Infection Control & Hospital Epidemiology
and rehospitalizations, specialist availability, staffing ratios, and quality of care.8–12 Recognizing studies on antimicrobial stewardship in rural nurs-
ing homes are limited, the Antimicrobial Stewardship in Rural Continuing Care: Impact of Interprofessional Education and Clinical Decision Tool Implementation on Urinary Tract Infection Treatment (UTI in LTC) intervention was designed based on positive antimicrobial stewardship interventions. It used a multimodal approach that incorporated training, education, sys- tem-level changes and evaluation plus feedback, and it was cus- tomized to the characteristics of rural practice.13–15 Addressing the perceived lore, it is expected to prevent unnec-
essary urine testing and empiric prescribing to prevent the chal- lenge of dealing with test results in the absence of clinical symptoms. We hypothesized that the intervention would result in a decrease in the rate of urine culture testing and antimicrobial prescribing for ASB.
Methods Study setting and design
The UTI in LTC intervention used a cluster randomized con- trolled study design, with sites matched within ±10%of the num- ber of beds to ensure comparability between control and intervention groups. There are 175 nursing homes in Alberta, Canada. Sites were eligible for inclusion if they (1) were located in centers with a population census <15,000 persons, (2) were operated by Alberta Health Services (AHS), (3) used Meditech (Medical Information Technology, Westwood MA) as their phar- macy dispensation database, and (4) were able to obtain opera- tional approval. In total, 64 eligible nursing homes were identified, with 21 sites selected by blinded randomization with a random-numbers table (odd or even) to be included in the intervention group. This approach was deemed reasonable for the investigators to complete the intervention and exceeded the minimum number needed to detect statistical significance. No nursing homes were excluded from the study due to inability tomatchwithacontrolsite. In a staggered fashion, the intervention was delivered at each site at
a point between April 2015 and January 2016. Baseline data were col- lected for the 6months prior to each site’s wash-in month and post- intervention data were collected for the 12 months following the wash-in month (Table 1). This study was approved by the Health Research Ethics Board of Alberta (no.
HREBA.CHC-14-0031).
Intervention
The multimodal intervention was based on the principles of build- ing a culture of safe, effective, and sustainable antimicrobial use, and it targeted key stakeholders in the continuum of care: physicians, nursing staff, and families or caregivers.4 Materials incorporated the following themes: (1) increased awareness of anti- microbial stewardship (with profession specific background docu- ments), (2) best practices for the diagnosis and treatment of UTI and management of ASB (Myths and Facts and Practice Points posters), (3) a pamphlet written in plain language for family and caregivers, and (4) considerations in assessing subtle clinical or behavioural changes in nursing home residents (DELIRIUMS tool).16 A clinical decision-making tool (the Urinary Tract Infections in LTC Facilities Checklist) guided staff to identify UTIs based upon clinical symptoms, to collect a urine culture only when indicated, and to review antimicrobial therapy if prescribed.
Table 1. Nursing Home and Resident Characteristics Variable
Mean beds per nursing home, no. (SD, range)
Unique residents (n=1,248), no. (%)
Mean resident age, y (SD, range)
Female, no. (%) Note. SD, standard deviation.
The checklist acted as an interprofessional communication tool.17 This tool is available in the supplementary Appendix online, and the remainder of materials will be made available upon request. The intervention nursing homes received onsite, face-to-face
education sessions that included site leadership and frontline staff, and individual or small group academic detailing sessions with physicians, all conducted by an antimicrobial stewardship pharma- cist with training in academic detailing. Participants were asked to incorporate the clinical decision-making tool in their practices. Intervention sites were also presented with the baseline urine culture and antimicrobial prescribing rates at the group sessions, and each site was provided 6-month postintervention rates, along with opportunities for additional education sessions upon request, which could be delivered in person or via webinar. To encourage conversation and to assist with identifying local bar-
riers, all sessions included a discussion that beganwith, “What do you need to make these changes happen?” The antimicrobial stewardship pharmacist and participants addressed these barriers together, and plans for implementation with a local context were made. (Examples of the barriers are provided in the Discussion section.) Participants were encouraged to contact the antimicrobial steward- ship pharmacist for assistance with any barriers that occurred during
implementation.Control siteswere not contacted by the investigators.
Outcomes
Recognizing that positive urine culture results (regardless ofwhether the resident is exhibiting criteria for clinical diagnosis ofUTI) drives antimicrobial prescribing and that the main theme of the interven- tion is to test urine only when there is a strong clinical suspicion of UTI, the primary outcomes of this study were the change in number of urine cultures performed per 1,000 resident days (RD) and the number of antimicrobial prescriptions per 1,000 RD between the control and intervention groups from the baseline to the postinter- vention
periods.The number of urine cultures processed eachmonth at each site was obtained from AHS Provincial Laboratory Services. Prescriptions selected for data collection included oral andparenteral antimicrobials typically used forUTI treatment in the nursing home population: amoxicillin-clavulanic acid, cefixime, ciprofloxacin, fos- fomycin, gentamicin, nitrofurantoin, norfloxacin, sulfamethoxazole/ trimethoprim, tobramycin, and trimethoprim. Prescription data were retrieved from a Meditech Custom Search report. Duplicate entries, “stat” or single doses (except for fosfomycin), and prescrip- tions with a charted diagnosis other than UTI were excluded. Secondary outcomes included evaluation of harms from reducing antimicrobial therapy (ie, acute-care and emergency department admissions and mortality per 1,000 RD between control and inter- vention groups between the baseline and postintervention periods).
Control Nursing Homes (n=21)
41
(29, 8–112) 620 (49)
83.0
(2.2, 25–106) 388 (62.5)
Intervention Nursing Homes (n=12)
47
(26, 15–107) 638 (51)
83.8
(11.0, 33–102) 417 (65.4)
.22 P
Value .25
433
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