Antimicrobial stewardship in rural nursing homes: Impact of interprofessional education and clinical decision tool implementation on urinary tract infection treatment in a cluster randomized trial

2019 ◽  
Vol 40 (4) ◽  
pp. 432-437 ◽  
Author(s):  
Darren K. Pasay ◽  
Micheal S. Guirguis ◽  
Rhonda C. Shkrobot ◽  
Jeremy P. Slobodan ◽  
Adrian S. Wagg ◽  
...  
Keyword(s):  
Urinary Tract ◽  
Nursing Homes ◽  
Antimicrobial Stewardship ◽  
Hospital Admissions ◽  
Urine Culture ◽  
Intervention Group ◽  
Clinical Decision ◽  
Rural Nursing ◽  
Antimicrobial Prescribing ◽  
Cluster Randomized

AbstractObjectives:To measure the impact of an antimicrobial stewardship initiative on the rate of urine culture testing and antimicrobial prescribing for urinary tract infections (UTIs) between control and intervention sites. Secondary objectives included evaluation of potential harms of the intervention and identifying characteristics of the population prescribed antimicrobials for UTI.Design:Cluster randomized controlled trial.Setting:Nursing homes in rural Alberta, Canada.Participants:The study included 42 nursing homes ranging from 8 to 112 beds.Methods/interventions:Intervention sites received on-site staff education, physician academic detailing, and integrated clinical decision-making tools. Control sites provided standard care. Data were collected for 6 months prior to and 12 months after the intervention.Results:Resident age (83.0 vs 83.8 years) and sex distribution (female, 62.5% vs 64.5%) were similar between the groups. Statistically significant decreases in the rate of urine culture testing (−2.1 tests per 1,000 resident days [RD]; 95% confidence interval [CI], −2.5 to −1.7;P< .001) and antimicrobial prescribing for UTIs (−0.7 prescriptions per 1,000 RD; 95% CI, −1.0 to −0.4;P< .001) were observed in the intervention group. There was no difference in hospital admissions (0.00 admissions per 1,000 RD; 95% CI, −0.4 to 0.3;P= .76), and the mortality rate decreased by 0.2 per 1,000 RD in the intervention group (95% CI, −0.5 to −0.1;P= .002). Chart reviews indicated that UTI symptoms were charted in 16% of cases and that urine culture testing occurred in 64.5% of cases.Conclusion:A multimodal antimicrobial stewardship intervention in rural nursing homes significantly decreased the rate of urine culture testing and antimicrobial prescriptions for UTI, with no increase in hospital admissions or mortality.

LO91: Urinary tract infections in the paediatric emergency department: A quality improvement initiative to promote diagnostic and antimicrobial stewardship

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S41
Author(s):  
V. Singh ◽  
L. Morrissey ◽  
M. Science ◽  
O. Ostrow
Keyword(s):  
Emergency Department ◽  
Urinary Tract ◽  
Antimicrobial Stewardship ◽  
Urine Culture ◽  
Diagnostic Algorithm ◽  
Antimicrobial Treatment ◽  
Stewardship Program ◽  
Common Diagnosis ◽  
Negative Urine Culture ◽  
Tract Infections

Background: Urinary tract infection (UTI) is a common diagnosis in children presenting to the Emergency Department (ED) and often leads to empiric antibiotic treatment prior to culture results. A recent study at our centre found that 47% of children diagnosed with a UTI and discharged on antibiotics had a negative urine culture. None of these patients were notified of the negative result or to discontinue antimicrobial treatment. Aim Statement: The aim of this study was to improve UTI diagnostic accuracy by 50% while promoting antimicrobial stewardship through timely antibiotic discontinuation and standardized antimicrobial treatment for uncomplicated UTIs over the next 12 months. Measures &amp; Design: Three interventions were developed using plan-do-study-act (PDSA) cycles. In collaboration with the hospital's Choosing Wisely campaign and antimicrobial stewardship program, an evidence-based empiric UTI diagnostic algorithm was created to aid with diagnostic decision-making and reduce practice variation. A daily call-back system was also implemented for urine cultures where patients who had a negative urine culture were contacted to stop antibiotics. Lastly, a practice alert was integrated in the EMR as a reminder of appropriate antimicrobial prescription duration. The main outcome measures were the percentage of inappropriately diagnosed UTIs and percentage with timely antimicrobial discontinuation. Process measures included antibiotic days saved, treatment duration, and physician adherence to the algorithm. As a balancing measure, positive urine cultures were reviewed to assess accuracy of the algorithm to detect UTIs and potential harm from delayed UTI diagnoses. Evaluation/Results: Early results from the 530 children included in the analysis demonstrated a 14% reduction in inappropriate UTI diagnoses. With the initiation of the call-back system, the antibiotic days saved increased from 0 to 495 days. Call-backs for negative cultures increased from 0% to 68% of the time. Of those positive cultures with a missed UTI diagnosis, only 5 patients in 5 months had a return visit within 72 hours and none required admission. Discussion/Impact: Appropriate diagnosis and treatment of UTIs in our ED has improved with the implementation of a diagnostic algorithm. A larger impact is anticipated once the algorithm is embedded in the EMR as a form of decision support, but these changes take time to implement. Although labour intensive, the call-back system has greatly impacted the antimicrobial days saved and reduced risk for harm in this population.

scholarly journals Antibiotic Treatment for Urinary Tract Infections in Nursing Homes: Identifying Opportunities for Antimicrobial Stewardship

2015 ◽  
Vol 2 (suppl_1) ◽  
Author(s):  
Kelly Ground ◽  
Wallace Jones ◽  
Cynthia Drake ◽  
Gregory Gahm ◽  
Sung-Joon Min ◽  
...  
Keyword(s):  
Urinary Tract ◽  
Nursing Homes ◽  
Antibiotic Treatment ◽  
Urinary Tract Infections ◽  
Antimicrobial Stewardship ◽  
Tract Infections

Antimicrobial resistance patterns of urine culture specimens from 27 nursing homes: Impact of a two-year antimicrobial stewardship intervention

2019 ◽  
Vol 40 (7) ◽  
pp. 780-786 ◽  
Author(s):  
Meera Tandan ◽  
Philip D. Sloane ◽  
Kimberly Ward ◽  
David J. Weber ◽  
Akke Vellinga ◽  
...  
Keyword(s):  
Antimicrobial Resistance ◽  
Nursing Homes ◽  
Antimicrobial Stewardship ◽  
Pathogenic Bacteria ◽  
Intervention Program ◽  
Urine Culture ◽  
Effect Change ◽  
E Coli ◽  
Resistance Patterns ◽  
Culture Positive

AbstractObjective:Identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures during a 2-year antimicrobial stewardship intervention program in nursing homes (NHs).Design:Before-and-after intervention study.Setting:The study included 27 NHs in North Carolina.Methods:We audited all urine cultures ordered before and during an antimicrobial stewardship intervention. Analyses compared culture rates, culture positive rates, and pathogen antimicrobial resistance patterns.Results:Of 6,718 total urine cultures collected, 68% were positive for potentially pathogenic bacteria. During the intervention, significant reductions in the urine culture and positive culture rates were observed (P= .014). Most of the identified potentially uropathogenic isolates wereEscherichia coli(38%),Proteusspp (13%), andKlebsiella pneumoniae(12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance amongE. coli(P≤ .001) and ciprofloxacin resistance amongProteusspp (P≤ .001); however carbapenem resistance increased forProteusspp (P≤ .001). Multidrug resistance also increased forProteusspp compared to the baseline. The high baseline resistance ofE. colito the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.Conclusions:The antimicrobial stewardship intervention program significantly reduced urine culture and culture-positive rates. Overall, very high proportions of antimicrobial resistance were observed among common pathogens; however, antimicrobial resistance trended downward but reductions were too small and scattered to conclude that the intervention significantly changed antimicrobial resistance. Longer intervention periods may be needed to effect change in resistance patterns.

scholarly journals Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial

2015 ◽  
Vol 188 (2) ◽  
pp. 108-115 ◽  
Author(s):  
Akke Vellinga ◽  
Sandra Galvin ◽  
Sinead Duane ◽  
Aoife Callan ◽  
Kathleen Bennett ◽  
...  
Keyword(s):  
Urinary Tract Infection ◽  
Urinary Tract ◽  
Tract Infection ◽  
Randomized Trial ◽  
Cluster Randomized Trial ◽  
Antimicrobial Prescribing ◽  
Cluster Randomized

A Randomized Controlled Trial of an Electronic Clinical Decision Support Tool for Inpatient Antimicrobial Stewardship

2020 ◽  
Author(s):  
Jessica P Ridgway ◽  
Ari Robicsek ◽  
Nirav Shah ◽  
Becky A Smith ◽  
Kamaljit Singh ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Decision Support ◽  
Antimicrobial Stewardship ◽  
Antibiotic Prescription ◽  
Controlled Trial ◽  
Intervention Group ◽  
Clinical Decision ◽  
Control Group ◽  
Randomized Controlled ◽  
Empiric Antibiotic

Abstract Background The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). Methods We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. Results In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [−0.97, −0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). Conclusions Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.

scholarly journals Point-Counterpoint: Reflex Cultures Reduce Laboratory Workload and Improve Antimicrobial Stewardship in Patients Suspected of Having Urinary Tract Infections

2015 ◽  
Vol 54 (2) ◽  
pp. 254-258 ◽  
Author(s):  
Romney M. Humphries ◽  
Jennifer Dien Bard
Keyword(s):  
Urinary Tract ◽  
Los Angeles ◽  
Urinary Tract Infections ◽  
Antimicrobial Stewardship ◽  
Urine Analysis ◽  
Urine Culture ◽  
Outpatient Setting ◽  
Clinical Encounters ◽  
Performing Culture ◽  
Tract Infections

Urinary tract infections (UTIs) are frequent and lead to a large number of clinical encounters. A common management strategy for patients suspected of having a urinary tract infection is to test for pyuria and bacteria by urine analysis (UA) of midstream urine, with initiation of antibiotic therapy and urine culture if one or both tests are positive. Although this practice was first used in an outpatient setting with midstream urine samples, some institutions allow its use in the management of catheterized patients. The ideas behind the reflex urine culture are to limit laboratory workload by not performing culture on negative specimens and to improve antimicrobial stewardship by not giving antimicrobials to patients with negative UA results. The questions are, first, whether reflex urine culture reduces workloads significantly and, second, whether it improves antimicrobial stewardship in the era of increasing numbers of urinary tract infections due to extensively drug-resistant Gram-negative bacilli. Romney Humphries from UCLA supports the idea that reflex urine cultures are of value and describes what reflex parameters are most useful, while Jennifer Dien Bard of Children's Hospital Los Angeles discusses their limitations.

scholarly journals Antimicrobial Prophylaxis and Stewardship in Nursing Home: A Narrative Review

2021 ◽  
pp. 1-6
Author(s):  
M. Tandan
Keyword(s):  
Nursing Home ◽  
Urinary Tract ◽  
Nursing Homes ◽  
Respiratory Tract ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Prophylaxis ◽  
Inappropriate Prescribing ◽  
Significant Risk ◽  
Nursing Home Residents ◽  
Tract Infections

The rapid increase in antimicrobial resistance is a great concern in safeguarding the nursing home population. Improving inappropriate prescribing is the main agenda of antimicrobial stewardship. It is complicated to articulate the appropriateness of antimicrobial prescribed in nursing home residents, especially the prophylaxis. It is tricky because most of the residents are often on multiple medications, and there are no guidelines available for prescribers to decide on the appropriateness. Except for urinary tract infections, prescribing instructions rarely exists for other infections in nursing homes. Very few studies discuss prophylactic prescribing, and most of them are prevalence studies. These studies showed the urinary tract, respiratory tract, and skin-related problem as the most common cause of antimicrobial prophylaxis. However, this information is presented as total proportion without disaggregated analysis of conditions and types of the urinary and respiratory tract and skin-related infections. Further, the definition used is vague, and significant risk factors of antimicrobial prophylaxis and precision about the use remain unanswered. Lack of appropriate definition and unanswered questions are potentially challenging for stewardship in nursing homes. This review summarizes the current situation of antimicrobial prophylaxis and discusses gaps in the literature and pertinent areas for moving forward for antimicrobial stewardship in nursing home settings.

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