The Urine-culturing Cascade: Variation in Nursing Home Urine Culturing and Association With Antibiotic Use and Clostridiodes difficile Infection

Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies

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.

Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System

IMPORTANCE

Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited.

OBJECTIVE

To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021.

INTERVENTION

Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator.

MAIN OUTCOMES AND MEASURES

Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse.

RESULTS

Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days.

CONCLUSIONS AND RELEVANCE

The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.

Resident-Related Factors Influencing Antibiotic Treatment Decisions for Urinary Tract Infections in Dutch Nursing Homes

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.

Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline

PURPOSE

To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification.

METHODS

We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted.

RESULTS

One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively).

CONCLUSIONS

Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.

Case-based audit and feedback around a decision aid improved antibiotic choice and duration for uncomplicated cystitis in primary care clinics

OBJECTIVES

The objective of our study was to evaluate the impact of a multifaceted stewardship intervention on adherence to the evidence-based practice guidelines on treatment of uncomplicated cystitis in primary care. We hypothesised that our intervention would increase guideline adherence in terms of antibiotic choice and duration of treatment.

DESIGN

A preintervention and postintervention comparison with a contemporaneous control group was performed. During the first two study periods, we obtained baseline data and performed interviews exploring provider prescribing decisions for cystitis at both clinics. During the third period in the intervention clinic only, the intervention included a didactic lecture, a decision algorithm and audit and feedback. We used a difference-in-differences analysis to determine the effects of our intervention on the outcome and guideline adherence to antibiotic choice and duration.

SETTING

Two family medicine clinics (one intervention and one control) were included.

PARTICIPANTS

All female patients with uncomplicated cystitis attending the study clinics between 2016 and 2019.

RESULTS

Our sample included 932 visits representing 812 unique patients with uncomplicated cystitis. The proportion of guideline-adherent antibiotic regimens increased during the intervention period (from 33.2% (95% CI 26.9 to 39.9) to 66.9% (95% CI 58.4 to 74.6) in the intervention site and from 5.3% (95% CI 2.3 to 10.1) to 17.0% (95% CI 9.9 to 26.6) in the control site). The increase in guideline adherence was greater in the intervention site compared with the control site with a difference-in-differences of 22 percentage points, p=0.001.

CONCLUSION

A multifaceted intervention increased guideline adherence for antibiotic choice and duration in greater magnitude than similar trends at the control site. Future research is needed to facilitate scale-up and sustainability of case-based audit and feedback interventions in primary care.

Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data

BACKGROUND

Antibiotic resistance is an increasing threat to public health globally. Indicators on antibiotic prescribing are required to guide antibiotic stewardship interventions in nursing homes. However, such indicators are not available in the literature. Our main objective was to provide a set of quantity metrics and proxy indicators to estimate the volume and appropriateness of antibiotic use in nursing homes.

METHODS

Recently published articles were first used to select quantity metrics and proxy indicators, which were adapted to the French nursing home context. A cross-sectional observational study was then conducted based on reimbursement databases. We included all community-based nursing homes of the Lorraine region in northeastern France. We present descriptive statistics for quantity metrics and proxy indicators. For proxy indicators, we also assessed performance scores, clinimetric properties (measurability, applicability, and room for improvement), and conducted case-mix and cluster analyses.

RESULTS

A total of 209 nursing homes were included. We selected 15 quantity metrics and 11 proxy indicators of antibiotic use. The volume of antibiotic use varied greatly between nursing homes. Proxy indicator performance scores were low, and variability between nursing homes was high for all indicators, highlighting important room for improvement. Six of the 11 proxy indicators had good clinimetric properties. Three distinct clusters were identified according to the number of proxy indicators for which the acceptable target was reached.

CONCLUSIONS

This set of 15 quantity metrics and 11 proxy indicators may be adapted to other contexts and could be used to guide antibiotic stewardship programs in nursing homes.

Virtual learning collaboratives to improve urine culturing and antibiotic prescribing in long-term care: controlled before-and-after study

BACKGROUND

Urine culturing practices are highly variable in long-term care and contribute to overprescribing of antibiotics for presumed urinary tract infections. The purpose of this study was to evaluate the use of virtual learning collaboratives to support long-term care homes in implementing a quality improvement programme focused on reducing unnecessary urine culturing and antibiotic overprescribing.

METHODS

Over a 4-month period (May 2018-August 2018), 45 long-term care homes were self-selected from five regions to participate in virtual learning collaborative sessions, which provided an orientation to a quality improvement programme and guidance for implementation. A process evaluation complemented the use of a controlled before-and-after study with a propensity score matched control group (n=127) and a difference-in-difference analysis. Primary outcomes included rates of urine cultures performed and urinary antibiotic prescriptions. Secondary outcomes included rates of emergency department visits, hospital admission and mortality. An 18-month baseline period was compared with a 16-month postimplementation period with the use of administrative data sources.

RESULTS

Rates of urine culturing and urinary antibiotic prescriptions per 1000 resident days decreased significantly more among long-term care homes that participated in learning collaboratives compared with matched controls (differential reductions of 19% and 13%, respectively, p<0.0001). There was no statistically significant changes to rates of emergency department visits, hospital admissions or mortality. These outcomes were observed with moderate adherence to the programme model.

CONCLUSIONS

Rates of urine culturing and urinary antibiotic prescriptions declined among long-term care homes that participated in a virtual learning collaborative to support implementation of a quality improvement programme. The results of this study have refined a model to scale this programme in long-term care.

Quality of the Diagnostic Process, Treatment Decision, and Predictors for Antibiotic Use in General Practice for Nursing Home Residents with Suspected Urinary Tract Infection

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.

Urinary tract infection treatment practices in nursing homes reporting to the National Healthcare Safety Network, 2017

We describe differences between urinary tract infection treatment and events reported by nursing homes enrolled in the National Healthcare Safety Network. In 2017, almost 4 times as many antibiotic starts as infection events were reported, suggesting that opportunities exist for antibiotic stewardship and improvement of urinary tract infection reporting.

Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era

OBJECTIVE

Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.

METHODS

Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.

RESULTS

Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.

CONCLUSIONS

Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship.

The Winter Respiratory Viral Season During the COVID-19 Pandemic

The winter respiratory virus season always poses challenges for long-term care settings; this winter, severe acute respiratory syndrome coronavirus 2 will compound the usual viral infection challenges. This special article discusses unique considerations that Coronavirus Disease 2019 (COVID-19) brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. Specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. Policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a COVID-19 vaccine when it becomes available. Research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. If there is a positive side to this year's winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection.

Trends in Health Care-Associated Infection Prevention Practices in US Veterans Affairs Hospitals From 2005 to 2017

IMPORTANCE

Health care-associated infection (HAI) is associated with substantial harm. To reduce HAI, the largest integrated health care system in the United States-the Veterans Health Administration-was an early adopter of infection prevention policies and initiatives. Whether these efforts translated into increased use of practices to prevent HAI in Veterans Affairs (VA) hospitals is unknown.

OBJECTIVE

To evaluate changes over time in infection prevention practices and the perception of the importance of infection prevention to hospital leadership.

DESIGN, SETTINGS, AND PARTICIPANTS

For this survey study, every 4 years between 2005 and 2017, infection preventionists were surveyed at all VA hospitals on use of practices associated with common HAIs, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and (beginning in 2013) Clostridioides difficile infection. Data analysis was performed from February 1, 2019, to July 1, 2019.

MAIN OUTCOMES AND MEASURES

Reported regular use of key infection prevention practices and perceived importance of infection prevention to hospital leadership.

RESULTS

Between 2005 and 2017, 320 total surveys were completed with response rates ranging from 59% (73 of 124) in 2017 to 80% (95 of 119) in 2005. Use of 12 different infection prevention practices increased. Since 2013, 92% (69 of 75) to 100% of VA hospitals reported regular use of key infection prevention practices for C difficile infection and CLABSI. In contrast, adoption of many practices to prevent CAUTI, although increasing, have lagged. Despite reported increases in the use of some practices for VAP such as semirecumbent positioning (89% [79 of 89] in 2005 vs 97% [61 of 63] in 2017, P = .007 for trend) and subglottic secretion drainage (23% [19 of 84] in 2005 vs 65% [40 of 62] in 2017, P < .001), use of other key practices such as daily interruptions of sedation (85% [55 of 65] in 2009 vs 87% [54 of 62] in 2017, P = .66) and early mobilization (81% [52 of 64] in 2013 vs 82% [51 of 62] in 2017, P = .88) has not increased. Antibiotic stewardship programs are now reported in nearly every VA hospital (97% [71 of 73]); however, some hospitals report practices for microbiologic testing for HAIs (eg, 22% [16 of 72] report routine urine culture testing in 2017) that could also contribute to antibiotic overuse.

CONCLUSIONS AND RELEVANCE

From 2005 to 2017, reported use of 12 different infection prevention practices increased in VA hospitals. Areas for continued improvement of infection prevention practices appear to include CAUTI, certain VAP practices, and diagnostic stewardship for HAI. The reported adoption of many infection prevention practices in VA hospitals was higher than in non-VA hospitals. As hospitals continue to merge and health systems become increasingly integrated, these successes could help inform patient safety broadly.

Prescriber-led practice changes that can bolster antimicrobial stewardship in community health care settings

Stabilizing the emerging resistance of antibiotics depends on our ability to practise appropriate antimicrobial stewardship (AMS). Over 90% of antibiotics dispensed for human use are prescribed in community health care settings rather than in hospitals, with the main prescribers being family physicians, dentists, pharmacists and nurse practitioners working across a broad range of private offices, family health teams, urgent care clinics, emergency departments and long-term care homes. To improve the reach of AMS in community health care settings, the Public Health Agency of Canada partnered with Choosing Wisely Canada in 2017 to develop a focused campaign titled Using Antibiotics Wisely. This campaign is led by the prescribers of antibiotics themselves, who work in community health care settings and are better equipped to identify the specific changes that would support more appropriate use of antibiotics. This article describes these practice changes, the strengths and challenges of Using Antibiotics Wisely and future opportunities to further advance AMS across community health care settings.

Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents

OBJECTIVES

Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents.

DESIGN

Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017.

SETTING AND PARTICIPANTS

Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP).

METHODS

EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home-specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4.

RESULTS

Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home-specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used.

CONCLUSIONS AND IMPLICATIONS

One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home-specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.