Syndromic Antibiograms and Nursing Home Clinicians' Antibiotic Choices for Urinary Tract Infections

Importance

Empirical antibiotic prescribing in nursing homes (NHs) is often suboptimal. The potential for antibiograms to improve empirical antibiotic decision-making in NHs remains poorly understood.

Objective

To determine whether providing NH clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections (UTIs).

Design, Setting, and Participants

This was a survey study using clinical vignettes. Participants were recruited via convenience sampling of professional organization listservs of NH clinicians practicing in the US from December 2021 through April 2022. Data were analyzed from July 2022 to June 2023.

Interventions

Respondents were randomized to complete vignettes using a traditional antibiogram (TA), a weighted-incidence syndromic combination antibiogram (WISCA), or no tool. Participants randomized to antibiogram groups were asked to use the antibiogram to empirically prescribe an antibiotic. Participants randomized to the no tool group functioned as controls.

Main Outcomes and Measures

Empirical antibiotic selections were characterized as microbiologically (1) active and (2) optimal according to route of administration and spectrum of activity.

Results

Of 317 responses, 298 (95%) were included in the analysis. Duplicate responses (15 participants), location outside the US (2 participants), and uninterpretable responses (2 participants) were excluded. Most respondents were physicians (217 respondents [73%]) and had over 10 years of NH practice experience (155 respondents [52%]). A mixed-effects logistic model found that use of the TA (odds ratio [OR], 1.41; 95% CI, 1.19-1.68; P < .001) and WISCA (OR, 1.54; 95% CI, 1.30-1.84; P < .001) were statistically superior to no tool when choosing an active empirical antibiotic. A similarly constructed model found that use of the TA (OR, 1.94; 95% CI, 1.42-2.66; P < .001) and WISCA (OR, 1.7; 95% CI, 1.24-2.33; P = .003) were statistically superior to no tool when selecting an optimal empirical antibiotic. Although there were differences between tools within specific vignettes, when compared across all vignettes, the TA and WISCA performed similarly for active (OR, 1.09; 95% CI, 0.92-1.30; P = .59) and optimal (OR, 0.87; 95% CI, 0.64-1.20; P = .69) antibiotics.

Conclusions and Relevance

Providing NH clinicians with a urinary antibiogram was associated with selection of active and optimal antibiotics when empirically treating UTIs under simulated conditions. Although the antibiogram format was not associated with decision-making in aggregate, context-specific effects may have been present, supporting further study of syndromic antibiograms in clinical practice.

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition

OBJECTIVE

Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation.

DESIGN

Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches.

SETTING

This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia.

PARTICIPANTS

Staff performing home-infusion CLABSI surveillance.

METHODS

From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation.

RESULTS

Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive.

CONCLUSIONS

The home-infusion CLABSI surveillance definition was valid and feasible to implement.

1749. Nursing Home Providers’ Empiric Antibiotic Choices for Residents with Urinary Tract Infections: A National Survey

Background

Urinary tract infections (UTIs) are the most common indication for antibiotic prescriptions in nursing homes (NHs) and frequently result in fluoroquinolone (FQ) prescriptions. We performed a vignette-based survey of NH providers to better understand empiric UTI treatment decision-making.

Methods

Study participants were recruited nationally through professional organizations and snowball sampling from December 2021 to February 2022. Clinical vignettes depicting four UTI presentations in NH residents (1. simple cystitis, 2. pyelonephritis with cephalosporin allergy, 3. catheter-associated UTI and 4. cystitis with history of resistant organism) were developed and distributed via electronic survey. Respondents provided free-text antibiotic choice, which two physicians independently reviewed and implicitly determined if a preferred or not-preferred antibiotic was selected. A panel of three physicians adjudicated discrepancies between the primary reviewers. Analysis was performed in R.

Results

Of 86 respondents, 74% were physicians and 26% were advanced practitioners. Half of respondents (50%) had >10 years NH experience, 41% were geriatrics trained, and none were infectious disease trained. Figure 1 details antibiotic choices and preferred agents for each case. Overall, 70% of antibiotic choices were deemed preferred antibiotics, with the least number of preferred choices observed for case 3 depicting catheter-associated UTI (53%). FQs (43%) and nitrofurantoin (14%) were the most frequent non-preferred choices. Case 2 received the greatest proportion of FQ prescriptions (38%), but this was a preferred agent. In cases where FQs were not a preferred choice, they comprised 17% of antibiotic choices. There was no difference in FQ or preferred prescribing choices by role. Providers with >10 years NH experience, however, prescribed fewer FQs over the four cases than those with less NH experience (0.7 vs. 1.1, p=0.04).

Antibiotic Choice and Preferred Agents per Case

Antibiotic choices are ordered from highest to lowest cumulative frequency.

Conclusion

This sample of NH providers made mostly preferred empiric antibiotic choices, however, FQ use remained high, particularly in providers with less NH practice experience. Further exploration of decision-support tools for empiric antibiotic prescribing in this setting may improve antibiotic stewardship.

Disclosures

Robin L. Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant.

An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings

Infectious Disease (ID)-trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities.

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19

Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2 decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.

93. Developing Urinary Tract Infection Clinical Vignettes for the Nursing Home Setting: A Mixed-Methods Approach

Background

Little is known about how providers choose antibiotics for nursing home residents when concerned about urinary tract infections. To better assess this in a simulated setting, we used a mixed-methods approach to develop robust clinical vignettes.

Methods

First, we developed 7 vignettes and distributed them to resident physicians as a survey, randomizing participants’ response type to rank-order or free-text entry. Second, we shared 5 vignettes with nursing home prescribers and conducted semi-structured interviews that asked providers to explain their thinking out loud (Think Aloud structure). Interviews were continued until content saturation was achieved. Two authors (LT & RJ) determined appropriateness of decisions about antibiotic initiation and antibiotic choice; two authors (LT & JI) coded feedback on the vignettes with adjudication by a third (RJ).

Results

Of 23 residents (11 rank-choice; 12 free-response) that participated in the pilot survey, only 6 (26%) completed 7 vignettes, with a mean completion of 69.4%. Completion of all vignettes was similar between groups, however, greater attrition at the first question was observed in respondents randomized to rank-choice (4/11) compared to free-response (6/12). Of the original 7 vignettes, 5 free-response cases were chosen for further development. We conducted semi-structured interviews with 7 nursing home prescribers, 4 of whom were physicians. The prescribers had a median age 39 (range 34 to 54) and a median of 10 years of post-graduation experience. Figure 1 summarizes appropriateness of respondents’ answers regarding antibiotic initiation and antibiotic choice. The most common inappropriate choice was a fluoroquinolone. Vignettes were edited iteratively based on participant feedback on each case’s realistic characteristics, missing necessary clinical data, formatting changes, and clarity (Figure 2).

Figure 1. Appropriateness of antibiotic initiation and antibiotic choice per clinical vignette.

Conclusion

This mixed-methods approach effectively captured prescribers’ feedback about length, response method, and case characteristics for our clinical vignettes. Responses assessed differences in prescribers’ decision to initiate antibiotic treatment and antibiotic choice. The refined vignettes will be used in a national survey.

Disclosures

Robin L. Jump, MD, PhD, Pfizer (Individual(s) Involved: Self): Consultant

130. Effects of COVID-19 on a Complex Behavioral Intervention to Improve the Diagnosis and Management of UTI in Nursing Homes

Background

Half of all urinary tract infections (UTI) are probably unnecessary. We conducted a cluster-randomized trial in which a toolkit to enhance the diagnosis and treatment of UTIs was introduced in study NHs via usual implementation versus an enhanced implementation approach based on external facilitation and peer comparison reporting.

Methods

Thirty Wisconsin NHs were randomized to each treatment arm in a 1.5:1 ratio. NHs used an online portal to report urine culture and antibiotic treatment data over a 6-month pre-intervention period (Jan-June 2019), a pre-COVID 8-month post intervention period (July 2019-Feb 2020) and an 8-month post-COVID intervention period (Mar-Oct 2020). Study outcomes included urine culture (UC), antibiotic start (AS), and antibiotic days of therapy (DOT) rates per 1,000 resident days. A generalized estimating equation model for panel data was used to assess differences in study outcomes between treatment arms before and after onset of the COVID-19 pandemic. STATA 16.1 was used for all analyses.

Results

A total of 802 UCs (457 pre-COVID, 345 post-COVID), 724 AS (401 pre-COVID, 323 post-COVID), and 6,454 DOT (3553 pre-COVID and 2901 post-COVID) were reported over the 16-month intervention period. No significant differences in the study outcomes were observed during the pre-COVID intervention period, however, UC rates in NHs assigned to the usual care arm of the study increased while those in the enhanced arm declined following onset of COVID-19 (Figure 1). AS and DOT rates followed a similar pattern although the differences between the study arms were not statistically significant.

Figure 1. Post Implementation Periods

Conclusion

Our findings suggest that NHs assigned to usual implementation regressed in their diagnosis and treatment of UTIs during the COVID-19 pandemic while those receiving external facilitation and peer comparison reports were more resilient to the effects of COVID-19.

Disclosures

All Authors: No reported disclosures

Optimal Urine Culture Diagnostic Stewardship Practice- Results from an Expert Modified-Delphi Procedure

BACKGROUND

Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.

METHODS

A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped in three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed in a virtual meeting, and a then second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.

RESULTS

165 questions were reviewed with the panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional reflex urine cultures and urine white blood cell as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.

CONCLUSIONS

These 18 guidance statements can optimize use of the imperfect urine culture for better patient outcomes.

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project

BACKGROUND

Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration.

METHODS

Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations.

RESULTS

Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap.

DISCUSSION

Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change.

CONCLUSIONS

Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

200. Frequency and Characteristics of Patients Switched from Intravenous to Oral Antibiotic Therapy on Discharge to Nursing Homes

Background

Determining eligibility for intravenous (IV) to oral (PO) antibiotic conversion is challenging in patients transitioning to nursing homes (NHs) due to atypical infection presentation, increased diagnostic uncertainty, and multimorbidity. Understanding current practice and patient characteristics influencing prescriber behavior is necessary to provide effective antibiotic stewardship in this vulnerable population. We compared the frequency and characteristics of patients discharged with IV antibiotics to those switched from IV to PO therapy.

Methods

This was a retrospective cohort study of Oregon Health & Science University Hospital patients treated with IV antibiotics and discharged to a NH from 1/1/2016-12/31/2018. We focused on IV to PO antibiotic switch within 48 hours of discharge. Using a repository of electronic health record data, we collected patient demographic, diagnosis, length of stay, and treatment duration data.

Results

Among 2,410 patients discharged to a NH on antibiotics, 1,483 (61.5%) received an IV antibiotic within 48 hours of discharge. IV to PO switch occurred in 46.7% of patients prior to discharge, and these patients had fewer baseline comorbidities (Table 1). Of those continuing IV antibiotics, 96.1% were prescribed a different PO medication at discharge indicating potential to take PO medications. Cephalosporins (45%) and penicillins (22%) were the most commonly prescribed IV antibiotics, with IV to PO conversion rates of 26% and 46%, respectively. The median (interquartile range) outpatient duration of therapy was 21 (12–33) days for IV antibiotics and 7 (4–10) days for PO antibiotics. Osteomyelitis diagnosis was more frequent among IV therapy patients; pneumonia and urinary tract infections were more frequent in IV to PO switch patients. IV to PO switch patients were less likely to experience a hospital stay > 7 days or receive an infectious disease consult (p < 0.001).

Table 1. Comparison of Patient and Treatment Characteristics among IV and Oral Antibiotic Prescriptions on Discharge

Conclusion

The proportion of patients discharged to a NH on IV antibiotics remains high, even among patients able to tolerate PO medication. Continuing IV therapy was associated with longer treatment durations, hospital stays, and broad spectrum regimens, while patients with IV to PO switch had a higher comorbidity burden at baseline.

Disclosures

All Authors: No reported disclosures

246. Antibiotic Prescribing Patterns for Residents in Assisted Living Facilities

Background

Knowledge about antibiotic utilization in Assisted Living Facilities (ALFs) is limited. Studies have primarily focused on aggregate prescribing patterns, clinical indications for antibiotics, and the types of antibiotics prescribed. Information about individual resident prescribing patterns is limited. This project addresses the gap by using data from a convenient sample of ALFs.

Methods

Data on antibiotic prescriptions from 3 ALFs in Wisconsin were collected for a one-year period. Information included start and stop dates, clinical indication, and antibiotic prescribed. Antibiotic orders for the same resident were categorized as distinct events to capture treatment courses if 1) the days between the end date of the prior antibiotic and the initiation date of subsequent antibiotic orders were &gt; 4 days, or 2) if the identified indications for the prior and subsequent antibiotic were different. Event-level indication was further defined based on (2). Descriptive statistics were used to understand antibiotic prescribing patterns at the individual and event level.

Results

A total of 207 antibiotic events among 110 assisted-living residents were identified. The patterns of antibiotic use at the resident and treatment course levels are described in tables 1 and 2, respectively. On average, each resident was received 1.9 (range:1 to 10) antibiotic treatment courses for an average of 24.8 (range: 1 to 237) total antibiotic days. The treatment duration of each treatment course averaged 14.5 days (range: 1 to 306). About 10 % of residents had 4 or more antibiotic events and days of therapy over 56 days. 43% of residents were prescribed an antibiotic without a clinical indication and 26% of the antibiotic events were not indicated. UTI was the most common indication for antibiotic treatment (31%) and ciprofloxacin was the most commonly prescribed antibiotic (22%).

Conclusion

The current study demonstrates multiple opportunities to improve antibiotic use in ALFs, including: 1) specification of indication for the antibiotic; 2) reducing unnecessary antibiotic treatments; 3) shortening durations of treatments; and 4) reducing use of broad-spectrum antibiotics. Studies on interventions that target these areas are needed.

Disclosures

All Authors: No reported disclosures

137. Evaluating a Novel Antibiogram Format for use in Wisconsin Nursing Homes

Background

Nursing homes (NHs) increasingly use antibiograms to track antibiotic-related outcomes and guide antibiotic choice. Creation of a facility-specific antibiogram is hampered by low number of cultures collected in NHs. A weighted-incidence syndromic combination antibiogram (WISCA) is an alternative approach that may provide more stable estimates of antibiotic activity. In this study, we compare traditional antibiograms and WISCAs in a sample of Wisconsin NHs.

Methods

We created urine-specific antibiograms using traditional and WISCA approaches at facility and regional levels using culture data collected in study NHs from 01/01/2018 – 12/31/2018. Susceptibility results were standardized across laboratories using CLSI breakpoints. Traditional antibiograms were deemed reliable when ≥ 20 isolates were recovered for at least one species and species exceeding this threshold comprised 75% of all isolates. WISCAs were deemed reliable if ≥ 20 urinary isolates were recovered. Bootstrapped regional mean susceptibilities and confidence intervals for traditional antibiograms and WISCAs were calculated. Susceptibilities calculated at the facility-level were compared to regional estimates. Facility-level susceptibility estimates were deemed concordant if within 1 SD, moderately discordant if between 1 and 2 SDs, and severely discordant if greater than 2 SDs of the regional estimate.

Results

462 urine isolates were obtained from 23 NHs in 2 regions. None of the facility-specific traditional antibiograms met reliability criteria. 10 of 23 facility-specific WISCAs were reliable and increased to 19 of 23 when 2-years of microbiology data were utilized (table). Severe discordance between facility-specific and regional estimates was identified with 62/107 NH species-antibiotic means and 98/119 NH urine isolate-antibiotic means falling outside of 2 SD of corresponding bootstrap regional susceptibility means (figure).

Table. Reliability analysis of facility-specific urinary WISCAs and traditional antibiograms. 2-year projection was created using the assumption of similar culture results over 2-years.

Conclusion

WISCAs are more reliable than traditional antibiograms for estimating antibiotic susceptibilities using facility-specific data. The high degree of discordance observed between facility-specific and regional antibiograms raises concerns about pooling culture data from multiple facilities.

Disclosures

All Authors: No reported disclosures

885. Feasibility of Observing Traffic Patterns (FOOT Patter) in Veterans Health Administration Operating Rooms

Background

Surgical site infections (SSIs) complicate nearly 6% of surgeries performed in Veterans Health Administration (VA) hospitals and occur despite adoption of practices known to reduce them. SSIs are associated with prolonged hospitalization and an increased risk of readmission, reoperation and mortality. Operating room (OR) door openings may increase SSI through disruption of desired OR air flow patterns and increased wound microbe counts. Our study objectives were to: 1) develop a methodological approach for collecting data on entry/exit traffic patterns in VA ORs and 2) characterize patterns across different surgery types.

Methods

Trained researchers from 10 VA-Centers for Disease Control and Prevention (CDC) Practice-based Research Network sites observed staff entering and exiting VA ORs. Staff were categorized and identified by role. Exits/entries were recorded on a standardized tracking sheet. Surgery type and observation duration from incision to closure were noted. Mean hourly door openings across procedure and role types were compared via a one-way ANOVA using Stata ver. 15.0.

Results

We observed 56 surgeries on 55 patients (Fig. 1). During 9,801 observation minutes, 766 staff opened doors 3,882 times. Door openings by role differed significantly (p < 0.001) with nurses, perfusionists, anesthesia and vendors having the highest mean door-opening rate. Coronary artery bypass grafts (CABGs) accounted for most door openings and significantly greater surgical duration than other procedures (p=0.012). Time-adjusted OR door opening rate was similar across procedure types at ~22-26 hourly openings (p=0.186).

Figure 1. FOOT Patter results

Conclusion

The hourly rate of door openings varied notably by staff role. Our data show that measurement of OR movements is feasible although gaining access and approval to observe, achieving ideal observer positioning in complex floor plans, and potential misidentification of entering/exiting staff are challenges of direct methods. Scaling this study up may require automated processes. Studies exploring influences of traffic patterns on OR air quality metrics and impact on risk of SSI, identifying rationale and necessity for door openings and effective strategies for reducing unneeded door openings are needed.

Disclosures

All Authors: No reported disclosures

201. Healthcare utilization outcomes of patients prescribed fluoroquinolones on discharge from the hospital to nursing homes

Background

Fluoroquinolones (FQs) are frequently prescribed in nursing homes (NHs) despite concerns regarding broad spectrum antibiotic selective pressure, increased risk of Clostridioides difficile infection, and other adverse events. NH antibiotics are also frequently initiated in hospitals prior to NH admission. We quantified the frequency and outcomes of patients prescribed FQs on discharge from the hospital to NHs.

Methods

This was a retrospective cohort study of adult (age ≥ 18 years) inpatients prescribed a FQ on discharge from Oregon Health & Science University Hospital (OHSU) to a NH between 1/1/2016 and 12/31/2018. Study data were collected from a repository of electronic health record data. The outcome of interest was a composite of 30-day hospital readmission or emergency department (ED) visit to OHSU. Associations were quantified using odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Among 9,546 patients discharged to a NH, 2,410 (25%) were prescribed at least one antibiotic and 423 (17.6%) were prescribed a FQ. Of these patients, 36.9% were age ≤ 65, 53% were male, 11.6% received a specialty infectious diseases consultation, 34.8% had a surgical diagnosis, and 49.7% had a hospital length of stay > 7 days. The most prevalent comorbidities were cancer (30.5%), chronic obstructive pulmonary disease (29.6%), and renal disease (26%). The most prevalent FQs prescribed were ciprofloxacin (56.7%), levofloxacin (40.2%), and moxifloxacin (3.1%). Duration of NH therapy > 7 days occurred in 37.6% of patients. The most common infectious diagnoses were bloodstream infection and endocarditis (39%), pneumonia (17%), and urinary tract infection (14.2%). Of patients prescribed a FQ, 276 (65.3%) had an ED visit or hospital admission to index facility within 30 days of discharge. Patients who were ≤ 65 years old (OR 2.3, 95% CI 1.4–3.5), male (OR 1.6, 95% CI 1.1–2.5), had comorbid renal disease (OR 1.8, 95% CI 1.1–2.9), or osteomyelitis as infectious diagnosis (OR 2.4, 95% CI 1.0–5.7) were more likely to have a 30-day ED visit or hospital admission.

Conclusion

Patients prescribed FQs on discharge to NHs frequently returned to the hospital for an ED visit or inpatient admission within 30 days of discharge.

Disclosures

All Authors: No reported disclosures

63. Frequency and Outcomes of Patients Prescribed Antibiotics for Extended Durations on Discharge from the Hospital to Nursing Homes

Background

Nursing home (NH) residents are at increased risk of being prescribed antibiotic for extended durations and experiencing antibiotic-associated adverse events. However, many of these antibiotics are prescribed in the hospital prior to NH admission. We quantified the frequency, characteristics and outcomes of patients receiving antibiotic treatment in the hospital and discharged to NHs with an antibiotic prescription for greater than 7 days.

Methods

This was a retrospective cohort study of adult (age >18 years) patients with a prescription for an antibiotic on discharge from Oregon Health & Science University Hospital (OHSU) to a NH between January 1, 2016 and December 31, 2018. Study data were collected from an electronic repository of patients’ electronic health record data. Outcomes of interest included having an emergency department (ED) visit, inpatient hospital admission, or inpatient admission for Clostridioides difficile infection (CDI) at the index facility within 30 days of discharge.

Results

Among 2969 antibiotic prescriptions on discharge, 1267 (42.7%) were prescribed for greater than 7 days to a total of 1059 patients. A diagnosis of a bacterial infection was present for 902 (85.2%) patients. The most frequent diagnoses were bloodstream/endocarditis (21.8%), osteomyelitis (11.6%), and skin and soft tissue infections (10.6%). The most frequently prescribed antibiotics were cephalosporins (24.2%), penicillins (14.1%), glycopeptides (12.9%), and fluoroquinolones (12.6%). Of the 1059 identified patients, 126 (11.9%) had an ED visit, 216 (20.4%) inpatient admission, and 16 (1.5%) had an admission for CDI within 30 days of discharge.

Conclusion

More than 40% of antibiotic prescriptions on discharge to a NH were for greater than 7 days. This frequency and associated poor outcomes suggest extended antibiotic duration are a high-value target to improve antibiotic prescribing on discharge to NHs.

Disclosures

All Authors: No reported disclosures

Workflow Barriers and Strategies to Reduce Antibiotic Overuse in Nursing Homes

OBJECTIVES

Antibiotic overuse is a significant problem in nursing homes (NHs). Strategies to improve antibiotic prescribing practices in NHs are a critical need. In this study, we analyzed antibiotic prescribing workflows to identify strategies for improving antibiotic prescribing in NHs.

DESIGN

Qualitative descriptive study using prospective field-based assessment of workflows.

SETTING

Six NHs in Wisconsin (n = 3) and Pennsylvania (n = 3).

PARTICIPANTS

A total of 44 interviews with 68 NH professionals, including leadership, nurses, and prescribers.

MEASUREMENTS

During a 1-day field visit in each NH, we conducted semistructured interviews with NH professionals, collected artifacts (policies, procedures, and documentation and communication tools), and observed clinical meetings. Study participants were interviewed (30-60 minutes) about antibiotic prescribing workflows in their facility. Information collected during site visits was used to create a representative workflow map of NH antibiotic prescribing. The workflow map guided thematic analysis to identify barriers corresponding to workflow steps across multiple NHs.

RESULTS

The representative antibiotic preprescribing workflow map included 17 steps, beginning with resident change in condition and ending with the decision to prescribe an antibiotic. Thematic analysis identified common step-specific barriers to antibiotic stewardship centering on three themes: (A) information barriers, comprising (A1) inconsistent nurse assessment report and (A2) misalignment between the work and tools of information sharing within the facility, (B) communication barriers, comprising (B1) mismatched perception of prescriber information needs and (B2) difficulty reaching prescribers for direct interaction, and (C) professional barriers, comprising (C1) low prescriber confidence in nurse assessment report and (C2) nurse reluctance to express their professional opinions.

CONCLUSION

Strategies addressing workflow barriers are important targets for antibiotic stewardship. Such strategies include structured information tools, nurse and prescriber education, and organizational improvement. Future research can build on combinations of existing and new strategies to measure their effects in improving antibiotic prescribing. J Am Geriatr Soc 68:2222-2231, 2020.

A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents

IMPORTANCE

Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections.

OBJECTIVE

To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents.

DESIGN, SETTING, AND PARTICIPANTS

A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018.

INTERVENTIONS

Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death.

RESULTS

Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]).

CONCLUSIONS AND RELEVANCE

This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.

Antibiotic Stewardship for Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge

Inappropriate antibiotic use is common in older adults (aged >65 y), and they are particularly vulnerable to serious antibiotic-associated adverse effects such as cardiac arrhythmias, delirium, aortic dissection, drug-drug interactions, and Clostridioides difficile. Antibiotic prescribing improvement efforts in older adults have been primarily focused on inpatient and long-term care settings. However, the ambulatory care setting is where the vast majority of antibiotic prescribing to older adults occurs. To help improve the clinical care of older adults, we review drivers of antibiotic prescribing in this population, explore systems aspects of ambulatory care that can create barriers to optimal antibiotic use, discuss existing stewardship interventions, and provide guidance on priority areas for future inquiry. J Am Geriatr Soc 68:244-249, 2020.

Effect of a Standard vs Enhanced Implementation Strategy to Improve Antibiotic Prescribing in Nursing Homes: A Trial Protocol of the Improving Management of Urinary Tract Infections in Nursing Institutions Through Facilitated Implementation (IMUNIFI) Study

IMPORTANCE

Suspicion of urinary tract infection (UTI) is the major driver of overuse and misuse of antibiotics in nursing homes (NHs). Effects of interventions to improve the recognition and management of UTI in NHs have been mixed, potentially owing to differences in how interventions were implemented in different studies. An improved understanding of how implementation approach influences intervention adoption is needed to achieve wider dissemination of antibiotic stewardship interventions in NHs.

OBJECTIVE

To compare the effects of 2 implementation strategies on the adoption and effects of a quality improvement toolkit to enhance recognition and management of UTIs in NHs.

DESIGN, SETTING, AND PARTICIPANTS

This cluster-randomized hybrid type 2 effectiveness-implementation clinical trial will be performed over a 6-month baseline (January to June 2019) and 12-month postimplementation period (July 2019 to June 2020). A minimum of 20 Wisconsin NHs with 50 or more beds will be recruited and randomized in block sizes of 2 stratified by rurality (rural vs urban). All residents who are tested and/or treated for UTI in study NHs will be included in the analysis. All study NHs will implement a quality improvement toolkit focused on enhancing the recognition and management of UTIs. Facilities will be randomized to either a usual or enhanced implementation approach based on external facilitation (coaching), collaborative peer learning, and peer comparison feedback. Enhanced implementation is hypothesized to be associated with improvements in adoption of the quality improvement toolkit and clinical outcomes. Primary outcomes of the study will include number of (1) urine cultures per 1000 resident days and (2) antibiotic prescriptions for treatment of suspected UTI per 1000 resident-days. Secondary outcomes of the study will include appropriateness of UTI treatments, treatment length, use of fluoroquinolones, and resident transfers and mortality. A mixed-methods evaluation approach will be used to assess extent and determinants of adoption of the UTI quality improvement toolkit in study NHs.

DISCUSSION

Knowledge gained during this study could help inform future efforts to implement antibiotic stewardship and quality improvement interventions in NHs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03520010.

Decisional Guidance Tool for Antibiotic Prescribing in the Skilled Nursing Facility

OBJECTIVES

To derive weighted-incidence syndromic combination antibiograms (WISCAs) in the skilled nursing facility (SNF). To compare burden of resistance between SNFs in a region and those with and without protocols designed to reduce inappropriate antibiotic use.

DESIGN

Retrospective analysis of microbial data from a regional laboratory.

SETTING

We analyzed 2484 isolates collected at a regional laboratory from a large mixed urban and suburban area from January 1, 2015, to December 31, 2015.

PARTICIPANTS

A total of 28 regional SNFs (rSNFs) and 7 in-network SNFs (iSNFs).

MEASUREMENTS

WISCAs were derived combining Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, and reports restricted to fluoroquinolones, cefazolin, amoxicillin clavulanate, and trimethoprim/sulfamethoxazole.

RESULTS

Pooling the target isolates into WISCAs resulted in an average of 28 of 37 achieving a number greater than 30 with an average of 50 isolates (range = 11-113; >97% urinary). Significant differences were found in antibiotic susceptibility between grouped rSNF data and iSNF data of 75% vs 65% (2.76-11.77; P = .002). The susceptibilities were higher in iSNFs with active antibiotic reduction protocols compared with iSNFs without protocols and rSNFs (effect size = .79 vs .67 and .65, respectively) (I² = 93.33; P < .01). Susceptibilities to cefazolin (95% vs 76%; P < .001) and fluoroquinolones (72% vs 64%; P = .048) were significantly higher in iSNFs with active urinary tract infection protocols as compared with iSNFs without antibiotic reduction protocols.

CONCLUSION

These results suggest that WISCAs can be developed in most SNFs, and their results can serve as indicators of successful antibiotic stewardship programs. J Am Geriatr Soc 68:55-61, 2019.

Infectious Diseases in Older Adults of Long-Term Care Facilities: Update on Approach to Diagnosis and Management

The diagnosis, treatment, and prevention of infectious diseases in older adults in long-term care facilities (LTCFs), particularly nursing facilities, remains a challenge for all health providers who care for this population. This review provides updated information on the currently most important challenges of infectious diseases in LTCFs. With the increasing prescribing of antibiotics in older adults, particularly in LTCFs, the topic of antibiotic stewardship is presented in this review. Following this discussion, salient points on clinical relevance, clinical presentation, diagnostic approach, therapy, and prevention are discussed for skin and soft tissue infections, infectious diarrhea (Clostridium difficile and norovirus infections), bacterial pneumonia, and urinary tract infection, as well as some of the newer approaches to preventive interventions in the LTCF setting.

The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents

OBJECTIVE

To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality.

DESIGN

Two-round modified Delphi survey.

PARTICIPANTS

Expert panel of 19 clinical pharmacists.

MEASUREMENTS

Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score.

RESULTS

The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine).

CONCLUSION

An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539-545, 2019.

Infections in Older Adults: A Case-Based Discussion Series Emphasizing Antibiotic Stewardship

INTRODUCTION

Compared with younger populations, adults 65 years and older are more likely to suffer infection-related morbidity and mortality, experience antibiotic-related adverse events, and acquire multidrug-resistant organisms. We developed a series of case-based discussions that stressed antibiotic stewardship while addressing management of common infections in older adults.

METHODS

Five 1-hour case-based discussions address recognition, diagnosis, and management of infections common in older adults, including those living in long-term care settings: urinary tract infections, upper respiratory tract infections, lower respiratory tract infections, skin and soft tissue infections, and Clostridium difficile infection. The education was implemented at the skilled nursing centers at 15 Veterans Affairs medical centers. Participants from an array of disciplines completed an educational evaluation for each session as well as a pre- and postcourse knowledge assessment.

RESULTS

The number of respondents to the educational evaluation administered following each session ranged from 68 to 108. Learners agreed that each session met its learning objectives (4.80-4.89 on a 5-point Likert scale, 5 = strongly agree) and that they were likely to make changes (2.50-2.89 on a 3-point scale, 3 = highly likely to make changes). The average score on the five-question knowledge assessment increased from 3.6 (72%) to 3.9 (78%, p = .06).

DISCUSSION

By stressing recognition of atypical signs and symptoms of infection in older adults, diagnostic tests, and antibiotic stewardship, this series of five case-based discussions enhanced clinical training of learners from several disciplines.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents

Objectives:

To identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in non-catheterized nursing home residents ≥ 65 years of age using consensus based methods informed by a literature review.

Design:

Literature review and modified Delphi survey with strict inclusion criteria.

Setting and Participants:

Expert panel of 20 physicians certified in geriatric medicine and / or medical direction, actively practicing in post-acute and long-term care settings.

Methods:

The authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including non-specific “quality control” items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert scale (1= strongly disagree to 5= strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use.

Results:

The literature review identified 16 signs and symptoms that were evaluated in three Delphi survey rounds. The response rate was 100% for round one and 95% for the second two rounds. Consensus agreement for inclusion was achieved for dysuria on round one with exclusion of the three quality controls, and “offensive smelling urine”. Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round three evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached.

Conclusions/Implications

The panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute / long-term care populations.

The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure

OBJECTIVES

Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population.

DESIGN

A Delphi consensus procedure.

SETTING AND PARTICIPANTS

An international panel of practitioners recognized as experts in the field of UTI in frail older patients.

MEASURES

In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool.

RESULTS

Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter.

CONCLUSIONS

A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.

Antibiotic Stewardship in Nursing Facilities

Misuse and overuse of antibiotic therapy is a frequent cause of resident harm in nursing facilities. As a result, newly released policy and regulatory initiatives will require antibiotic stewardship programs (ASPs) in nursing facilities. Although implementing ASPs can be challenging, improving the quality of antibiotic prescribing is achievable in this setting. The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.

Acquisition and persistence of strain-specific methicillin-resistant Staphylococcus aureus and their determinants in community nursing homes

Background

Nursing home residents are frequently colonized with various strains of methicillin-resistant Staphylococcus aureus (MRSA) but the intra-facility dynamics of strain-specific MRSA remains poorly understood. We aimed at identifying and quantifying the associations between acquisition and carriage of MRSA strains and their potential risk factors in community nursing homes using mathematical modeling.

Methods

The data was collected during a longitudinal MRSA surveillance study in six nursing homes in South Central Wisconsin. MRSA cultures were obtained from subjects every 3 months for up to one year. MRSA isolates were subsequently strain-typed by pulsed-field gel electrophoresis (PFGE), and their genetic similarity was established based on the Dice coefficients. Bayesian network analysis, logistic regression and elastic net were used to quantify the associations between acquisition and carriage of MRSA strains discriminated at 80% and 95% strain similarity thresholds and potentially modifiable resident characteristics including previous antibiotic exposure, comorbidity, medical devices, chronic wounds, functional and cognitive status and recent hospitalizations.

Results

Absence of severe cognitive impairment as well as presence of a wound, device and severe comorbidity was associated with elevated probability of USA100 carriage although there was a variation based on the combination of those risk factors. Residents with severe comorbidity and cognitive status and presence of device and wound were identified as certain carriers of USA100 in our sample. Residents with a chronic wound were more likely to carry USA100 MRSA (OR = 2.77, 95% CI = 1.37–5.87). Functional status was identified as an important determinant of carriage of USA100 and USA300 strains. Comorbidity and cognitive status were the two factors associated with carriage of all clonal groups in the study (USA100, USA300 and USA1200).

Conclusions

The combination of Bayesian network analysis, logistic regression and elastic net can be used to identify associations between acquisition and carriage of MRSA strains and their potential risk factors in the face of scarce data. The revealed associations may be used to generate hypothesis for further study of determinants of acquisition and carriage of selected MRSA subtypes and to better inform infection control efforts in community nursing homes.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2837-3) contains supplementary material, which is available to authorized users.

Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings

In response to a rising concern for multidrug resistance and Clostridium difficile infections, the Centers for Medicare and Medicaid services (CMS) will require all long-term care (LTC) facilities to establish an antibiotic stewardship program by November 2017. Thus far, limited evidence describes implementation of antibiotic stewardship in LTC facilities, mostly in academic- or hospital-affiliated settings. To support compliance with CMS requirements and aid facilities in establishing a stewardship program, the Infection Advisory Committee at AMDA-The Society for Post-Acute and Long-Term Care Medicine, has developed an antibiotic stewardship policy template tailored to the LTC setting. The intent of this policy, which can be adapted by individual facilities, is to help LTC facilities implement an antibiotic stewardship policy that will meet or exceed CMS requirements. We also briefly discuss implementation of an antibiotic stewardship program in LTC settings, including a list of free resources to support those efforts.

Important Care and Activity Preferences in a Nationally Representative Sample of Nursing Home Residents

OBJECTIVES

Person-centered care (PCC), which considers nursing home resident preferences in care delivery, has been linked to important outcomes such as improved quality of life, resident satisfaction with care, and mood and reduced behavioral symptoms for residents with dementia. Delivery of PCC fundamentally relies on knowledge of resident preferences. The Minimum Data Set (MDS) 3.0 Preference Assessment Tool (PAT) is a standardized, abbreviated assessment that facilitates systematic examination of preferences from a population of nursing home residents. However, it is unknown how well the PAT discriminates preferences across residents or items. The purpose of this study was to use MDS 3.0 PAT data to describe (1) overall resident preferences, (2) variation in preferences across items, and (3) variation in preferences across residents.

DATA

Data from admission MDS assessments between October 1, 2011 and December 31, 2011 were used for this study.

SAMPLE

A nationally representative sample of 244,718 residents over the age of 65 years who were able to complete the resident interview version of preference, cognition, and depression assessments were included.

MEASUREMENTS

Importance ratings of 16 daily care and activity preferences were the primary outcome measures. Resident factors including function (MDS Activities of Daily Living-Long Form), depression (Patient Health Questionnaire-9), cognitive impairment (Brief Interview for Mental Status), and sociodemographics (age, race, sex, and marital status) were used as predictors of important preferences.

ANALYSIS

Overall preferences were examined using descriptive statistics. Proportional differences tests were used to describe variation across items. Logistic regression was used to describe variation in preferences across residents.

RESULTS

The majority of residents rated all 16 preferences important. However, there was variation across items and residents. Involvement of family in care and individualizing daily care and activities were rated important by the largest proportion of residents. Several resident factors including cognitive impairment, depression, sex, and race were significant predictors of preferences.

CONCLUSIONS

Findings demonstrate the PAT captures variation in preferences across items and residents. Residents with possible depression and cognitive impairment were less likely to rate preferences important than residents without those conditions. Non-Caucasian and male residents reported some preferences differently than Caucasian and female residents. Additional assessment and care planning may be important for these residents. More research is needed to determine the factors that influence preferences and the ways to incorporate them into care.

Challenges and Strategies for Prevention of Multidrug-Resistant Organism Transmission in Nursing Homes

PURPOSE OF REVIEW

Nursing home residents are at high risk for colonization and infection with bacterial pathogens that are multidrug-resistant organisms (MDROs). We discuss challenges and potential solutions to support implementing effective infection prevention and control practices in nursing homes.

RECENT FINDINGS

Challenges include a paucity of evidence that addresses MDRO transmission during the care of nursing home residents, limited staff resources in nursing homes, insufficient infection prevention education in nursing homes, and perceptions by nursing home staff that isolation and contact precautions negatively influence the well being of their residents. A small number of studies provide evidence that specifically address these challenges. Their outcomes support a paradigm shift that moves infection prevention and control practices away from a pathogen-specific approach and toward one that focuses on resident risk factors.

The Association Between Geographic Density of Infectious Disease Physicians and Limb Preservation in Patients With Diabetic Foot Ulcers

Background

Avoiding major (above-ankle) amputation in patients with diabetic foot ulcers is best accomplished by multidisciplinary care teams with access to infectious disease specialists. However, access to infectious disease physicians is partially influenced by geography. We assessed the effect of living in a hospital referral region with a high geographic density of infectious disease physicians on major amputation for patients with diabetic foot ulcers. We studied geographic density, rather than infectious disease consultation, to capture both the direct and indirect (eg, informal consultation) effects of access to these providers on major amputation.

Methods

We used a national retrospective cohort of 56440 Medicare enrollees with incident diabetic foot ulcers. Cox proportional hazard models were used to assess the relationship between infectious disease physician density and major amputation, while controlling for patient demographics, comorbidities, and ulcer severity.

Results

Living in hospital referral regions with high geographic density of infectious disease physicians was associated with a reduced risk of major amputation after controlling for demographics, comorbidities, and ulcer severity (hazard ratio, .83; 95% confidence interval, .75–.91; P < .001). The relationship between the geographic density of infectious disease physicians and major amputation was not different based on ulcer severity and was maintained when adjusting for socioeconomic factors and modeling amputation-free survival.

Conclusions

Infectious disease physicians may play an important role in limb salvage. Future studies should explore whether improved access to infectious disease physicians results in fewer major amputations.

Identifying conditions for elimination and epidemic potential of methicillin-resistant Staphylococcus aureus in nursing homes

BACKGROUND

Residents of nursing homes are commonly colonized with methicillin-resistant Staphylococcus aureus (MRSA) but there is a limited understanding of the dynamics and determinants of spread in this setting. To address this gap, we sought to use mathematical modeling to assess the epidemic potential of MRSA in nursing homes and to determine conditions under which non-USA300 and USA300 MRSA could be eliminated or reduced in the facilities.

METHODS

Model parameters were estimated from data generated during a longitudinal study of MRSA in 6 Wisconsin nursing homes. The data included subject colonization status with strain-specific MRSA collected every 3 months for up to 1 year. Deterministic and stochastic co-colonization and single-strain models were developed to describe strain-specific dynamics of MRSA in these facilities. Basic reproduction numbers of strain-independent MRSA, non-USA300 and USA300 MRSA were estimated numerically. The impact of antibiotic use in the past 3 months on the prevalence of strain-specific MRSA and associated basic reproduction numbers were evaluated.

RESULTS

Our models predicted that MRSA would persist in Wisconsin nursing homes, and non-USA300 would remain the dominant circulating strain. MRSA eradication was theoretically achievable by elimination of MRSA-positive admissions over the course of years. Substantial reductions in MRSA prevalence could be attained through marked increase in clearance rates or reduction in MRSA-positive admissions sustained over years. The basic reproduction number of strain-independent MRSA was 0.18 (95 % CI = 0.13-0.23). Recent antibiotic use increased the prevalence of strain-specific MRSA and associated basic reproduction numbers, but was unlikely to lead to an outbreak.

CONCLUSIONS

Based on our model, MRSA elimination from nursing homes, while theoretically possible, was unlikely to be achieved in practice. Decolonization therapy that can sustain higher clearance rates or lower MRSA-positive introductions over years may reduce strain-specific prevalence of MRSA in the facilities, and antibiotic stewardship may contribute to this effort. Large-scale MRSA outbreaks were unlikely in this setting.

The Effects of Prolonged Ethanol Exposure on the Mechanical Properties of Polyurethane and Silicone Catheters Used for Intravascular Access

Background:

Products containing alcohol are commonly used with intravascular devices at insertion, to remove lipids from occluded intravascular devices used during parenteral nutrition, and increasingly for the prevention and treatment of intravascular device-related bloodstream infection. The effects of alcohol on the integrity of intravascular devices remain unknown.

Methods:

Two types of widely used commercial peripherally inserted central catheters, one made of polyether-urethane and one made of silicone, were exposed to a 70% etha-nol lock solution for up to 10 weeks. Mechanical testing was performed to identify force-at-break, stress, strain, modulus of elasticity, modulus of toughness, and wall area of ethanol-exposed and control catheters.

Results:

No significant differences between exposed and unexposed catheters were identified for any of the mechanical parameters tested except for a marginal reduction in the modulus of elasticity for both polyetherurethane and silicone catheters and minor increases in the wall area of polyetherurethane catheters.

Conclusions:

These data indicate that exposure to a 70% ethanol lock solution does not appreciably alter the integrity of selected commercial polyetherurethane and silicone catheters. Given the greatly expanded use of alcoholic solutions with intravascular devices of all types, we believe that manufacturers would be well advised to subject their catheters and other intravascular devices to formal testing of the type employed in this study.

Results of a Veterans Affairs employee education program on antimicrobial stewardship for older adults

We describe a course in the Veterans Affairs (VA) Employee Education System designed to engage nursing staff working in VA long-term care facilities as partners in antimicrobial stewardship. We found that the course addressed an important knowledge gap. Our outcomes suggest opportunities to engage nursing staff in advancing antimicrobial stewardship, particularly in the long-term care setting.

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.

Knowledge, beliefs, and confidence regarding infections and antimicrobial stewardship: a survey of Veterans Affairs providers who care for older adults

We conducted an anonymous survey of providers who care for older adults from 10 Veterans Affairs long-term-care facilities to assess their knowledge, beliefs, and confidence toward treating infections and antimicrobial stewardship. The average score on 5 questions assessing knowledge was 3.6 out of 5.0 (95% confidence interval, 3.3-3.9), which supports a need for education regarding the care of older adults with infections.

Longitudinal Trends in Antibiotic Resistance in US Nursing Homes, 2000-2004

We evaluated antibiotic resistance trends in US nursing homes using the Minimum Data Set. Significant increases in the number and proportion of infections caused by antibiotic-resistant bacteria were documented over the 5-year study. Further research on antibiotic resistance in nursing homes is urgently needed.

Barriers and facilitators of universal HIV screening among internal medicine residents

BACKGROUND

Adoption of universal HIV screening has been low despite national recommendations.

OBJECTIVE

To describe the barriers and facilitators to adoption of universal HIV screening in a low-prevalence setting.

DESIGN

Qualitative, thematic analysis of focus group discussions among internal medicine residents who introduced universal HIV screening into their primary care practice in Madison, Wisconsin.

APPROACH

Deductive and inductive codes constructed a hybridized thematic analysis model. Deductive codes stemmed from a knowledge-attitude-behavior framework for physician nonadherence to guidelines. Inductive codes emerged from the focus group discussions and were embedded into broader deductive codes to provide an HIV-specific model.

KEY RESULTS

Residents were knowledgeable and had positive attitudes toward recommendations for universal HIV screening. Residents felt the majority of their patients were receptive to HIV screening, especially when introduced with normalizing techniques and reference to an expert authority such as the Centers for Disease Control and Prevention (CDC). They still perceived patient discussions as challenging due to stigma surrounding HIV and patients' perceptions of being at low risk. Residents employed individualized electronic medical record cues as a memory aid to discuss the issue.

CONCLUSION

This qualitative study of internal medicine residents training in an area with low HIV prevalence suggests that stigma and patient perception of being at low risk are barriers that should be addressed to effectively integrate universal HIV screening into primary care.