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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

Published online by Cambridge University Press:  20 February 2019

Darren K. Pasay Open the ORCID record for Darren K. Pasay [Opens in a new window] ,
Micheal S. Guirguis Open the ORCID record for Micheal S. Guirguis [Opens in a new window] ,
Rhonda C. Shkrobot ,
Jeremy P. Slobodan ,
Adrian S. Wagg Open the ORCID record for Adrian S. Wagg [Opens in a new window] ,
Cheryl A. Sadowski ,
John M. Conly ,
Lynora M. Saxinger  and
Lauren C. Bresee Open the ORCID record for Lauren C. Bresee [Opens in a new window]
Darren K. Pasay*
Affiliation:
Pharmacy Services, Alberta Health Services, Vegreville, Alberta, Canada
Micheal S. Guirguis
Affiliation:
Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
Rhonda C. Shkrobot
Affiliation:
Pharmacy Services, Alberta Health Services, Vegreville, Alberta, Canada
Jeremy P. Slobodan
Affiliation:
Pharmacy Services, Alberta Health Services, Red Deer, Alberta, Canada
Adrian S. Wagg
Affiliation:
Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
Cheryl A. Sadowski
Affiliation:
Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
John M. Conly
Affiliation:
Departments of Medicine, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine, Snyder Institute for Chronic Diseases, University of Calgary and Alberta Health Services – Calgary and Area, Calgary, Alberta, Canada
Lynora M. Saxinger
Affiliation:
Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
Lauren C. Bresee
Affiliation:
Scientific Affairs, Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada
*
Author for correspondence: Darren K. Pasay, Email: [email protected]
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Abstract

Objectives:

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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 4 , April 2019 , pp. 432 - 437
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

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Footnotes

PREVIOUS PRESENTATION: A preliminary analysis of this study was presented as an oral presentation at the Canadian Pharmacists Association Conference 2017 on June 4, 2017, in Quebec City, Quebec, Canada.

References

Mitchell, SL, Shaffer, ML, Loeb, MB, et al. Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia. JAMA Intern Med 2014;174:1660–1667.CrossRefGoogle ScholarPubMed
Doernberg, SB, Dudas, V, Trivedi, KK. Implementation of an antimicrobial stewardship program targeting residents with urinary tract infections in three community long-term care facilities: a quasi-experimental study using time-series analysis. Antimicrob Resist Infect Control 2015;4:54.CrossRefGoogle ScholarPubMed
Flokas, ME, Andreatos, N, Alevizakos, M, et al. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis 2017;4:ofx207.CrossRefGoogle ScholarPubMed
Fleming, A, Bradley, C, Cullinan, S, et al. Antimicrobial prescribing in long-term care facilities: a qualitative, multidisciplinary investigation. BMJ Open 2014;4:e006442.CrossRefGoogle Scholar
Charani, E, Edwards, R, Sevdalis, N, et al. Behaviour change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis 2011;53:651–662.CrossRefGoogle Scholar
Nicolle, LE, Bentley, DW, Garibaldi, R, et al. Antimicrobial use in long-term–care facilities. Infect Control Hosp Epidemiol 2000;21:537–545.CrossRefGoogle ScholarPubMed
Rowe, TA, Juthani-Mehta, M. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin N Am 2014;28:76–89.CrossRefGoogle ScholarPubMed
Temkin-Greener, H, Zheng, NT, Mukamel, DB. Rural-urban differences in end-of-life nursing home care: facility and environmental factors. Gerontologist 2012;52:335–344.CrossRefGoogle ScholarPubMed
Wilson, DM, Thomas, R, Burns, KK, et al. Canadian rural–urban differences in end-of-life care setting transitions. Glob J Health Sci 2012;4:1–13.CrossRefGoogle ScholarPubMed
Clement, JP, Khushalani, J, Baernholdt, M. Urban–rural differences in skilled nursing facility rehospitalization rates. JAMDA 2018;19:902–906.Google ScholarPubMed
Koller, D, Eisele, M, Kaduszkiewicz, H, et al. Ambulatory health services utilization in patients with dementia—Is there an urban-rural difference? Int J Health Geogr 2010;9:59.CrossRefGoogle Scholar
Blake, ME, Fordyce, EM, Pieper, HG. A comparison of nursing home in rural and urban communities in Indiana. Contemp Rur Soc Work 2012;4:91–100.Google Scholar
Allegranzi, B, Gayet-Ageron, A, Damani, N, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis 2013;13:843–851.CrossRefGoogle ScholarPubMed
Loeb, M, Brazil, K, Lohfeld, L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ 2005;331:669.CrossRefGoogle ScholarPubMed
Zabarsky, TF, Sethi, AK, Donskey, CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control 2008;36:476–480.CrossRefGoogle Scholar
Flaherty, JH, Tumosa, N. Saint Louis University Geriatric Evaluation Mnemonics and Screening Tools (SLU GEMS). Saint Louis University School of Medicine Division of Geriatric Medicine and the Geriatric Research, Education, and Clinical Center St. Louis VA Medical Center website. https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/slu-gems-book.pdf. Accessed January 15, 2019.Google Scholar
Toward Optimized Practice (TOP) Working Group for Urinary Tract Infections in Long Term Care Facilities. Diagnosis and management of urinary tract infections in long term care facilities: clinical practice guideline. Toward Optimized Practice website. www.topalbertadoctors.org. Published January 2015. Accessed October 16, 2017.Google Scholar
Landgren, FT, Harvey, KJ, Mashford, ML, et al. Changing antibiotic prescribing by educational marketing. Med J Aust 1988;149:595–599.Google ScholarPubMed
Crnich, CJ, Jump, R, Trautner, B, et al. Optimizing antimicrobial stewardship in nursing homes: a narrative review and recommendations for improvement. Drugs Aging 2015;32:699–716.CrossRefGoogle Scholar
Trautner, BW, Grigoryan, L, Petersen, NJ, et al. Effectiveness of an antimicrobial stewardship approach for urinary catheter associated asymptomatic bacteriuria. JAMA Intern Med 2015;175:1120–1127.CrossRefGoogle ScholarPubMed
van Buul, LW, Sikkens, JJ, van Agtmael, MA, et al. Participatory action research in antimicrobial stewardship: a novel approach to improving antimicrobial prescribing in hospitals and long-term care facilities. J Antimicrob Chemothe 2014;69:1734–1741.CrossRefGoogle ScholarPubMed
Daley, P, Penney, C, Wakeham, S, et al. Urinary tract infection diagnosis and response to therapy in long-term care: a prospective observational study. Can J Infect Dis Med Microbiol 2015;26:133–136.CrossRefGoogle ScholarPubMed
Phillips, CD, Adepoju, O, Stone, N, et al. Asymptomatic bacteriuria, antimicrobial use, and suspected urinary tract infections in four nursing homes. BMC Geriatr 2012;12:73.CrossRefGoogle ScholarPubMed
McMaughan, DK, Nwaiwu, O, Zhao, H, et al. Impact of a decision-making aid for suspected urinary tract infections on antimicrobial overuse in nursing homes. BMC Geriatr 2016;16:1–9.CrossRefGoogle ScholarPubMed
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