Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse

ObjectivesTo determine what information is most important to registered nurses' (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents.DesignWeb-based discrete choice experiment with 19 clinical scenarios.Setting and ParticipantsOnline survey with a convenience sample of RNs (N = 881) recruited from a health care research panel.MethodsClinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non–evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression.ResultsFor all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16–5.65], obvious blood in urine (OR 4.66, 95% CI 3.99–5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28–4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53–7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53–5.47) had highest odds for the forced-deliberation group.Conclusions and ImplicationsThis study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses' assessment of signs and symptoms of potential infections and how they weigh resident information.     

Nursing Home Antibiotic Stewardship Policy and Antibiotics Use: 2013–2017

ObjectivesReducing inappropriate nursing home (NH) antibiotic usage by implementing stewardship programs is a national priority. Our aim is to evaluate the influence of antibiotic stewardship programs on antibiotic use rates in NHs over time.DesignRetrospective, repeated cross-sectional analysis.Setting and ParticipantsLong-term residents not receiving hospice care in freestanding NHs that participated in 1 or both surveys in 2013 and 2017.MethodsSurvey data were merged with the Minimum Data Set and the Certification and Survey Provider Enhanced Reporting data. Our outcome was a binary indicator for antibiotic use. The main predictor was the NH antibiotic stewardship policy intensity. Using multivariate linear regression models adjusting for resident and facility characteristics that differed between the 2 years, we calculated antibiotic use rates in 2013 and 2017 for all residents, those with Alzheimer's disease, and those with any infection including urinary tract infections (UTIs).ResultsOur sample included 317,003 resident assessments from 2013 and 267,537 assessments from 2017, residing in 953 and 872 NHs, respectively. NH antibiotic stewardship policy intensity increased from 2013 to 2017 (P < .01) and among all NH residents, including those with Alzheimer's disease, antibiotic use rate decreased (P < .05), with 45% of the decline attributable to strengthening stewardship programs. For most residents, policy intensity was associated with decreased usage in residents with UTI. However, among Alzheimer's disease residents with a UTI, this association did not persist.Conclusions and ImplicationsAlthough there was a decrease in antibiotic use in 2017, more time is needed to see the full impact of antibiotic stewardship policy into practice. Adjustments to programs that directly address barriers to implementation and appropriate UTI antibiotic use for residents with Alzheimer's disease are necessary to continue strengthening NH antibiotic stewardship and improve care.     

The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure

Objectives

Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population.

Strategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis

ObjectivesA systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.MethodsThe review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for “5As” (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.ResultsThirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing “5As” delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6–2.1] for “ask”, 1.6 [95% CI 1.4–1.8] for “advice”, 9.3 [95% CI 6.8–12.8] for “assist” (quit date) and 3.5 [95% CI 2.8–4.2] for “assist” (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5–2.0] and multi-component interventions [OR 2.2; 95% CI 1.7–2.8] were found to significantly increase smoking abstinence.ConclusionMulti-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.     

Stratification by demographic and clinical data of the antibiotic susceptibility of Escherichia coli from urinary tract infections of the community

AimTo determine the patterns of antibiotic susceptibility of Escherichia coli strains isolated from adult patients with urinary tract infection (UTI), and to stratify the results by age and type of UTI to verify if there are statistically significant differences that can help physicians to prescribe better empirical antibiotherapy.DesignCross-sectional prospective study.LocationCommunity of Getafe (Madrid). Primary care level.Participants100 E. coli strains, randomly chosen, isolated from the urine (10⁴–10⁵ cfu/ml) of different patients from primary care centers in the Getafe area.Main measurementsThe antibiotic susceptibility of the strains was evaluated and the results were stratified by age and type of UTI. The clinical and demographic data of the patients were analyzed, classifying each episode as complicated UTI or uncomplicated UTI.ResultsStrains isolated from patients with uncomplicated UTI showed significantly greater susceptibility than those of complicated UTI to amoxicillin (65.9% vs. 30.6%, p = 0.001), amoxicillin/clavulanic acid (95.5% vs. 77.6%, p = 0.013) and ciprofloxacin (81.8% vs. 63.3%, p = 0.047). In complicated UTI, susceptibility to ciprofloxacin was significantly greater in the ≤65 years age group compared to the older age group (78.3% vs. 50%, respectively, p = 0.041). In the rest of antibiotics, no statistically significant differences were obtained when comparing by age (≤65 years versus >65 years), both in uncomplicated and complicated UTI.ConclusionsClinical and demographic data of patients with UTI are of great importance in the results of the antibiotic susceptibility in E. coli. Antibiograms stratified by patient characteristics may better facilitate empirical antibiotic selection for UTI in primary care.     

Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents.

Among 101 nursing home residents with suspected urinary tract infection (UTI), we determined the negative predictive value of dipstick testing for leukocyte esterase and nitrite to be 100% (95% confidence interval, 74%-100%), compared with laboratory evidence of UTI (greater than 10 white blood cells/mm(3) on urinalysis and greater than 100,000 colony forming units/mL on urine culture). Nursing home dipstick testing effectively excluded the possibility of UTI.     

The Effect of Cranberry Juice Consumption on the Recurrence of Urinary Tract Infection: Relationship to Baseline Risk Factors

Objective: The objective of this study was to assess relationships between clinical predictors of urinary tract infection (UTI) and effects of cranberry juice consumption on recurrence in a post hoc analysis of a 24-week, randomized, double-blind, placebo-controlled, multicenter clinical trial in women with a recent history of UTI.

Methods: Participants consumed a cranberry (n = 185) or placebo (n = 188) beverage (240 mL) daily. Odds ratios (OR) from 20 candidate predictor variables were evaluated in univariate analyses to assess clinical UTI incidence relationships in the placebo group. A multivariate logistic regression model was developed. The effects of cranberry juice consumption were evaluated in subsets categorized by the likelihood of a UTI event based on the prediction model.

Results: In the placebo group, the final multivariate regression model identified four variables associated with the odds for having ≥ 1 UTI: intercourse frequency ≥ 1 time during the prior 4 weeks (OR: 2.36; 95% confidence interval [CI]: 0.98, 5.71; p = 0.057), use of vasectomy or hormonal methods for contraception (OR: 2.58; 95% CI: 1.20, 5.58; p = 0.016), most recent UTI < 90 days prior to screening (OR: 2.28; 95% CI; 1.12, 4.67; p = 0.024), and living in France compared with the United States (OR: 0.17; 95% CI: 0.04, 0.79; p = 0.024). Three propensity categories were investigated (24-week probability < 10%, 10%–21%, and > 21%). Incidence rate ratios for the cranberry vs placebo groups were 0.76 (95% CI: 0.22, 2.60; p = 0.663) for those with < 10% probability, 0.73 (95% CI: 0.35, 1.53; p = 0.064) for those with 10% to 21% probability, and 0.58 (95% CI: 0.35, 0.97; p = 0.039) for those with > 21% probability.

Conclusions: Results suggest that clinical predictors identify women with low and high risk of clinical UTI recurrence, which may be useful for design of clinical studies evaluating preventive therapies.     

Urinary Symptoms in Adolescent Females: STI or UTI?

PurposeTo determine if urinary symptoms or urinary tract infections (UTI) were associated with sexually transmitted infections (STI) and which history, clinical, and laboratory findings could distinguish these infections in symptomatic women.MethodsA cross-sectional sample of 296 sexually active females aged 14–22 years attending a hospital-based teen health center or emergency department were recruited. Genitourinary symptoms, medical and sexual history, and urinalysis results were recorded. STI was defined as a vaginal swab positive for Trichomonas vaginalis or urine nucleic acid amplification test positive for Neisseria gonorrheae or Chlamydia trachomatis. A urine culture with >10,000 colonies of a single pathogen was considered a positive UTI.ResultsIn the full sample, prevalence of UTI and STI were 17% and 33%, respectively. Neither urinary symptoms nor UTI was significantly associated with STI. Further analyses are reported for the 154 (51%) with urinary symptoms: Positive urine leukocytes, more than one partner in the last three months and history of STI predicted STI. Urinalysis results identified four groups: (1) Normal urinalysis—67% had no infection; (2) Positive nitrites or protein—55% had UTI; (3) Positive leukocytes or blood—62% had STI; and (4) Both nitrites/protein and leukocytes/blood positive—28% had STI and 65% had UTI. Those without a documented UTI were more likely to have trichomoniasis than those with a UTI, and 65% of those with sterile pyuria had STI, mainly trichomoniasis or gonorrhea.ConclusionsAdolescent females with urinary symptoms should be tested for both UTI and STIs. Urinalysis results may be helpful to direct initial therapy.     

Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents

ObjectivesDescribe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents.DesignAnalysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017.Setting and participantsResidents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP).MethodsEIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home–specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4.ResultsAmong 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home–specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used.Conclusions and ImplicationsOne in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home–specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.     

Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study

ObjectivesThe use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists.DesignRetrospective cohort study.Setting and ParticipantsWe included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded.MethodsPhysicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics.ResultsOf the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists.Conclusions and ImplicationsAlthough the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.     

Absence of religious beliefs,unhealthy eating habits,illicit drug abuse,and self-rated health is associated with alcohol and tobacco use among college students — PADu study

Aim

Describing the factors associated with the alcohol consumption, tobacco use, binge drinking, and “binge drinking and tobacco use” by college students.

Subject and methods

Cross-sectional study carried out with 356 first-semester college students of a public educational institution at Minas Gerais, Brazil. Sociodemographic characteristics, lifestyle habits (alcohol consumption, tobacco and illicit drugs use, exposure time on screens, and eating habits), and health conditions (weight, height, self-rated health, symptoms of anxiety, and depression) were collected. Statistical analysis was performed using Stata® software version 13.0.

Results

The prevalence of alcohol consumption, tobacco use, binge drinking, and “binge drinking and tobacco use” were 73.9%, 17.4%, 43.5%, and 13.4%, respectively. Had no religious beliefs was associated with alcohol consumption (OR: 1.86 95% CI 1.06–3.27), tobacco use (OR: 2.00 95% CI 1.06–3.78), and “binge drinking and tobacco use” (OR: 2.33 95% CI 1.09–4.96). Unhealthy eating habits was associated with alcohol consumption (OR: 2.06 95% CI 1.06–3.97) and tobacco use (OR: 2.74 95% CI 1.33–5.68; OR: 0.75 95% CI 0.31–1.80). Illicit drugs was associated with alcohol consumption (OR: 8.55 95% CI 1.12–65.42) and tobacco use (OR: 3.19 95% CI 1.20–8.51). Self-rated health was associated with tobacco use, combined (OR: 2.93 95% CI 1.37–6.28) or not (OR: 2.46 95% CI 1.32–4.61) with binge drinking. Additionally, tobacco use was associated with white skin color (OR: 2.62 95% CI 1.35–5.07) and being homosexual (OR: 0.37 95% CI 0.18–0.75). Moreover, “binge drinking” was associated with being overweight (OR: 1.72 95% CI 1.03–2.84). Associations remained in the age and sex adjustment.

Conclusion

It was observed that some factors associated with alcohol consumption and tobacco use are modifiable risk factors. Therefore, we suggest strategic actions focusing on raising the population’s awareness to change these factors. Longitudinal studies are necessary to understand the causal relationship between studied variables and, thus, develop strategic actions to improve the life quality of this population group.

     

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital–Nursing Home Collaboration

ObjectiveNursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones.DesignQuasi-experimental, pre- and post-intervention study.Setting and participantsSix NHs in Monroe County, NY.MethodsA hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time.ResultsPostintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042).Conclusions and implicationsA hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.     

Survey of U.S. adults with spina bifida

BackgroundSpina Bifida (SB) is one of the most common birth defects and causes of permanent disability in the United States (US), with approximately 3.5 cases per 10,000 live births. Objective: To identify complications associated with SB related to skin breakdown, pain, and urinary tract infections (UTIs), and to examine socio-demographic differences related to these complications. Methods: Exploratory cross-sectional study via online of a national US convenience sample of adults with SB. Results: We collected 1485 survey responses, of which 852 had complete, useable data. Skin breakdown in one or more locations during the past year was reported by 43.1%. After controlling for socio-demographic characteristics, only mobility variables remained significant predictors of skin breakdown (assistive device use OR = 3.119, 95% CI: 1.749, 5.564; using a wheelchair OR = 6.336, 95% CI: 3.442, 11.662). Pain in past seven days was reported by 46.9%. Single respondents (OR = 0.621; 95% CI: 0.419, 0.921) and those with at least a Bachelor's degree (vs high school degree or less, OR = 0.468; 95% CI: 0.283, 0.774) were less likely, and those using assistive devices were significantly more likely (OR = 1.960; 95% CI: 1.163, 3.303), to report pain. About one-third (32.7%) reported having a UTI within the past 12 months. Notably, almost half (49.6%) of respondents did not answer this question. The presence of UTIs was not significantly related to any socio-demographic characteristics assessed. Conclusions: Adults with SB in the US live with a wide range of complications which are potentially under-monitored, with predictors of complications that require further research.