Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial

Abstract

Background Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process. Methods A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals. Discussion This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care. Trial registration The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555.

Nursing Effect Analysis of Urinary Tract Infections in Urology Surgery Patients: a Systematic Review and Meta-analysis

“…Study designs of included articles are shown in the second column of Table 2 . Studies [ 12 , 14 , 16 , 17 , 20 , 21 ] were mainly focused on diagnosing UTIs in patients, while studies [ 18 , 19 ] investigated the treatment approaches of UTI patients. The rest of the studies [ 13 , 15 ] assessed UTI prophylaxis and asymptomatic bacteriuria (UTI), as shown in Table 2 .…”

“…The rest of the studies [ 13 , 15 ] assessed UTI prophylaxis and asymptomatic bacteriuria (UTI), as shown in Table 2 . There were five studies [ 15 , 16 , 18 , 19 , 21 ] performed at nursing homes in the USA, two each in Norway [ 13 , 17 ] and the Netherlands [ 12 , 20 ]. Study [ 14 ] was conducted at nursing homes in Italy.…”

“…Study [ 14 ] was conducted at nursing homes in Italy. Studies [ 12 , 13 , 17 , 19 , 20 ] mentioned the agents used to treat patients at nursing homes. All of the included studies reported techniques to diagnose or treat UTI patients at nursing homes.…”

Resident-Related Factors Influencing Antibiotic Treatment Decisions for Urinary Tract Infections in Dutch Nursing Homes

“…Thus, guideline recommendations alone do not prevent treatment of non-specific symptoms and additional approaches to improve antibiotic prescribing behaviour are warranted. Involvement, education, and coaching of both physician and nursing staff have already been presented as strategies to improve antibiotic stewardship [ 19 , 26 , 27 , 28 , 29 , 30 , 31 ]. Additional strategies include providing communication tools to nurses to improve effective communication among healthcare workers [ 32 ] and interventions directed at appropriate urine culturing [ 33 ].…”

“…Despite the recommended guideline, inappropriate antibiotic prescriptions persists. A strategy to enhance appropriate antibiotic prescriptions in this setting is to improve the diagnostic process of suspected UTI in older adults, for example, by implementing a decision tool that automatically generates treatment advice into the electronic health record [ 19 ]. For any antibiotic stewardship strategy to improve prescribing behaviours for UTIs, more insight into antibiotic treatment decisions and influencing factors is essential.…”