1
|
Kagansky N, Rosenberg R, Derazne E, Mazurez E, Levy Y, Barchana M. Implementation of a program for treatment of acute infections in nursing homes without hospital transfer. Front Med (Lausanne) 2024; 11:1333523. [PMID: 38831988 PMCID: PMC11144856 DOI: 10.3389/fmed.2024.1333523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/26/2024] [Indexed: 06/05/2024] Open
Abstract
Background Nursing care residents have high hospitalization rates. To address this, we established a unique virtual geriatric unit that has developed a program aimed at providing support to nursing homes. Aims We aimed to evaluate effectiveness of in-house intravenous antibiotic treatment in nursing hospitals after the implementation of the specially designed training program. Methods A cohort study of nursing home residents to evaluate a training program for providers, designed to increase awareness and give practical tools for in-house treatment of acute infections. Data obtained included types of infections, antibiotics used, hospital transfer, and length of treatment. Primary outcomes were in-house recovery, hospitalization and mortality. Univariate analysis and multivariable logistic regression analysis to assess association between different factors and recovery. Results A total of 890 cases of acute infections were treated with intravenous antibiotics across 10 nursing homes over a total of 4,436 days. Of these cases, 34.8% were aged 90 years or older. Acute pneumonia was the most prevalent infection accounted for 354 cases (40.6%), followed by urinary tract infections (35.7%), and fever of presumed bacterial infection (17.1%). The mean duration of intravenous antibiotic treatment was 5.09 ± 3.86 days. Of the total cases, 800 (91.8%) recovered, 62 (7.1%) required hospitalization and nine (1.0%) resulted in mortality. There was no significant difference observed in recovery rates across different types of infections. Discussion Appling a simple yet unique intervention program has led to more "in-house" residents receiving treatment, with positive clinical results. Conclusion Treating in-house nursing home residents with acute infections resulted in high recovery rates. Special education programs and collaboration between healthcare organizations can improve treatment outcomes and decrease the burden on the healthcare system.
Collapse
Affiliation(s)
- Nadya Kagansky
- Clalit Health Services, Tel Aviv, Israel
- Shmuel Harofe Geriatric Medical Center, Beer Ya’akov, Israel
| | - Reena Rosenberg
- Clalit Health Services, Tel Aviv, Israel
- Tel Aviv University School of Medicine, Ramat Aviv, Israel
| | - Estela Derazne
- Tel Aviv University School of Medicine, Ramat Aviv, Israel
| | | | - Yochai Levy
- Tel Aviv University School of Medicine, Ramat Aviv, Israel
- Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Micha Barchana
- Technion University School of Public Health, Haifa, Israel
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Matovelle P, Olivan-Blázquez B, Magallón-Botaya R, García-Sangenís A, Monfà R, Morros R, Navarro Sanmartín A, Mateos-Nozal J, Sáez Bejar C, Rodríguez Jiménez C, López Pérez E, Llor C. Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis. Antibiotics (Basel) 2024; 13:152. [PMID: 38391537 PMCID: PMC10885965 DOI: 10.3390/antibiotics13020152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.
Collapse
Affiliation(s)
- Priscila Matovelle
- Geriatrics Department, Hospital San Juan de Dios, 50006 Zaragoza, Spain
- Geriatrics Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Bárbara Olivan-Blázquez
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Rosa Magallón-Botaya
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Medicine Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Ana García-Sangenís
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | - Ramon Monfà
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | | | - Jesús Mateos-Nozal
- Geriatrics Department, Hospital Universitario Ramón y Cajal (IRYCIS), 28034 Madrid, Spain
| | - Carmen Sáez Bejar
- Internal Medicine Department, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria (IIS-Princesa), 28006 Madrid, Spain
- Research Institute of Princesa (IIS Princesa), 28006 Madrid, Spain
| | - Consuelo Rodríguez Jiménez
- Pharmacology Department, Complejo Hospitalario Universitario de Canarias, 38320 Santa Cruz de Tenerife, Spain
| | | | - Carl Llor
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
- Institut Català de la Salut, 08038 Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark
| |
Collapse
|
4
|
Rutten JJS, Smalbrugge M, van Buul LW, van Eijk J, Geerlings SE, Natsch S, Sloane PD, van der Wouden JC, Hertogh CMPM, Gerritsen DL. A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes. J Am Med Dir Assoc 2024; 25:146-154.e9. [PMID: 38173264 DOI: 10.1016/j.jamda.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention. DESIGN Mixed-methods process evaluation study. SETTING AND PARTICIPANTS Physicians, nursing staff, client council members, and residents of Dutch NHs. METHODS We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members. RESULTS Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture. CONCLUSIONS AND IMPLICATIONS Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.
Collapse
Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
| | - Jorna van Eijk
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of General Practice, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community care, Radboudumc Alzheimer Center, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| |
Collapse
|
5
|
Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
Collapse
Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
| |
Collapse
|
6
|
Salam MA, Al-Amin MY, Salam MT, Pawar JS, Akhter N, Rabaan AA, Alqumber MAA. Antimicrobial Resistance: A Growing Serious Threat for Global Public Health. Healthcare (Basel) 2023; 11:1946. [PMID: 37444780 DOI: 10.3390/healthcare11131946] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Antibiotics are among the most important discoveries of the 20th century, having saved millions of lives from infectious diseases. Microbes have developed acquired antimicrobial resistance (AMR) to many drugs due to high selection pressure from increasing use and misuse of antibiotics over the years. The transmission and acquisition of AMR occur primarily via a human-human interface both within and outside of healthcare facilities. A huge number of interdependent factors related to healthcare and agriculture govern the development of AMR through various drug-resistance mechanisms. The emergence and spread of AMR from the unrestricted use of antimicrobials in livestock feed has been a major contributing factor. The prevalence of antimicrobial-resistant bacteria has attained an incongruous level worldwide and threatens global public health as a silent pandemic, necessitating urgent intervention. Therapeutic options of infections caused by antimicrobial-resistant bacteria are limited, resulting in significant morbidity and mortality with high financial impact. The paucity in discovery and supply of new novel antimicrobials to treat life-threatening infections by resistant pathogens stands in sharp contrast to demand. Immediate interventions to contain AMR include surveillance and monitoring, minimizing over-the-counter antibiotics and antibiotics in food animals, access to quality and affordable medicines, vaccines and diagnostics, and enforcement of legislation. An orchestrated collaborative action within and between multiple national and international organizations is required urgently, otherwise, a postantibiotic era can be a more real possibility than an apocalyptic fantasy for the 21st century. This narrative review highlights on this basis, mechanisms and factors in microbial resistance, and key strategies to combat antimicrobial resistance.
Collapse
Affiliation(s)
- Md Abdus Salam
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan 25200, Malaysia
| | - Md Yusuf Al-Amin
- Purdue University Interdisciplinary Life Sciences Graduate Program, Purdue University, West Lafayette, IN 47907, USA
- Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | | | - Jogendra Singh Pawar
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN 47907, USA
- The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH 43210, USA
| | - Naseem Akhter
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Mohammed A A Alqumber
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Albaha University, Al Baha 65431, Saudi Arabia
| |
Collapse
|
7
|
Huang Y, Wei WI, Correia DF, Ma BHM, Tang A, Yeoh EK, Wong SYS, Ip M, Kwok KO. Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis. J Hosp Infect 2023; 131:107-121. [PMID: 36202187 DOI: 10.1016/j.jhin.2022.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization. METHODS MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year. RESULTS In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia. CONCLUSION The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.
Collapse
Affiliation(s)
- Y Huang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - W I Wei
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - D F Correia
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - B H M Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - A Tang
- College of Computing and Informatics, Sungkyunkwan University, Seoul, Republic of Korea
| | - E K Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - S Y S Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - M Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - K O Kwok
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Shenzhen Research Institute of the Chinese University of Hong Kong, Shenzhen, China; Hong Kong Institute of Asia-Pacific Studies, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| |
Collapse
|
8
|
Gontjes KJ, Gibson KE, Lansing BJ, Mantey J, Jones KM, Cassone M, Wang J, Mills JP, Mody L, Patel PK. Association of Exposure to High-risk Antibiotics in Acute Care Hospitals With Multidrug-Resistant Organism Burden in Nursing Homes. JAMA Netw Open 2022; 5:e2144959. [PMID: 35103795 PMCID: PMC8808331 DOI: 10.1001/jamanetworkopen.2021.44959] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Little is known about the contribution of hospital antibiotic prescribing to multidrug-resistant organism (MDRO) burden in nursing homes (NHs). OBJECTIVES To characterize antibiotic exposures across the NH patient's health care continuum (preceding health care exposure and NH stay) and to investigate whether recent antibiotic exposure is associated with MDRO colonization and room environment contamination at NH study enrollment. DESIGN, SETTING, AND PARTICIPANTS This is a secondary analysis of a prospective cohort study (conducted from 2013-2016) that enrolled NH patients and followed them up for as long as 6 months. The study was conducted in 6 NHs in Michigan among NH patients who were enrolled within 14 days of admission. Clinical metadata abstraction, multi-anatomical site screening, and room environment surveillance for MDROs were conducted at each study visit. Data were analyzed between May 2019 and November 2021. EXPOSURES Antibiotic data were abstracted from NH electronic medical records by trained research staff and characterized by class, route, indication, location of therapy initiation, risk for Clostridioides difficile infection (C diffogenic agents), and 2019 World Health Organization Access, Watch, and Reserve (AWARE) antibiotic stewardship framework categories. MAIN OUTCOMES AND MEASURES The primary outcomes were MDRO colonization and MDRO room environment contamination at NH study enrollment, measured using standard microbiology methods. Multivariable logistic regression was used to identify whether antibiotic exposure within 60 days was associated with MDRO burden at NH study enrollment. Additionally, antibiotic exposure data were characterized using descriptive statistics. RESULTS A total of 642 patients were included (mean [SD] age, 74.7 [12.2] years; 369 [57.5%] women; 402 [62.6%] White; median [IQR] NH days to enrollment, 6.0 [3.0-7.0]). Of these, 422 (65.7%) received 1191 antibiotic exposures: 368 (57.3%) received 971 hospital-associated prescriptions, and 119 (18.5%) received 198 NH-associated prescriptions. Overall, 283 patients (44.1%) received at least 1 C diffogenic agent, and 322 (50.2%) received at least 1 high-risk WHO AWARE antibiotic (watch or reserve agent). More than half of NH patients (364 [56.7%]) and room environments (437 [68.1%]) had MDRO-positive results at enrollment. In multivariable analysis, recent antibiotic exposure was positively associated with baseline MDRO colonization (odds ratio [OR], 1.70; 95% CI, 1.22-2.38) and MDRO environmental contamination (OR, 1.67; 95% CI, 1.17-2.39). Exploratory stratification by C diffogenic agent exposure increased the effect size (MDRO colonization: OR, 1.99; 95% CI, 1.33-2.96; MDRO environmental contamination: OR, 1.86; 95% CI, 1.24-2.79). Likewise, exploratory stratification by exposure to high-risk WHO AWARE antibiotics increased the effect size (MDRO colonization: OR, 2.32; 95% CI, 1.61-3.36; MDRO environmental contamination: OR, 1.86; 95% CI, 1.26-2.75). CONCLUSIONS AND RELEVANCE The findings of this study suggest that high-risk, hospital-based antibiotics are a potentially high-value target to reduce MDROs in postacute care NHs. This study underscores the potential utility of integrated hospital and NH stewardship programming on regional MDRO epidemiology.
Collapse
Affiliation(s)
- Kyle J. Gontjes
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
- Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor
| | - Kristen E. Gibson
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Bonnie J. Lansing
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Julia Mantey
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Karen M. Jones
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Marco Cassone
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Joyce Wang
- Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor
| | - John P. Mills
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Lona Mody
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Geriatrics Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Division of Infectious Diseases, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| |
Collapse
|
9
|
Kolodziej LM, Kuil SD, de Jong MD, Schneeberger C. Resident-Related Factors Influencing Antibiotic Treatment Decisions for Urinary Tract Infections in Dutch Nursing Homes. Antibiotics (Basel) 2022; 11:antibiotics11020140. [PMID: 35203742 PMCID: PMC8868192 DOI: 10.3390/antibiotics11020140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/15/2022] [Accepted: 01/18/2022] [Indexed: 02/04/2023] Open
Abstract
The aim of this cohort study was to identify resident-related factors that influence antibiotic treatment decisions for urinary tract infections (UTIs) in nursing home residents and to provide an overview of the appropriateness of antibiotic treatment decisions according to the updated Dutch guideline for UTIs in frail older adults. The PROGRESS study dataset, consisting of 298 suspected UTI episodes in Dutch nursing home residents, was used. The presence of dysuria was associated with the highest frequency of antibiotic prescription (87.8%). Positive leukocyte esterase dipstick results showed the greatest increase in the risk of antibiotic prescription (RR 2.1, 95% CI 1.44 to 3.06). Treatment decisions were considered adequate in 64.1% of the suspected UTI episodes. Overtreatment occurred more often than undertreatment. Of the inadequate treatment decisions, 29.3% was due to treatment of UTI episodes in which solely non-specific symptoms were present. A high proportion of nitrofurantoin prescriptions were incorrect in UTIs with signs of tissue invasion (54.8%), indwelling catheter-associated UTIs (37.5%), and UTIs in men (29.2%). Although this is considered inadequate, non-specific symptoms were associated with antibiotic prescription for suspected UTIs in Dutch nursing home residents and nitrofurantoin was inadequately prescribed in particular groups, such as men.
Collapse
|
10
|
Rutten JJS, van Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, Sloane PD, van der Wouden JC, Twisk JWR, Hertogh CMPM. An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc 2021; 23:387-393. [PMID: 34896069 DOI: 10.1016/j.jamda.2021.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents. DESIGN Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual. SETTING AND PARTICIPANTS 212 residents with suspected UTI, from 16 NHs in the Netherlands. METHODS Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level. RESULTS 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02). CONCLUSION AND IMPLICATIONS Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.
Collapse
Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Radboud Institute for Health Sciences, Radboudumc Alzheimer Center, Department of Primary and Community care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| |
Collapse
|
11
|
Cooper DL, Buterakos R, Wagner LM, Tith J, Lee SYD. A retrospective comparison of guidelines to assess hospital-diagnosed urinary tract infection in nursing home residents. Am J Infect Control 2021; 49:1354-1358. [PMID: 33872686 DOI: 10.1016/j.ajic.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Inappropriate antibiotic treatments for urinary tract infection (UTI) in nursing home (NH) residents are common and contribute to antibiotic resistance. Published guidelines aim to improve accurate assessment, diagnosis, and treatment of UTIs. This study assessed whether records from hospitalized NH residents diagnosed with UTI, while comparing the Cooper Tool and Stone criteria, supported appropriate treatment. METHODS A retrospective chart review was conducted using electronic medical record (EMR) data from residents of 3 NHs who were diagnosed with UTI when hospitalized over a 3-year period. The Cooper Tool and Stone criteria were used to assess treatment appropriateness. RESULTS Of 79 hospitalized residents treated for UTI, 11 (13.9%) were appropriately treated according to the Cooper Tool and 9 (11.4%) according to Stone. The 2 criteria agreed in 9 of the cases including 100% of those with catheters. Urinalysis was documented in 72% of residents and 24% had documentation of culture and sensitivity. CONCLUSIONS Appropriate UTI treatment rates using both tools were low but much higher in those with catheters. Future research is necessary to validate the use of these tools in the hospital setting which have the potential to improve treatment accuracy and reduce unnecessary antibiotics use.
Collapse
|
12
|
Comparison of criteria for determining appropriateness of antibiotic prescribing in nursing homes. Infect Control Hosp Epidemiol 2021; 43:860-863. [PMID: 34162459 DOI: 10.1017/ice.2021.221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Measuring the appropriateness of antibiotic prescribing in nursing homes remains a challenge. The revised McGeer criteria, which are widely used to conduct infection surveillance in nursing homes, were not designed to assess antibiotic appropriateness. The Loeb criteria were explicitly designed for this purpose but are infrequently used outside investigational studies. The extent to which the revised McGeer and Loeb criteria overlap and can be used interchangeably for tracking antibiotic appropriateness in nursing homes remains insufficiently studied. METHODS We conducted a cross-sectional chart review study in 5 Wisconsin nursing homes and applied the revised McGeer and Loeb criteria to all nursing home-initiated antibiotic treatment courses. Kappa (κ) statistics were employed to assess level of agreement overall and by treatment indications. RESULTS Overall, 734 eligible antibiotic courses were initiated in participating nursing homes during the study period. Of 734 antibiotic courses, 372 (51%) satisfied the Loeb criteria, while only 211 (29%) of 734 satisfied the revised McGeer criteria. Only 169 (23%) of 734 antibiotic courses satisfied both criteria, and the overall level of agreement between them was fair (κ = 0.35). When stratified by infection type, levels of agreement between the revised McGeer and Loeb criteria were moderate for urinary tract infections (κ = 0.45), fair for skin and soft-tissue infections (0.36), and slight for respiratory tract infections (0.17). CONCLUSIONS Agreement between the revised McGeer and Loeb criteria is limited, and nursing homes should employ the revised McGeer and Loeb criteria for their intended purposes. Studies to establish the best method for ongoing monitoring of antibiotic appropriateness in nursing homes are needed.
Collapse
|
13
|
Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:1431-1438. [PMID: 34118423 DOI: 10.1016/j.cmi.2021.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/14/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Long-term care facilities (LTCFs) are health-care settings with high antimicrobial consumption and hence need to develop effective antimicrobial stewardship programmes (ASPs). OBJECTIVE To assess the effects of ASPs on care-related, clinical and ecological outcomes in LTCFs. METHODS Data sources were PubMed, EMBASE, CINAHL and SCOPUS. Study eligibility criteria were original research articles (controlled clinical trials or controlled before and after studies) published up to 1 October 2020. Participants were adult residents of LTCFs, residential aged-care facilities, nursing homes, veterans' homes, skilled nursing facilities and assisted living facilities for older people. Interventions included ASPs versus standard care. Outcomes assessed were antimicrobial consumption and appropriateness, infections, hospital admissions and mortality. Available data were pooled in a meta-analysis, and inconsistency between studies was evaluated using the I2 statistic. Certainty of evidence was assessed using the GRADE approach. RESULTS Of the 3111 papers identified, 12 studies met the inclusion criteria. All of them analysed the impact of interventions on antimicrobial use based on consumption-related variables (n = 8) and/or percentage of inappropriate prescriptions (n = 6). Pooled data showed a mean difference of -0.47 prescriptions per 1000 resident-days in favour of ASPs (95% CI -0.87 to -0.07, I2 = 71%). Five studies analysed the clinical effect of ASPs on the number of hospital admissions and/or resident mortality. The meta-analysis showed a mean difference of 0.17 hospital admissions per 1000 resident-days (95% CI -0.07 to 0.41, I2 = 17%) and a mean difference of -0.02 deaths per 1000 resident-days (95% CI -0.14 to 0.09, I2 = 0%). Only two studies included infections as a study outcome. CONCLUSIONS ASPs appear to improve antimicrobial use in this setting without increasing hospital admissions or deaths, indicating that these programmes do not lead to under-treatment of infections. Nonetheless, further higher-quality clinical trials are required to understand the effects of ASPs in LTCFs. PROSPERO REGISTRATION NUMBER CRD42021225127.
Collapse
|
14
|
Dwyer RA, Gabbe BJ, Tran T, Smith K, Lowthian JA. Residential aged care homes: Why do they call '000'? A study of the emergency prehospital care of older people living in residential aged care homes. Emerg Med Australas 2021; 33:447-456. [PMID: 33040460 DOI: 10.1111/1742-6723.13650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the clinical characteristics, medical interventions and patterns of ambulance service use related to the emergency, prehospital care of older people living in residential aged care (RAC) homes. METHODS Retrospective cohort study using secondary analyses of routinely collected clinical and administrative data from Ambulance Victoria and population data from the Australian Bureau of Statistics for the state of Victoria, Australia. Participants included people aged 65 years and over, attended by emergency ambulances from 2008 to 2013, with data captured in the Ambulance Victoria electronic record. RESULTS The mean (standard deviation) age of RAC residents attended by emergency ambulance was 85 (7.3) years and 63% were women. Common comorbidities included dementia (32.7%), ischaemic heart disease (27.7%) and osteoarthritis (24.6%). Polypharmacy was prevalent with 70% currently prescribed antibiotics, over 20% prescribed sedatives and a further 14.9% antipsychotics. Fifteen percent of attendances were for falls, which were more frequent among women than men. Other common reasons for ambulance call-out included uncontrolled pain, respiratory tract infection, non-specific febrile illness and altered conscious state. Almost 90% of people were transported to hospital from the RAC, with just over half of call-outs occurring out-of-hours. CONCLUSION This is the first study to describe emergency prehospital care, case-mix and intervention of frail, older people living in RAC. These results demonstrate a clinically complex group of people with high rates of comorbidity, cognitive impairment and polypharmacy. These valuable data will inform education and training of prehospital clinicians, assist in targeting preventative medicine and primary care programmes and further development of alternate, acute and emergency care pathways for this unique patient group.
Collapse
Affiliation(s)
- Rosamond A Dwyer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency Department, Peninsula Health, Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thach Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Judy A Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| |
Collapse
|
15
|
Mahmoud E, Abanamy R, Binawad E, Alhatmi H, Alzammam A, Habib A, Alturaifi D, Alharbi A, Alqahtani H, Aldohayan M. Infections and patterns of antibiotic utilization in support and comfort care patients: A tertiary care center experience. J Infect Public Health 2021; 14:839-844. [PMID: 34118733 DOI: 10.1016/j.jiph.2021.05.002] [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: 04/12/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Little is known regarding the burden of infections and clinical practice towards hospitalized patients with limits on life-sustaining measures. We aim to describe the infectious syndromes, clinical care, the emergence of multi-drug resistant organisms and outcomes in this population. PATIENTS AND METHODS Retrospective cohort of patients labeled as support or comfort care in a tertiary care center between 2016-2019. RESULTS A total of 347 patients were included with a mean age of 68.5 years, who were predominantly males (59.94%), bedbound (69.74%), on tube feeding (66.86%), and required indwelling urinary catheters (61.96%). The total number of admissions during the first year was 498, with the mean length of stay being 30 days. The number of infectious syndromes identified during that period was 821episodes, with a mean of 2 infectious syndromes per admission. The most common infection identified was pneumonia (41.66%) followed by urinary tract infections (27.16%). A total of 3891 microbiological cultures were taken with a mean of 5 cultures per infectious syndrome. The most commonly identified pathogens were Gram-negative bacteria (61.03%), with a high rate of multidrug-resistant organisms (MDROs) (48.53%). The one-year mortality was 86.4%. Using carbapenem antibiotic and pneumonia were the independent predictors used for the MDROs. CONCLUSION Our study reflects the high burden of infections, antimicrobial resistance, and hospital admissions among a population with limited life expectancy. A consensus regarding investigating and managing of infectious syndromes, and antimicrobial prescription is needed to reduce the harms associated with overuse of antimicrobials.
Collapse
Affiliation(s)
- Ebrahim Mahmoud
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
| | - Reem Abanamy
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Eman Binawad
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hind Alhatmi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ali Alzammam
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Habib
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Dana Alturaifi
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Alharbi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hajar Alqahtani
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Aldohayan
- Department of Health Informatics, CPHHI, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Data and Business Intelligence Management Department, ISID, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
16
|
Ford JH, Liao CY, Crnich CJ. Exploring Antibiotic Utilization in Assisted Living: Identifying Opportunities for Improvement. J Am Med Dir Assoc 2021; 22:1772-1773.e1. [PMID: 33932353 DOI: 10.1016/j.jamda.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- James H Ford
- Social & Administrative Sciences Division, School of Pharmacy, University of Wisconsin, Madison, WI, USA
| | - Chi-Yin Liao
- Social & Administrative Sciences Division, School of Pharmacy, University of Wisconsin, Madison, WI, USA
| | - Christopher J Crnich
- Department of Medicine, School of Medicine & Public Health, University of Wisconsin, Madison, WI, USA; William S. Middleton VA Hospital, Madison, WI, USA
| |
Collapse
|
17
|
Wang J, Cassone M, Gibson K, Lansing B, Mody L, Snitkin ES, Rao K. Gut Microbiota Features on Nursing Home Admission Are Associated With Subsequent Acquisition of Antibiotic-resistant Organism Colonization. Clin Infect Dis 2021; 71:3244-3247. [PMID: 32478813 DOI: 10.1093/cid/ciaa662] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Nursing home (NH) patients often acquire colonization with antibiotic-resistant organisms (AROs). We show that patients exposed to broad-spectrum antibiotics during previous hospitalizations have elevated enterococcal relative abundances on NH admission and higher risk of subsequent ARO acquisition. Our findings suggest that interventions preventing ARO spread should extend beyond NH doors.
Collapse
Affiliation(s)
- Joyce Wang
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Marco Cassone
- Division of Geriatrics and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kristen Gibson
- Division of Geriatrics and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Bonnie Lansing
- Division of Geriatrics and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lona Mody
- Division of Geriatrics and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Geriatric Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Evan S Snitkin
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Division of Infectious Diseases, Department of Medicine, University of Michigan, Medical School, Ann Arbor, Michigan, USA
| | - Krishna Rao
- Division of Infectious Diseases, Department of Medicine, University of Michigan, Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
18
|
Sommer-Larsen SD, Arnold SH, Holm A, Aamand Olesen J, Cordoba G. Quality of the Diagnostic Process, Treatment Decision, and Predictors for Antibiotic Use in General Practice for Nursing Home Residents with Suspected Urinary Tract Infection. Antibiotics (Basel) 2021; 10:antibiotics10030316. [PMID: 33803831 PMCID: PMC8003235 DOI: 10.3390/antibiotics10030316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
Urinary tract infections (UTIs) are common in nursing home (NH) residents and Denmark is one of the countries with the highest antibiotic use in NHs. The aim of this study was to assess the quality of the diagnostic process and treatment decision on the day of the first contact from NHs to general practice and assess predictors for prescription of antibiotics in NH residents without an indwelling urinary catheter. The study was a prospective observational study in general practice in the Capital Region of Denmark; 490 patients were included; 158 out of 394 (40.1%, 95% CI 35; 45) patients with suspected UTI had urinary tract symptoms; 270 out of 296 (91.2%, 95% CI 87; 94) patients without urinary tract symptoms had a urine culture performed. Performing urine culture in the general practice was inversely associated to prescription of antibiotics on day one (OR 0.27, 95% CI 0.13; 0.56). It is imperative to support the implementation of interventions aimed at improving the quality of the diagnostic process on day one, as less than half of the patients given the diagnosis "suspected UTI" had urinary tract symptoms, and most patients without urinary tract symptoms had a urine culture performed.
Collapse
|
19
|
Valmadrid LC, Schwei RJ, Maginot E, Pulia MS. The impact of health care provider relationships and communication dynamics on urinary tract infection management and antibiotic utilization for long-term care facility residents treated in the emergency department: A qualitative study. Am J Infect Control 2021; 49:198-205. [PMID: 32653562 PMCID: PMC7348612 DOI: 10.1016/j.ajic.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND For older adults, over diagnosis of urinary tract infections (UTI) is a primary driver of inappropriate antibiotic use. This risk is increased for patients in long-term care facilities (LTCF), especially as they transition back and forth to emergency departments (ED). In this study, we aimed to understand how health care provider communication and relationship dynamics affect LTCF residents treated in the ED to identify barriers to antibiotic stewardship for UTIs. METHODS We conducted semi-structured interviews with nurses and physicians from LTCFs and EDs, guided by the Systems Engineering Initiative for Patient Safety framework. Data were systematically coded and underwent iterative, conventional, content analysis. RESULTS We interviewed 16 LTCF and 16 ED providers across Wisconsin. ED and LTCF nurses have a critical role in both intrafacility and interfacility communication. Fragmented communication and interprofessional power dynamics were identified barriers to optimal antibiotic prescribing for UTIs. Identified strategies to overcome these issues included using objective diagnostic criteria, development of communication scripts, and nurse-to-nurse education. CONCLUSIONS Our qualitative approach revealed important insights about how communication and relationship dynamics influence UTI diagnosis and optimal antibiotic stewardship for LTCF residents evaluated in the ED. Future interventions should strengthen communications between settings and across provider types, and address standardization of diagnostic and treatment communication pathways for LTCF residents with suspected infections transitioning between EDs and LTCFs.
Collapse
Affiliation(s)
- Luke Carmichael Valmadrid
- University of North Carolina at Chapel Hill, Chapel Hill, NC; University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Rebecca J Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Elizabeth Maginot
- University of Wisconsin Madison School of Medicine and Public Health, Madison, WI
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI.
| |
Collapse
|
20
|
Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review. Drugs Aging 2020; 38:29-41. [PMID: 33174126 DOI: 10.1007/s40266-020-00814-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.
Collapse
|
21
|
Crayton E, Richardson M, Fuller C, Smith C, Liu S, Forbes G, Anderson N, Shallcross L, Michie S, Hayward A, Lorencatto F. Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review. BMC Geriatr 2020; 20:237. [PMID: 32646382 PMCID: PMC7350746 DOI: 10.1186/s12877-020-01564-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities’ antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes. Method A systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as ‘very promising’ (all outcomes statistically significant), ‘quite promising’ (some outcomes statistically significant), or ‘not promising’ (no outcomes statistically significant). ‘Promise ratios’ (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2. Results Twenty studies (of19 interventions) were included. Seven interventions (37%) were ‘very promising’, eight ‘quite promising’ (42%) and four ‘not promising’ (21%). Most promising intervention types were ‘persuasion’ (n = 12; promise ratio (PR) = 5.0), ‘enablement’ (n = 16; PR = 4.33) and ‘education’ (n = 19; PR = 3.75). Most promising behaviour change techniques were ‘feedback on behaviour’ (n = 9; PR = 8.0) and ‘restructuring the social environment’ (e.g. staff role changes; n = 8; PR = 7.0). Conclusion Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.
Collapse
Affiliation(s)
- Elise Crayton
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Michelle Richardson
- Institute of Education (IOE), University College London, London, WC1H 0NS, UK
| | - Chris Fuller
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Catherine Smith
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Sunny Liu
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Gillian Forbes
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Niall Anderson
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.,Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.,Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| | - Andrew Hayward
- Institute of Epidemiology & Health, University College London, London, WC1E 7HB, UK
| | - Fabiana Lorencatto
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.,Health Protection Research Unit in Evaluation of Interventions, National Institute of Health Research (NIHR), London, BS8 2BN, UK
| |
Collapse
|
22
|
Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
Collapse
Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
| |
Collapse
|
23
|
Fu CJ, Mantell E, Stone PW, Agarwal M. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey. Am J Infect Control 2020; 48:13-18. [PMID: 31447117 PMCID: PMC6935405 DOI: 10.1016/j.ajic.2019.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.
Collapse
Affiliation(s)
| | | | | | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY.
| |
Collapse
|
24
|
Furuno JP, Mody L. Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes. J Am Geriatr Soc 2019; 68:11-14. [PMID: 31825520 DOI: 10.1111/jgs.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Detroit, Michigan.,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Detroit, Michigan
| |
Collapse
|
25
|
Combining Procalcitonin and Rapid Multiplex Respiratory Virus Testing for Antibiotic Stewardship in Older Adult Patients With Severe Acute Respiratory Infection. J Am Med Dir Assoc 2019; 21:62-67. [PMID: 31791902 PMCID: PMC7106143 DOI: 10.1016/j.jamda.2019.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/14/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Virus infection is underevaluated in older adults with severe acute respiratory infections (SARIs). We aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (PCT) level for antibiotic stewardship in the emergency department (ED). DESIGN A prospective twin-center cohort study was conducted between January 2017 and March 2018. SETTING AND PARTICIPANTS Older adult patients who presented to the ED with SARIs received a rapid molecular test for 17 respiratory viruses and a PCT test. MEASURES To evaluate the clinical impact, we compared the outcomes of SARI patients between the experimental cohort and a propensity score-matched historical cohort. The primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ED. The secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. RESULTS A total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. More than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. Compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ED (26.0% vs 16.1%, P = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, P < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, P < .001). CONCLUSIONS AND IMPLICATIONS Combining rapid viral surveillance and PCT test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. Clustered viral respiratory infections in a nursing home is common. Patients transferred from nursing homes to ED may benefit from this approach.
Collapse
|
26
|
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.
Collapse
|