Reducing unnecessary urine culturing and antibiotic overprescribing in long-term care: a before-and-after analysis

Abstract

ates of antibiotic use in long-term care homes are highly variable and this variability is not associated with characteristics of long-term care residents. 1 However, high rates of antibiotic use are associated with antibiotic resistance and Clostridium difficile infection. 2-4 Antibioticassociated adverse events could be reduced if antibiotic overuse in long-term care was reduced. 5 Over 30% of antibiotics prescribed in long-term care are for urinary indications. 6 One practice that can contribute to overuse is the treatment of asymptomatic bacteriuria. 7,8 Asymptomatic bacteriuria is the presence of bacteria in the urine in the absence of clinical signs and symptoms of a urinary tract infection. 7 The prevalence of asymptomatic bacteriuria in long-term care residents is high: it is estimated that 15%-30% of men and 25%-50% of women have the condition. 9,10 Several randomized controlled trials have found that the systematic screening and treatment of asymptomatic bacteriuria in long-term care is not beneficial to residents. 11,12 The Infectious Diseases Society of America and the Association of Medical Microbiology and Infectious Disease Canada both discourage this practice. 8,13 In many long-term care homes, treatment of asymptomatic bacteriuria accounts for most urinary antibiotic use. 14 Public Health Ontario, an arm's length government agency that provides scientific expertise and technical support to front-line health care workers, developed a multistrategy Urinary Tract Infection Program to improve diagnosis and management of urinary tract infections in noncatheterized residents of long-term care homes. The program built on several studies showing that interventions designed to improve diagnosis and management of urinary tract infections are effective at reducing antimicrobial use in long-term care homes. 5,15,16 Rather than focusing on a single guideline, the program focused on 5 practice changes by incorporating 9 strategies to address specific barriers to practice change. 17 We aimed to address 2 questions before further rollout of the program in the province: first, whether the program decreased

Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: a systematic review and meta-analysis

“…Lastly, since we ran our searches in November 2018, we have identified three more articles describing before-after studies of interventions to improve antibiotic prescribing in LTCFs that meet our inclusion criteria. One study evaluated the impact of an educational intervention to improve antibiotic use for UTIs in 10 Canadian LTCFs and reported a 26% decrease (adjusted incidence rate ratio=0.74, 95% CI: 0.47 to 0.74) in the overall number of antibiotic prescriptions per 1000 resident days 10. The second study, in seven Canadian LTCFs, reported a decrease in the use of antibiotics for asymptomatic bacteriuria from 90% pre-intervention to 62.9% post-intervention (p=0.003), following an educational intervention 73.…”

“…Studies have estimated that between 47% and 70% of residents receive a course of antibiotics annually, and that between 77% to 88% of infections are treated with an antibiotic 7–9. Approximately 50% of these prescriptions are judged to be inappropriate,9 with inappropriate treatment of urinary tract infections and respiratory tract infections common in LTCF residents 7–12. Thus, there is considerable scope for improving antibiotic use in LTCFs.…”

Virtual learning collaboratives to improve urine culturing and antibiotic prescribing in long-term care: controlled before-and-after study

“…We determined that a minimum of 32 LTCHs would be required to detect a statistically significant difference between treatment and control groups with 80% power and 5% significance for rates of urine cultures performed. This estimate was based on the following assumptions: an event rate difference of −1.0 per 1000 resident days, control event rate of 3.2 per 1000 resident days, an average home bed size of 160 13 and an assumption that the coefficient of variation was 0.25. Using similar methods but with an event rate difference of −0.6 and control event rate of 1.5 per 1000 resident days, we determined that 22 LTCHs would be required for rates of urinary antibiotic prescriptions.…”

“…Previous studies of the UTI Programme and similar multimodal programmes have described experts delivering on-site support. 13 14 These types of supports present an opportunity to build the capacity of organisations to effectively implement practice change; however, tailored onsite visits may not be feasible beyond a pilot stage due to resource intensity. To help scale the UTI Programme in Ontario, Canada, virtual learning collaboratives were selected as a means to maintain support for implementation while also bringing together multiple long-term care homes (LTCHs) to facilitate shared learning.…”

Prescriber-led practice changes that can bolster antimicrobial stewardship in community health care settings

“…The optimal interventions to support these practice change statements are not yet known. Many organizations across Canada, for example, Alberta Health Services, Public Health Ontario and the Association of Medical Microbiology and Infectious Diseases, have developed tools to reduce overdiagnosis and subsequent overtreatment of UTI (24)(25)(26). One common theme is the need for an objective, standardized approach to the diagnosis of UTI in the long-term care resident population using evidence-based criteria so that all health care providers, patients and substitute decision-makers are aligned in their definition of UTI (27).…”