: PMC6149184 DOI: 10.1186/s12877-018-0909-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/05/2018] [Indexed: 01/02/2023] Open
Abstract
Background Urinary tract infections (UTIs) are the most prevalent infections in long-term care facilities (LTCFs). Numerous studies have described the problem of inadequate UTI diagnosis and treatment. We assessed the role of urine cultures in the diagnosis and treatment of UTIs in a LTCF. Methods In a 370-bed non-academic LTCF a retrospective assessment of antibiotic (AB) prescriptions for UTIs and urine cultures was performed from July 2014 to January 2016. The reasons why physicians, including 11 nursing home physicians and 2 junior doctors, ordered urine cultures were recorded using questionnaires. Results During the study period, 378 residents were prescribed 1672 AB courses; 803 were for UTIs. One hundred and fifty-five urine cultures were obtained from 135 residents; 66 of these cultures were performed on the same day as ABs were prescribed (8% of all prescriptions for UTI), while 89 were not. There was a discrepancy between the actions that seemed logical based on the culture results and the actions that were actually taken in 75% of the cases. In these cases, initial AB treatment was not adjusted when the isolated microorganism was resistant to the AB prescribed, the urine culture was positive and no ABs had previously been administered, or ABs were prescribed and no microorganism was isolated. The most frequent reason for ordering a urine culture was to confirm the diagnosis of a UTI. Conclusion In the majority of patients, AB therapy was not adjusted when the urine culture results suggested it may be appropriate. The physicians were erroneously convinced that UTIs could be diagnosed by a positive urine culture. Electronic supplementary material The online version of this article (10.1186/s12877-018-0909-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Haaijman
- River Region Elderly Care Centers (SZR), Burgemeester Meslaan 49, 4003CA, Tiel, The Netherlands.
| | - E E Stobberingh
- Faculty of Health, Medicine and Life sciences, Department of Medical Microbiology, Maastricht University Medical Center (MUMC), School of Public Health and Primary Care (CAPHRI), Maastricht, The Netherlands
| | - L W van Buul
- Amsterdam Public Health Research institute and Department of General Practice & Old Age Medicine, VU University Medical Center, 1081, BT, Amsterdam, The Netherlands
| | - C M P M Hertogh
- Amsterdam Public Health Research institute and Department of General Practice & Old Age Medicine, VU University Medical Center, 1081, BT, Amsterdam, The Netherlands
| | - H Horninge
- River Region Elderly Care Centers (SZR), Burgemeester Meslaan 49, 4003CA, Tiel, The Netherlands
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18
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Falcone M, Paul M, Yahav D, Orlando G, Tiseo G, Prendki V, Güerri-Fernández R, Gavazzi G, Mutters NT, Cookson B, Tinelli Marco M. Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities. Clin Microbiol Infect 2018; 25:562-569. [PMID: 30076978 DOI: 10.1016/j.cmi.2018.07.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/13/2018] [Accepted: 07/19/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting. OBJECTIVES This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting. SOURCE PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively. CONTENT Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions. IMPLICATIONS There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.
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Affiliation(s)
- M Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - M Paul
- Infectious Diseases Institute, Rambam Health Care Campus, The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - D Yahav
- Infectious Diseases Unit, Rabin Medical Centre, Beilinson Hospital, Petah-Tikva, Israel
| | - G Orlando
- Clinic of Infectious Diseases, University Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - G Tiseo
- Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Rome, Italy
| | - V Prendki
- Internal Medicine and Rehabilitation Unit, Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - R Güerri-Fernández
- Infectious Diseases, Hospital Del Mar Medical Research Institute, Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - G Gavazzi
- University of Grenoble-Alpes and Clinic of Geriatrics, University Hospital of Grenoble-Alpes, Grenoble, France
| | - N T Mutters
- Institute for Infection Prevention and Hospital Epidemiology, Medical Centre - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - B Cookson
- Division of Infection and Immunity, University College London, Gower Street, London, WCl E 68T, UK
| | - M Tinelli Marco
- Long Term Care Facility "Pio Albergo Trivulzio", Milan, Italy
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19
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Babich T, Zusman O, Elbaz M, Ben-Zvi H, Paul M, Leibovici L, Avni T. Empirical Antibiotic Treatment Does Not Improve Outcomes in Catheter-Associated Urinary Tract Infection: Prospective Cohort Study. Clin Infect Dis 2018; 65:1799-1805. [PMID: 29020203 DOI: 10.1093/cid/cix680] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 07/30/2017] [Indexed: 01/19/2023] Open
Abstract
Background Catheter associated urinary tract infection (CAUTI) is the most common healthcare-associated acquired infection. We aimed to describe the short- and long-term survival of patients with CAUTI and the impact of the empirical antibiotic treatment on survival rates. Methods In this prospective observational study we included consecutive adult patients with a chronic indwelling catheter-associated UTI and sepsis hospitalized in medical departments. The primary outcomes were 30-days all-cause mortality and long-term survival at end of the follow-up. A multivariate analysis using logistic regression and Cox proportional hazard model was performed to identify independent risk factors for an adverse outcome. A propensity-score model for receiving appropriate empirical antibiotic therapy was constructed and used to match patients. Results Overall, 315 consecutive patients with CAUTI were enrolled. The cohort consisted of elderly to very old patients (mean age 79.2 ± 11.5). The crude 30-day all-cause mortality rate was 30.8% (97/315). The median survival time was 82 days (interquartile range [IQR] 22-638). Appropriate early empirical treatment had no statistically significant association with 30-day mortality, propensity score-matched odds ratio (OR) 1.39 (0.76-2.55). Similarly, in the propensity-matched cohort, appropriate empirical treatment was not statistically associated with long-term survival (hazard ratio [HR] = 0.99, 95% confidence interval [CI] 0.75-1.3). Conclusions In our setting, patients with CAUTI had poor short- and long-term prognosis regardless of appropriate empirical antibiotic treatment. Avoiding empirical antibiotics for CAUTI might be an important antibiotic stewardship intervention in hospitals.
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Affiliation(s)
- Tanya Babich
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University
| | - Oren Zusman
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University
| | - Michal Elbaz
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University
| | - Haim Ben-Zvi
- Microbiology Lab, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University
| | - Tomer Avni
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University
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Murphy C. Innovating urinary catheter design: An introduction to the engineering challenge. Proc Inst Mech Eng H 2018; 233:48-57. [PMID: 29792114 DOI: 10.1177/0954411918774348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Every day, people around the world rely on intermittent and indwelling urinary catheters to manage bladder dysfunction, but the potential or actual harm caused by these devices is well-recognised. Current catheter designs can cause urinary tract infection and septicaemia, bladder and urethral trauma and indwelling devices frequently become blocked. Furthermore, the devices can severely disrupt users' lives, limiting their daily activities and can be costly to manage for healthcare providers. Despite this, little significant design innovation has taken place in the last 80 years. In this article current catheter designs and their limitations are reviewed, common catheter-associated problems are outlined and areas of design ripe for improvement proposed. The potential to relieve the individual and economic burden of catheter use is high.
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Affiliation(s)
- Cathy Murphy
- Clinical Academic Facility, Faculty of Health Sciences, University of Southampton, Southampton, UK
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21
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Lodeta B, Lovrinic D, Lodeta M, Zavidic T, Baric H. Use of Urinary Collection Devices in Community and Nursing Homes in Istria County. Urol Int 2018; 100:333-338. [PMID: 29502119 DOI: 10.1159/000486900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/17/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study is aimed at assessing the use of various types of urinary catheters, appropriateness of catheter placement and factors associated with antibiotic use in a population of chronically catheterized patients in Istria County. MATERIALS AND METHODS This cross-sectional study, conducted between March and June 2017 in Istria County, Croatia, was initiated through a network of general family medicine offices. Data were collected from general practitioners (GPs) and from medical managers in nursing homes. Participants were asked to review medical records of their patients and to complete a 10-item questionnaire designed to retrieve information on patients with urinary catheter. RESULTS All GPs in the county were surveyed. We identified 309 patients with urinary catheter: 216 men (70%) and 93 women (30%). The overall prevalence of individuals with urinary catheters was 0.18%: 4.7% in nursing home population and 0.1% among non-institutionalized adult population. Most common indication for catheterization was chronic urinary retention (52%). One hundred eighty-six patients (60.4%) reported antibiotic usage in the previous 3 months for treating urinary infection. CONCLUSIONS In Istria County, the prevalence of indwelling urinary catheters is highest in males, especially among patients in nursing homes. There is a need for focused education among GPs regarding urinary catheter maintenance and antibiotic prescription for suspected urinary tract infections.
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Affiliation(s)
- Branimir Lodeta
- Department of Urology, Klinikum Klagenfurt, Klagenfurt am Wörthersee, Austria
| | | | - Maja Lodeta
- Special Hospital for Medical Rehabilitation, Varazdinske Toplice, Croatia
| | | | - Hrvoje Baric
- Department of Neurosurgery, University Hospital Centre Zagreb, Zagreb, Croatia
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22
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Secular trends in the appropriateness of empirical antibiotic treatment in patients with bacteremia: a comparison between three prospective cohorts. Eur J Clin Microbiol Infect Dis 2018; 37:455-462. [PMID: 29353378 DOI: 10.1007/s10096-018-3190-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
The objective of this study was to explore whether the percentage of inappropriate empirical antibiotic treatment in patients with bacteremia changed over time and to understand the factors that brought on the change. Three prospective cohorts of patients with bacteremia in three different periods (January 1st, 1988 to December 31st, 1989; May 1st, 2004 to November 30, 2004; May 1st, 2010 to April 30, 2011) were compared. Analysis was performed on a total of 811 patients. In 2010-2011, 55.9% (76/136) of patients with bacteremia received inappropriate empirical treatment, compared with 34.5% (170/493) and 33.5% (55/164) in the first and second periods, respectively, in a significant upward trend (p = 0.001). Resistance to antibiotics increased significantly during the study period. The following variables were included in the multivariate analysis assessing risk factors for inappropriate empirical treatment: study period (third period) [odds ratio, OR = 2.766 (95% confidence interval, CI, 1.655-4.625)], gender (male) [OR = 1.511 (1.014-2.253)], pathogen carrying extended-spectrum beta-lactamases [OR = 10.426 (4.688-23.187)], multidrug-resistant Acinetobacter baumannii [OR = 5.428 (2.181-13.513)], and skin/soft infections [OR = 3.23 (1.148-9.084)]. A model excluding microbiological data included: gender (male) [OR = 1.648 (1.216-2.234)], study period (third period) [OR = 2.446 (1.653-3.620)], hospital-acquired infection [OR = 1.551 (1.060-2.270)], previous use of antibiotics [OR = 1.815 (1.247-2.642)], bedridden patient [OR = 2.019 (1.114-3.658)], and diabetes mellitus [OR = 1.620 (1.154-2.274)]. We have observed a worrisome increase in the rate of inappropriate empirical treatment of bacteremia. We need tools that will allow us better prediction of the pathogen and its susceptibilities during the first hours of managing a patient suspected of a severe bacterial infection.
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23
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Rosello A, Hayward AC, Hopkins S, Horner C, Ironmonger D, Hawkey PM, Deeny SR. Impact of long-term care facility residence on the antibiotic resistance of urinary tract Escherichia coli and Klebsiella. J Antimicrob Chemother 2017; 72:1184-1192. [PMID: 28077671 DOI: 10.1093/jac/dkw555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 11/24/2016] [Indexed: 11/14/2022] Open
Abstract
Background Long-term care facilities (LTCFs) are thought to be important reservoirs of antimicrobial-resistant (AMR) bacteria; however, there is no routine surveillance of resistance in LTCF residents, or large population-based studies comparing AMR in LTCFs with the community, so the relative burden of AMR in LTCFs remains unknown. Objectives To compare the frequency of antibiotic resistance of urinary tract bacteria from residents of LTCFs for the elderly and adults aged 70 years or older living in the community. Methods Positive urine specimens reported to any diagnostic microbiology laboratory in the West Midlands region (England) from 1 April 2010 to 31 March 2014 collected from individuals aged 70 years or older were analysed. The resistance of Escherichia coli and Klebsiella to trimethoprim, nitrofurantoin, third-generation cephalosporins and ciprofloxacin and the rate of laboratory-confirmed E. coli and Klebsiella urinary tract infection (UTI) were assessed in LTCF residents and in the community. Results LTCF residents had a laboratory-confirmed E. coli and Klebsiella UTI rate of 21 per 100 person years compared with 8 per 100 person years in the elderly living in the community [rate ratio (RR)=2.66, 95% CI = 2.58-2.73] and a higher rate of developing E. coli and Klebsiella UTIs caused by bacteria resistant to trimethoprim (RR = 4.41, 95% CI = 4.25-4.57), nitrofurantoin (RR = 4.38, 95% CI = 3.98-4.83), ciprofloxacin (RR = 5.18, 95% CI = 4.82-5.57) and third-generation cephalosporins (RR = 4.49, 95% CI = 4.08-4.94). Conclusions Residents of LTCFs for the elderly had more than double the rate of E. coli and Klebsiella UTI and more than four times the rate of E. coli and Klebsiella UTI caused by antibiotic-resistant bacteria compared with those living in the community.
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Affiliation(s)
- Alicia Rosello
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK.,Institute of Health Informatics, Farr Institute of Health Informatics Research, UCL, London NW1 2DA, UK
| | - Andrew C Hayward
- Institute of Health Informatics, Farr Institute of Health Informatics Research, UCL, London NW1 2DA, UK
| | - Susan Hopkins
- Department of Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London NW3 2QG, UK.,Healthcare Associated Infections Surveillance, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Carolyne Horner
- Regional Laboratory Leeds, Public Health England, Leeds LS1 3EX, UK
| | - Dean Ironmonger
- Field Epidemiology Service, Public Health England, Birmingham B3 2PW, UK
| | - Peter M Hawkey
- Institute of Microbiology & Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Public Health England Public Health Laboratory, Heart of England NHS Foundation Trust, Birmingham B9 5SS, UK
| | - Sarah R Deeny
- Data analytics, The Health Foundation, London WC2E 9RA, UK.,Modelling and Economics Unit, National Infection Service, Public Health England and Health Protection Research Unit in Modelling Methodology, London NW9 5EQ, UK
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24
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Nyborg G, Brekke M, Straand J, Gjelstad S, Romøren M. Potentially inappropriate medication use in nursing homes: an observational study using the NORGEP-NH criteria. BMC Geriatr 2017; 17:220. [PMID: 28927372 PMCID: PMC5606129 DOI: 10.1186/s12877-017-0608-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/06/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Frail residents in the nursing home sector call for extra care in prescribing. The Norwegian General Practice Nursing Home (NORGEP-NH) list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed explicitly for this population. The aim of this study was to employ the NORGEP-NH Criteria to study the extent of potentially inappropriate medication use among nursing home residents and explore possible associated factors. METHODS Cross-sectional observational pharmacoepidemiological study from residents in nursing homes in the county of Vestfold, Norway. Data collected 2009-11 included residents' demographic and clinical status and all medications, regular and on demand. RESULTS 881 patients from 30 institutions (mean 85.9 years, 68.6% female), were included. According to NORGEP-NH, 43.8% were prescribed at least one potentially inappropriate regular medication, and 9.9% regularly received three or more potentially inappropriate medications. When also including a) the NORGEP-NH Deprescribing Criteria and b) including drugs prescribed for use as needed, 92.7% of all residents received medication that needs particular surveillance according to the NORGEP-NH. 69.7% of the nursing home residents used at least one psychotropic drug regularly. Female residents received more often than males at least one potentially inappropriate regular medication (OR 1.60, p=0.007). Regarding the prescription of three or more concomitant psychotropic medications, odds ratio for females was 1.79 (p=0.03) compared to males. Residents with the best performance in activities of daily living, and residents residing in long-term wards, had higher risk of using three or more psychotropic drugs. Use of multiple psychoactive drugs increased the risk of falls in the course of an acute episode of infection or dehydration (odds ratio 1.70, p=0.009). CONCLUSIONS Prevalence of potentially inappropriate medications in nursing homes according to the NORGEP-NH was extensive, and especially the use of multiple psychotropic drugs. The high prevalence found in this study shows that there is a need for higher awareness of medication use and side effects in the elderly population. TRIAL REGISTRATION Retrospectively registered. Data obtained from clinical trial NCT01023763 registered with ClinicalTrials.gov 12/01/2009.
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Affiliation(s)
- Gunhild Nyborg
- Department of General Practice/Family Medicine, HELSAM, Institute of Health and Society, University of Oslo, P.o. Box 1130 Blindern, 0318 Oslo, Norway
| | - Mette Brekke
- Department of General Practice/Family Medicine, HELSAM, Institute of Health and Society, University of Oslo, P.o. Box 1130 Blindern, 0318 Oslo, Norway
| | - Jørund Straand
- Department of General Practice/Family Medicine, HELSAM, Institute of Health and Society, University of Oslo, P.o. Box 1130 Blindern, 0318 Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice/Family Medicine, HELSAM, Institute of Health and Society, University of Oslo, P.o. Box 1130 Blindern, 0318 Oslo, Norway
| | - Maria Romøren
- Department of General Practice/Family Medicine, HELSAM, Institute of Health and Society, University of Oslo, P.o. Box 1130 Blindern, 0318 Oslo, Norway
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25
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Kolšek-šušteršič M, Beg Krasnič A, Mioč V, Paragi M, Rifel J. Nasopharyngeal Carriage of Streptococcus Pneumoniae and Serotypes Indentified among Nursing Home Residents in Comparison to the Elderly and Patients Younger than 65 Years Living in Domestic Environment. Zdr Varst 2017; 56:172-178. [PMID: 28713446 PMCID: PMC5504543 DOI: 10.1515/sjph-2017-0023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/23/2017] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In Slovenia, there is little data available on pneumococcal vaccination rates and no data on asymptomatic NPCR and serotypes in the population of nursing home residents in comparison to the elderly living in domestic environment, therefore the goal was to gain these data. METHODS A cross sectional epidemiological study was performed. Nasopharyngeal swabs from 151 nursing home residents, 150 elderly living in domestic environment, and 38 adults less than 65 years old were collected twice (in two consecutive years). The swabs were analysed for pneumococcal identification and serotyping. Patient data were collected from medical files and medical history. RESULTS No statistically significant differences in NPCR were seen between compared groups in two consecutive years. An average NPCR in two consecutive years in nursing home residents was 1.45%, in the elderly living in domestic environment 0.85%, and in adults less than 65 years old 7.05%. Serotypes identified among nursing home residents were 6B and 9N, among the group of elderly living in domestic environment, 6A and among adults less than 65 years old, 35F, 18C and 3. Pneumococcal vaccination rates were low (3.3% in nursing home residents, 6% in the elderly from domestic environment and 0% in the group of adults less than 65 years old). CONCLUSIONS Our data suggests that NPCR and the proportion of people vaccinated with pneumococcal vaccine among the elderly are low. We identified different serotypes in all groups, only one person was a chronic carrier (serotype 35F).
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Affiliation(s)
| | | | - Verica Mioč
- National Laboratory of Health, Environment and Food, Centre for Medical Microbiology, Department for Public Health Microbiology, Grablovičeva 44, 1000Ljubljana, Slovenia
| | - Metka Paragi
- National Laboratory of Health, Environment and Food, Centre for Medical Microbiology, Department for Public Health Microbiology, Grablovičeva 44, 1000Ljubljana, Slovenia
| | - Janez Rifel
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000Ljubljana, Slovenia
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Johnson M, Hounkpatin H, Fraser S, Culliford D, Uniacke M, Roderick P. Using a linked database for epidemiology across the primary and secondary care divide: acute kidney injury. BMC Med Inform Decis Mak 2017; 17:106. [PMID: 28693548 PMCID: PMC5504785 DOI: 10.1186/s12911-017-0503-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 06/30/2017] [Indexed: 01/16/2023] Open
Abstract
Background NHS England has mandated the use in hospital laboratories of an automated early warning algorithm to create a consistent method for the detection of acute kidney injury (AKI). It generates an ‘alert’ based on changes in serum creatinine level to notify attending clinicians of a possible incident case of the condition, and to provide an assessment of its severity. We aimed to explore the feasibility of secondary data analysis to reproduce the algorithm outside of the hospital laboratory, and to describe the epidemiology of AKI across primary and secondary care within a region. Methods Using the Hampshire Health Record Analytical database, a patient-anonymised database linking primary care, secondary care and hospital laboratory data, we applied the algorithm to one year (1st January-31st December 2014) of retrospective longitudinal data. We developed database queries to modularise the collection of data from various sectors of the local health system, recreate the functions of the algorithm and undertake data cleaning. Results Of a regional population of 642,337 patients, 176,113 (27.4%) had two or more serum creatinine test results available, with testing more common amongst older age groups. We identified 5361 (or 0.8%) with incident AKI indicated by the algorithm, generating a total of 13,845 individual AKI alerts. A cross-sectional assessment of each patient’s first alert found that more than two-thirds of cases originated in the community, of which nearly half did not lead to a hospital admission. Conclusion It is possible to reproduce the algorithm using linked primary care, secondary care and hospital laboratory data, although data completeness, data quality and technical issues must be overcome. Linked data is essential to follow the significant proportion of people with AKI who transition from primary to secondary care, and can be used to assess clinical outcomes and the impact of interventions across the health system. This study emphasises that the development of data systems bridging across different sectors of the health and social care system can provide benefits for researchers, clinicians, healthcare providers and commissioners. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0503-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Johnson
- NIHR CLAHRC Wessex Methodological Hub, Faculty of Health Sciences, University of Southampton, Southampton, UK.
| | - H Hounkpatin
- NIHR CLAHRC Wessex, Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - S Fraser
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - D Culliford
- NIHR CLAHRC Wessex Methodological Hub, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - M Uniacke
- Wessex Kidney Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - P Roderick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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27
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Pärn T, Mäkelä M, Lyytikäinen O. Urinary tract infections and antimicrobial use among Finnish home care clients, April-September 2014. Am J Infect Control 2016; 44:1390-1392. [PMID: 27311509 DOI: 10.1016/j.ajic.2016.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 04/30/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
The 30-day prevalence of urinary tract infection (UTI) among Finnish home care clients (N = 6,887) estimated by the Resident Assessment Instrument was 4.5%, and 5.9% of the clients received antimicrobial agents, most commonly for UTI prophylaxis. Urinary catheter and female gender were the strongest factors independently associated with antimicrobial use and UTI. The Resident Assessment Instrument provides data that could be used when training home care providers and primary health care workers in the appropriate use of antimicrobial agents and UTI prevention.
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Affiliation(s)
- Triin Pärn
- Department of Infectious Diseases, National Institute for Health and Welfare, Helsinki, Finland; European Programme for Intervention Epidemiology Training, Stockholm, Sweden.
| | - Matti Mäkelä
- Department of Welfare, National Institute for Health and Welfare, Helsinki, Finland
| | - Outi Lyytikäinen
- Department of Infectious Diseases, National Institute for Health and Welfare, Helsinki, Finland
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28
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Trubiano JA, Pai Mangalore R, Baey YW, Le D, Graudins LV, Charles PGP, Johnson DF, Aung AK. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204:273. [PMID: 27078602 DOI: 10.5694/mja15.01329] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the nature, prevalence and description accuracy of recorded antibiotic allergy labels (AALs) in a cohort of general medical inpatients, and to assess the feasibility of an oral antibiotic re-challenge study. DESIGN Multicentre cross-sectional study. SETTING AND PARTICIPANTS All patients admitted to the general medical units of Austin Health and Alfred Health, 18 May - 5 June 2015. MAIN OUTCOME MEASURES Baseline demographics, medical and allergy history, infection diagnoses and antibiotic prescribing data for general medical inpatients were collected. A questionnaire was administered to clarify AAL history, followed by correlation of responses with electronic and admissions record descriptions. A hypothetical oral re-challenge in a supervised setting was offered to patients with low risk allergy phenotypes (non-immediate reaction, non-severe cutaneous adverse reaction, or unknown reaction more than 10 years ago). RESULTS Of the 453 inpatients, 107 (24%) had an AAL (median age, 82 years; interquartile range, 74-87 years); 160 individual AALs were recorded, and there was a mismatch in AAL description between recording platforms in 25% of cases. Most patients with an AAL were women (64%; P < 0.001), and more presented with concurrent immunosuppression than those without an AAL (23% v 8%; P < 0.001). β-Lactam penicillins were employed less frequently in patients with an AAL (16% v 35%; P = 0.02), while ceftriaxone (32% v 20%; P = 0.02) and fluoroquinolones (6% v 2%; P = 0.04) were used more often. Fifty-four per cent of patients with AALs were willing to undergo oral re-challenge, of whom 48% had a low risk allergy phenotype. CONCLUSIONS AAL prevalence in general medical inpatients was 24%, and was associated with excessive use of broad spectrum antibiotics. Allergies in a large proportion of patients with AALs were incorrectly documented, and were non-immune-mediated and potentially amenable to oral re-challenge. A direct oral re-challenge study in carefully selected patients with low risk allergy phenotypes appears feasible.
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Affiliation(s)
| | | | | | - Duy Le
- Austin Health, Melbourne, VIC
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29
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Schröder W, Sommer H, Gladstone BP, Foschi F, Hellman J, Evengard B, Tacconelli E. Gender differences in antibiotic prescribing in the community: a systematic review and meta-analysis. J Antimicrob Chemother 2016; 71:1800-6. [DOI: 10.1093/jac/dkw054] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/10/2016] [Indexed: 01/24/2023] Open
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30
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Tingström P, Milberg A, Rodhe N, Ernerud J, Grodzinsky E, Sund-Levander M. Nursing assistants: "he seems to be ill" - a reason for nurses to take action: validation of the Early Detection Scale of Infection (EDIS). BMC Geriatr 2015; 15:122. [PMID: 26459627 PMCID: PMC4603967 DOI: 10.1186/s12877-015-0114-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 09/30/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Signs and symptoms of infection in frail elderly are atypical, causing delay in diagnosis and treatment. To improve communication between healthcare staff of signs and symptoms of infection we developed an instrument, using qualitative data from observations by nursing assistants when they suspected infection. The aim of this study was to assess the validity of nursing assistants observations by developing and testing the instrument for early detection of infection in elderly nursing home residents. METHODS The early detection of infection (EDIS) instrument was based on data from focus interviews with nursing assistants. Over one year the nursing assistants used EDIS to document episodes of suspected early signs and symptoms of infection in 204 nursing home residents. Two physicians classified documented episodes as "no infection", "possible infection", and "infection". The content validity of the 13 items of the EDIS was established to explore the relationships between the items. The construct validity was used to explore the relationship between the items and the presence or absence of infection. The predictive value of the developed model was evaluated by the percentage of correct classifications of the observed cases. Generalized linear model (ordinal multinomial distribution and logit link) was used. RESULTS Of the 388 events of suspected infection, 20 % were assessed as no infection, 31 % as possible infection and 49 % as infection. Content validity analysis showed that 12/13 of the items correlated significantly with at least one other statement. The range in number of significant inter-correlations was from 0 ("pain") to 8 ("general signs and symptoms of illness"). The construct validity showed that the items "temperature" , "respiratory symptoms" and "general signs and symptoms of illness" were significantly related to "infection", and these were also selected in the model-building. These items predicted correct alternative responses in 61 % of the cases. CONCLUSION The validation of EDIS suggests that the observation of "general signs and symptoms of illness", made by nursing assistants should be taken seriously in detecting early infection in frail elderly. Also, the statement "He/She is not as usual" should lead to follow-up.
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Affiliation(s)
- P Tingström
- Department of Medical and Health Sciences, Linköping University, 58183, Linköping, Sweden.
| | - A Milberg
- Palliative Education & Research Centre and Department of Social and Welfare Studies, Linköping University, 601 74, Norrköping, Sweden.
| | - N Rodhe
- Department of Public Health and Caring Sciences, Faculty of Family Medicine and Preventive Medicine, Uppsala University, 751 05, Uppsala, Sweden.
| | - J Ernerud
- Department of Clinical and Experimental Medicine, Linköping, Sweden.
- Department of Clinical Immunology and Transfusion Medicine, Linköping University, 58183, Linköping, Sweden.
| | - E Grodzinsky
- Department of Medical and Health Sciences, Linköping University, 58183, Linköping, Sweden.
- Department of Pharmaceutical Research, Linköping, Sweden.
| | - M Sund-Levander
- Department of Medical and Health Sciences, Linköping University, 58183, Linköping, Sweden.
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