Infection Control & Hospital Epidemiology
Table 2. Primary and Secondary Outcomes between Control and Intervention Groups Variable
Phase Primary outcomes
Urine cultures per 1,000 RD
UTI antimicrobial prescriptions per 1,000 RD
Secondary outcomes Admissions per 1,000 RD
Baseline Postintervention
4.6 4.2
Difference [95% CI] 0.3 [−0.1 to 0.7] Baseline
Post Intervention Difference [95% CI]
Baseline Postintervention
All-cause mortality per 1,000 RD
3.0 3.3
0.3 [0.0 to 0.7]
3.0 3.0
Difference [95% CI] 0.00 [−0.3 to 0.4] Baseline
Postintervention Note. CI, confidence interval; RD, residence days.
0.7 0.8
Difference [95% CI] 0.1 [−0.3 to 0.1] .407 .92 .077 .138
5.1 3.0
−2.1 [−2.5 to −1.7] 3.2 2.5
<.001 −0.2 [−0.2 to 0.6] −0.7 [−1.0 to −0.4] <.0001
3.3 3.3
0.00 [−0.4 to 0.3] 1.0 0.8
−0.2 [−0.5 to −0.1] .76
−0.3 [−0.5 to −0.1] −0.1 [−0.2 to 0.1]
.002
.0007 .393
0.3 [−0.07 to 0.1] 0.3 [−0.03 to 0.5]
.116 .085
.308 −0.8 [−1.1 to −0.6] <.001 0. 6 [0.1 to 1.0] .026 −1.2 [−1.5 to −0.9] <.0001 Control
435
P Value
Intervention
P Value Difference [95% CI]
P Value
prescription occurred in 64.5% of instances. Urinary catheteriza- tion was present in 7.1% of reviewed cases.
Discussion
This multimodal intervention statistically significantly decreased urine culture testing by 2.1 tests per 1,000 RD and antimicrobial prescribing for UTI by 0.7 prescriptions per 1,000 RD. In practical terms, for a 40-bed nursing home over a 1-year period, there would be 31 fewer urine cultures performed and 10 fewer antimicrobial prescriptions. Admissions to acute-care facilities or emergency departments or mortality between the groups did not increase, indicating that reducing antimicrobial therapy did not cause harm. Linear regression analysis demonstrated that after an initial decrease, the outcome rates trended toward the baseline over time. This is a common phenomenon observed in antimicrobial stew- ardship, despite periodic follow-up with sites during the postinter- vention phase.14,18 This further emphasizes the need to include regular feedback cycles, clinical decision reminders, and coordi- nated educational efforts to sustain changes in practice.13,19 Urine culture rates decreased relatively more than prescription rates; other studies have observed different degrees of change in urine testing and prescription rates.14,20 During the discussion ses- sions, participants identified that routine urine culture testing was common, as was antimicrobial prescribing for UTIs empirically without urine testing, and that positive urine culture results would result in an antimicrobial order. The prevalence of these practices among the sites and the degree to which the educational themes resonated with participants may explain the relative difference in the primary outcomes. The educational themes introduced antimicrobial stewardship,
including why antimicrobials need to be used in an optimalmanner to preserve their value for society and for resident safety. Established guidelines and evidence were used in the UTI in LTC materials to address the perceptions of staff and physicians about the “lore” that nonspecific changes (defined as odorous or cloudy urine, lethargy, weakness,malaise, irritable or aggressive behaviours and falls) in the
absence of typical UTI symptoms required urine testing or antimi- crobial therapy. Although it was not purely a participatory action research activity, opening discussions with “What do you need to make these changes happen?” generated significant conversation among participants.21 Examples of barriers and solutions that par- ticipants identified included the needs for (1) improving communi- cation between staff, physicians, and family using the UTI in LTC Facility Checklist and family and caregiver pamphlet, (2) ensuring that behavioral changes are assessed holistically using a systematic process, and (3) maintaining resident hydration by diversifying the responsibility for administering fluids. The additional data available from 1,001 prescriptions reviewed
revealed that clinical information for a UTI diagnosis was present in up to 16% of cases. In contrast, 64.5% of cases had evidence of a urine culture obtained in the time surrounding the antimicrobial prescription. This implies that urine culture testing in the absence of typical UTI symptoms is a driver of antimicrobial prescribing for what could be considered ASB. Because the cases reviewed were not evenly distributed, the impact of the intervention on the chart- ing of UTI diagnostic criteria cannot be ascertained. This study has several strengths. The cluster design allowed for
randomization and analysis of groups of sites. The number of clus- ters required to detect differences between groups exceeded the min- imum amount estimated by the power calculation. A year-long follow-up period addressed seasonal variances and allowed for an assessment of howsustained the intervention impact was. The inter- vention used available resources and aimed to achieve modest and sustainable changes in practice without relying on additional fund- ing or unrealistic expectations of participants. Broad interprofes- sional engagement with participatory strategies tailored the intervention to each site and ensured that participants were engaged and that the intervention was relevant to the needs of the site. Since a large number and variety of rural sites across a vast geographic area were included, the outcomes are generally applicable. The limitations of this study require consideration. Contamination of the control group from other antimicrobial
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