Infection Control & Hospital Epidemiology (2019), 40,432–437 doi:10.1017/ice.2019.9
Original Article
Antimicrobial stewardship in rural nursing homes: Impact of interprofessional education and clinical decision tool implementation on urinary tract infection treatment in a cluster randomized trial
Darren K. Pasay BSc Pharm1 Pharm3, Adrian S. Wagg MD4
, Micheal S. Guirguis PhD2 , Rhonda C. Shkrobot BSc Pharm1, Jeremy P. Slobodan BSc , Cheryl A. Sadowski PharmD5, John M. Conly MD6, Lynora M. Saxinger MD7 and
Lauren C. Bresee PhD8 1Pharmacy Services, Alberta Health Services, Vegreville, Alberta, Canada, 2Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada, 3Pharmacy Services, Alberta Health Services, Red Deer, Alberta, Canada, 4Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada, 5Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada, 6Departments of Medicine, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine, Snyder Institute for Chronic Diseases, University of Calgary and Alberta Health Services – Calgary and Area, Calgary, Alberta, Canada, 7Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada and 8Scientific Affairs, Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada
Abstract
Objectives: To measure the impact of an antimicrobial stewardship initiative on the rate of urine culture testing and antimicrobial prescribing for urinary tract infections (UTIs) between control and intervention sites. Secondary objectives included evaluation of potential harms of the intervention and identifying characteristics of the population prescribed antimicrobials for UTI.
Design: Cluster randomized controlled trial. Setting: Nursing homes in rural Alberta, Canada. Participants: The study included 42 nursing homes ranging from 8 to 112 beds.
Methods/interventions: Intervention sites received on-site staff education, physician academic detailing, and integrated clinical decision- making tools. Control sites provided standard care. Data were collected for 6 months prior to and 12 months after the intervention.
Results: Resident age (83.0 vs 83.8 years) and sex distribution (female, 62.5% vs 64.5%) were similar between the groups. Statistically significant decreases in the rate of urine culture testing (−2.1 tests per 1,000 resident days [RD]; 95% confidence interval [CI],−2.5 to−1.7; P<.001) and antimicrobial prescribing for UTIs (−0.7 prescriptions per 1,000 RD; 95% CI,−1.0 to−0.4; P<.001) were observed in the intervention group. There was no difference in hospital admissions (0.00 admissions per 1,000 RD; 95% CI, −0.4 to 0.3; P = .76), and the mortality rate decreased by 0.2 per 1,000 RD in the intervention group (95% CI, −0.5 to −0.1; P = .002). Chart reviews indicated that UTI symptoms were charted in 16% of cases and that urine culture testing occurred in 64.5% of cases.
Conclusion: A multimodal antimicrobial stewardship intervention in rural nursing homes significantly decreased the rate of urine culture testing and antimicrobial prescriptions for UTI, with no increase in hospital admissions or mortality.
(Received 2 October 2018; accepted 26 December 2018)
Nursing homes are recognized for being areas of concern for the development of antimicrobial resistance.1,2 Antimicrobials are com- monly prescribed to residents that do not meet clinical criteria for
Author for correspondence: Darren K. Pasay, Email:
Darren.pasay@
ahs.ca PREVIOUS PRESENTATION:Apreliminary analysis of this study was presented as an
oral presentation at the Canadian Pharmacists Association Conference 2017 on June 4, 2017, in Quebec City, Quebec, Canada. Cite this article: Pasay DK, et al. (2019). Antimicrobial stewardship in rural nursing
homes: Impact of interprofessional education and clinical decision tool implementation on urinary tract infection treatment in a cluster randomized trial. Infection Control & Hospital Epidemiology, 40: 432–437,
https://doi.org/10.1017/ice.2019.9
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
urinary tract infection (UTI).2–5 Contributing factors to the overuse of antimicrobials have been linked to the overutilization of urine testing, specifically when investigating nonspecific symptoms, as well as embedded beliefs (“lore”) and practices (eg, prescribing etiquette), lack of knowledge regarding the difference between asymptomatic bacteriuria (ASB) and UTI, and a liberal prescribing culture.4–6 Failure to assess urine test results in the context of patient symptoms is a common theme recognized as an inappropriate use of resources.7 Prior studies of the influence of rurality of nursing home care suggest that there are differences in access, acute-care admissions
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