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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).
Before-and-after intervention study.
The study included 27 NHs in North Carolina.
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.
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 were Escherichia coli (38%), Proteus spp (13%), and Klebsiella pneumoniae (12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance among E. coli (P ≤ .001) and ciprofloxacin resistance among Proteus spp (P ≤ .001); however carbapenem resistance increased for Proteus spp (P ≤ .001). Multidrug resistance also increased for Proteus spp compared to the baseline. The high baseline resistance of E. coli to the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.
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.
To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs)
Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period
31 NHs in North Carolina
254 NH residents who had a urine culture ordered within the 1-month study period
We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs.
Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000–99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%).
Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available.
To describe the prevalence, characteristics, and appropriateness of systemic antibiotic use in assisted living (AL) and to conduct a preliminary quality improvement intervention trial to reduce inappropriate prescribing.
Pre-post study, with a 13-month intervention period.
Four AL communities.
All prescribers, all AL staff who communicate with prescribers, and all patients who had an infection during the baseline and intervention periods.
A standardized form for AL staff, an online education course and 5 practice briefs for prescribers, and monthly quality improvement meetings with AL staff.
Monthly inventory of all systemic antibiotic prescriptions; interviews with the prescriber, AL staff member, closest family member, and patient (when capable) regarding 85 antibiotic prescribing episodes (30 baseline, 55 intervention), with data review by an expert panel to determine prescribing appropriateness.
The mean number of systemic antibiotic prescriptions was 3.44 per 1,000 resident-days at baseline and 3.37 during the intervention, a nonsignificant change (P = .30). Few prescribers participated in online training. AL staff use of the standardized form gradually increased during the program. The proportion of prescriptions rated as probably inappropriate was 26% at baseline and 15% during the intervention, a nonsignificant trend (P = .25). Drug selection was largely appropriate during both time periods.
AL antibiotic prescribing rates appear to be approximately one-half those seen in nursing homes, with up to a quarter being potentially inappropriate. Interventions to improve prescribing must reach all physicians and staff and most likely will require long time periods to have the optimal effect.
Recent research indicates that n–3 fatty acids can inhibit cognitive decline,
perhaps differentially by hypertensive status.
We tested these hypotheses in a prospective cohort study (the Atherosclerosis
Risk in Communities). Dietary assessment using a food-frequency
questionnaire and plasma fatty acid exposure by gas chromatography were
completed in 1987–1989 (visit 1), while cognitive assessment with
three screening tools – the Delayed Word Recall Test, the Digit
Symbol Substitution Test of the Wechsler Adult Intelligence
Scale–Revised and the Word Fluency Test (WFT) – was
completed in 1990–1992 (visit 2) and 1996–1998 (visit
4). Regression calibration and simulation extrapolation were used to control
for measurement error in dietary exposures.
Four US communities – Forsyth County (North Carolina), Jackson
(Mississippi), suburbs of Minneapolis (Minnesota) and Washington County
Men and women aged 50–65 years at visit 1 with complete dietary
data (n = 7814); white men and women in
same age group in the Minnesota field centre with complete plasma fatty acid
data (n = 2251).
Findings indicated that an increase of one standard deviation in dietary
long-chain n–3 fatty acids (%
of energy intake) and balancing long-chain n−3/n–6 decreased the risk of 6-year cognitive decline in
verbal fluency with an odds ratio (95% confidence interval) of 0.79
(0.66–0.95) and 0.81 (0.68–0.96), respectively, among
hypertensives. An interaction with hypertensive status was found for dietary
long-chain n–3 fatty acids (g
day−1) and WFT decline (likelihood ratio test,
P = 0.06). This exposure in plasma
cholesteryl esters was also protective against WFT decline, particularly
among hypertensives (OR = 0.51, P
One implication from our study is that diets rich in fatty acids of marine
origin should be considered for middle-aged hypertensive subjects. To this
end, randomised clinical trials are needed.
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