Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial

Abstract

Background Urinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis. Objective The objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality. Methods The study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period. Results The trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020. Conclusions The greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI. Trial Registration ClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062 International Registered Report Identifier (IRRID) DERR1-10.2196/17710

Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents

“…The original idea included four components. We intended to combine a decision aid (based on Loeb et al) with a communication tool (based on McMaughan et al and Ydemann) that included the result of a C-reactive protein (CRP) point-of-care-test (POC-test) [ 29 , 30 , 31 , 32 ]. CRP is a test to identify severe bacterial infections.…”

“…We originally intended the tailoring process to consist of three focus groups with stakeholders [ 32 ]. However, after the first focus group interview, we realised that it was impossible to gather informants for the last two focus groups due to constraints on the informants’ time and resources.…”

“…The following are available online at , Figure S1: The first draft of the reflection tool used in phase 1 of the tailoring process, Figure S2: The first draft of the communication tool used in phase 1 of the tailoring process, Figure S3: The final draft of the reflection tool [ 32 ], Figure S4: The final draft of the communication tool [ 32 ], Text B1: Case used in phase 1, 4 and 5 of the tailoring process, Text S1: The complete case-based education material.…”

The influence of mental status on reported local urinary tract symptoms in patients with bacteraemic urinary tract infections

“…Fever and urinary tract symptoms are absent in a large proportion of adults 65 years diagnosed with UTI in the emergency department 4 and in order to decrease the overuse of antibiotics, consensus committees have recommended that the diagnosis of a UTI be reserved for patients with acute local urinary tract symptoms 5,6 . A prevalent opinion is that for older people who are cognitively intact and who are able to report symptoms, UTI diagnosis is not difficult 7 . However, such opinions are not evidence based because there is no way to determine if elderly patient with isolated bacteriuria has a UTI.…”

“…5,6 A prevalent opinion is that for older people who are cognitively intact and who are able to report symptoms, UTI diagnosis is not difficult. 7 However, such opinions are not evidence based because there is no way to determine if elderly patient with isolated bacteriuria has a UTI. On the contrary, patients with identical organisms identified in both the urine and blood and without extra-urinary tract infections are highly likely to have an actual UTI.…”