Development of an information leaflet and diagnostic flow chart to improve the management of urinary tract infections in older adults: a qualitative study using the Theoretical Domains Framework

Detection and management of suspected infections in people with dementia - A scoping review of current practices

People with dementia have an increased risk of hospitalization and mortality due to infections. We aimed to explore decision-making processes and interventions for detecting and managing suspected infections in people with dementia and involved actors and determinants. We conducted a scoping review, searching CINAHL and PubMed, and synthesized data through mapping and narratively. We identified 22 studies, based mostly on nursing homes and US data. Decision-making processes included recognition of infections based on observations of early signs and symptoms, actions when suspecting infections, and proxy/family involvement. Interventions included antimicrobial stewardship and other decision-support tools. Determinants included healthcare staff perceptions, and other system/person-related factors. Healthcare staff were the main actors, proxy/family were mentioned scarcely, and people with dementia only once. Our findings show scarcity of evidence on people with dementia and outside of the nursing homes. We highlight knowledge gaps and inform research shaping interventions for improving infection detection and management.

Preventing urinary tract infection in older people living in care homes: the 'StOP UTI' realist synthesis

BACKGROUND

Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.

OBJECTIVE

To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances.

METHODS

A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders.

RESULTS

56 articles were included in the review. Nine context-mechanism-outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff.

CONCLUSIONS

Care home staff have a vital role in preventing and recognising UTI in care home residents.Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.

Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study

BACKGROUND

Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families.

AIM

To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms.

DESIGN & SETTING

A qualitative interview study with primary care clinicians and care home staff in the UK.

METHOD

Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed.

RESULTS

Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas.

CONCLUSION

The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.

Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries

BACKGROUND

a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions.

OBJECTIVES

(1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults.

METHODS

we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers.

RESULTS

participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care.

CONCLUSIONS

decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.

Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection

Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally.

Empowering Patients to Self-Manage Common Infections: Qualitative Study Informing the Development of an Evidence-Based Patient Information Leaflet

Common self-limiting infections can be self-managed by patients, potentially reducing consultations and unnecessary antibiotic use. This qualitative study informed by the Theoretical Domains Framework (TDF) aimed to explore healthcare professionals' (HCPs) and patients' needs on provision of self-care and safety-netting advice for common infections. Twenty-seven patients and seven HCPs participated in semi-structured focus groups (FGs) and interviews. An information leaflet was iteratively developed and reviewed by participants in interviews and FGs, and an additional 5 HCPs, and 25 patients (identifying from minority ethnic groups) via online questionnaires. Qualitative data were analysed thematically, double-coded, and mapped to the TDF. Participants required information on symptom duration, safety netting, self-care, and antibiotics. Patients felt confident to self-care and were averse to consulting with HCPs unnecessarily but struggled to assess symptom severity. Patients reported seeking help for children or elderly dependents earlier. HCPs' concerns included patients' attitudes and a lack of available monitoring of advice given to patients. Participants believed community pharmacy should be the first place that patients seek advice on common infections. The patient information leaflet on common infections should be used in primary care and community pharmacy to support patients to self-manage symptoms and determine when further help is required.

Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial

BACKGROUND

When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI.

METHODS

This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062.

FINDINGS

Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33).

INTERPRETATION

The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality.

FUNDING

Danish Ministry of Health and the Velux Foundation.

Hospital clinical practice around urinalysis is an important opportunity for antimicrobial stewardship improvement activities

BACKGROUND

To identify nurses' knowledge, perception and practice around urinalysis and asymptomatic bacteriuria (ASB) and to determine drivers of inappropriate urinalysis practice in an Australian hospital setting.

METHODS

Undertaken in eight geriatric wards over four hospitals, a questionnaire inviting voluntary, anonymous participation tested nursing staff knowledge on urinalysis, recognition of urinary tract infection (UTI) and perception of the utility of urinalysis as a routine test on all ward admissions. A retrospective one-month audit was performed on admissions to a 32-bed geriatric ward.

RESULTS

132 of 220 (60%) distributed surveys were completed. Performing urinalysis on all new admissions was identified as routine practice by 89%, and with indwelling catheter change by 35% of respondents. Over-three-quarters believed that routine urinalysis on admission was useful practice and up to one-third believed urinalysis abnormalities warranted antibiotic prescribing. Dark urine (57.6%), foamy urine (55.3%) and vaginal itch (34.5%) were identified as features suggestive of a UTI. In the ward audit, routine urinalysis on admission accounted for most urinalysis testing (59%, 24/41). Of occasions with clinical prompt, delirium accounted for 60% of urinalysis and urinary symptoms 33% however urine culture was undertaken on 53% of occasions.

CONCLUSION

There was an overall lack of nursing knowledge regarding ASB, with a high perception that urinalysis abnormalities would be suspicious of a UTI irrespective of clinical findings and that routine urinalysis on ward admission was useful practice. In hospital settings, nursing stewardship can deliver strategies to increase knowledge, motivation and opportunity to improve appropriateness of UTI treatment and recognition of ASB.

A Qualitative Investigation of the Acceptability and Feasibility of a Urinary Tract Infection Patient Information Leaflet for Older Adults and Their Carers

Urinary tract infections (UTIs) can be life threatening in older adults. The aim of this study was to primarily understand the acceptability and feasibility of using a UTI leaflet for older adults in care homes and the community. Qualitative interviews and focus groups informed by the Theoretical Domains Framework were conducted in 2019 with 93 participants from two English areas where a UTI leaflet for older adults had been introduced to improve self-care advice. Discussions were conducted with care staff (carers and nurses), older adults, general practice staff (GPs, nurses and health care assistants), and other relevant stakeholders and covered experiences of using the leaflet; its implementation; and barriers and facilitators to use. Participants deemed the leaflet an acceptable tool. Clinicians and care staff believed that having information in writing would reinforce their messages to older adults. Care staff reported that some older adults may find the information overwhelming. Where implemented, care staff used the leaflet as an educational guide. Clinicians requested the leaflet in electronic and paper formats to suit preferences. Implementation barriers included lack of awareness of the leaflet, lack of staffing and resource, and weak working relationships between care homes and general practices. It is recommended that regional strategies must include plans for dissemination to care homes, training, promotion and easy access to the leaflet. Improvements to the leaflet consisted of inclusion of antibiotic course length, D-mannose, atrophic vaginitis and replacement of less alarmist terminology such as ‘life threatening’.

Diagnosis and Management of UTI in Primary Care Settings-A Qualitative Study to Inform a Diagnostic Quick Reference Tool for Women Under 65 Years

Background: To inform interventions to improve antimicrobial use in urinary tract infections (UTIs) and contribute to a reduction in Escherichia coli bloodstream infection, we explored factors influencing the diagnosis and management of UTIs in primary care. Design: Semi-structured focus groups informed by the Theoretical Domains Framework. Setting: General practice (GP) surgeries in two English clinical commissioning groups (CCGs), June 2017 to March 2018. Participants: A total of 57 GP staff within 8 focus groups. Results: Staff were very aware of common UTI symptoms and nitrofurantoin as first-line treatment, but some were less aware about when to send a urine culture, second-line and non-antibiotic management, and did not probe for signs and symptoms to specifically exclude vaginal causes or pyelonephritis before prescribing. Many consultations were undertaken over the phone, many by nurse practitioners, and followed established protocols that often included urine dipsticks and receptionists. Patient expectations increased use of urine dipsticks, and immediate and 5 days courses of antibiotics. Management decisions were also influenced by patient co-morbidities. No participants had undertaken recent UTI audits. Patient discussions around antibiotic resistance and back-up antibiotics were uncommon compared to consultations for respiratory infections. Conclusions: Knowledge and skill gaps could be addressed with education and clear, accessible, UTI diagnostic and management guidance and protocols that are also appropriate for phone consultations. Public antibiotic campaigns and patient-facing information should cover UTIs, non-pharmaceutical recommendations for "self-care", prevention and rationale for 3 days antibiotic courses. Practices should be encouraged to audit UTI management.