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Appropriateness of Initiating Antibiotics for Urinary Tract Infection Among Nursing Home Residents

Published online by Cambridge University Press:  02 November 2020

Taniece R. Eure
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
Nicola D. Thompson
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
Austin Penna
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
Wendy M. Bamberg
Affiliation:
Medical Epidemiology Consulting, Colorado Department of Public Health and Environment
Grant Barney
Affiliation:
New York Emerging Infections Program
Devra Barter
Affiliation:
Colorado Department of Public Health and Environment
Paula Clogher
Affiliation:
Connecticut Emerging Infections Program and the Yale School of Public Health
Malini DeSilva
Affiliation:
Minnesota Department of Health
Ghinwa Dumyati
Affiliation:
New York Emerging Infections Program, University of Rochester Medical Center
Erin Epson
Affiliation:
California Department of Health
Christina B. Felsen
Affiliation:
New York Emerging Infections Program, University of Rochester Medical Center
Linda Frank
Affiliation:
California Emerging Infections Program
Deborah Godine
Affiliation:
California Emerging Infections Program
Lourdes Irizarry
Affiliation:
New Mexico Department of Health
Helen Johnston
Affiliation:
Colorado Department of Public Health and Environment
Marion A. Kainer
Affiliation:
Tennessee Department of Health
Linda Li
Affiliation:
Maryland Department of Health
Ruth Lynfield
Affiliation:
Minnesota Department of Health
JP Mahoehney
Affiliation:
Minnesota Department of Health
Joelle Nadle
Affiliation:
California Emerging Infections Program
Valerie L. S. Ocampo
Affiliation:
Oregon Health Authority
Susan M. Ray
Affiliation:
Georgia Emerging Infections Program, Emory University
Monika E. Samper
Affiliation:
Oregon Health Authority
Sarah Shrum Davis
Affiliation:
New Mexico Department of Health
Marla Sievers
Affiliation:
New Mexico Department of Health
Krithika Srinivasan
Affiliation:
Connecticut Emerging Infections Program and the Yale School of Public Health
Lucy E. Wilson
Affiliation:
Maryland Department of Health
Alexia Y. Zhang
Affiliation:
Oregon Health Authority
Shelley S. Magill
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
Nimalie D. Stone
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
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Abstract

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Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.

Funding: None

Disclosures: None

Type
Poster Presentations
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.