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stewardship activities or staff working at more than 1 site is possible because control sites were not sequestered or restricted in pursuing other antimicrobial stewardship opportunities. This possibility would bias results towards the null, but this was unlikely because no change in prescription patterns was observed in the control group over the study period. The operational approval process may have resulted in socialization of the intervention prior to the wash-in month. In addition, some sites required more than a month to complete the intervention, which may have contributed to the primary outcomes being impacted in the latter portion of the baseline
period.Nevertheless, the results were still significant and add to the strength of the overall findings (Fig. 1). Utilization of theclinicaldecision-making toolpostintervention was not assessed; an idea of the uptake of the intervention over time would have been valuable feedback for the sites and explained why the primary outcomes gradually increased postintervention. Most of the antimicrobials included may be used for indications other than UTI, and efforts were made to exclude prescriptions that were obviously not for UTI from the data set. Nevertheless, prescription rates may have been influenced by the presence of other indications. Cluster randomization was performed based upon the number of beds only. There was no stratification for other variables, which might affect resident care: for example, the number of attending physicians at each site, staffing ratios, clinical pharmacist coverage, facility age, and whether the nursing home stood alone or was attached to an acute care facility. The primary investigator was responsible for screening antimicrobial prescriptions for inclusion in the database and was aware of the nursing homes’ allocation through delivery of the interven- tion. Clear, nonsubjective criteria for exclusion mitigated potential bias. To our knowledge, this is the first study to measure an anti-
microbial stewardship intervention focusing on urine testing and appropriate treatment of UTIs in a large number of rural nursing homes. The outcomes are similar to other studies that involved either a limited number of sites or were based in larger, urban nursing homes.14,15,20–24 Rurality was a consider- ationinthedelivery of the interventionbecausethestudysites were located in a large geographic area that required significant travel resources. The UTI in LTC intervention was able to significantly decrease
urine culture testing and UTI prescribing rates without an impact on admission or mortality rates. The concepts were well accepted by staff and physicians, with reassurance that limiting urine testing and antimicrobial prescribing to residents with strong clinical sus- picion of UTI would not cause harm. Coordination of resources across disciplines (ie, pharmacy, infection prevention and control, nurse educators and senior leaders) is needed to ensure that the impact of the intervention is sustained over time.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2019.9
Author ORCIDs. Darren K. Pasay, Guirguis,
Lauren C. Bresee,
0000-0002-8858-3129;AdrianS.Wagg, 0000-0002-4387-9612
0000-0001-8956-6032;Micheal S. 0000-0002-5372-530X;
Acknowledgments. The authors thank all of the staff, physicians, and the lead- ership at each of the interventionsites for their attentionandparticipation, aswell as
Darren K. Pasay et al
members of the study’sAdvisoryPanel (Anne-MarieEwanchuk, Shawna Reynolds, Dianne Calder, Bradley Bennett, Cindy McMinis, Sandra Leung, Alison Devine, and Vineet Saini).We thank Johnathon Tong and Camille Rudolf for developing educational documents, Julia (Bingjie) Jin, Raymond Lam, and Daniel Leung for data collection assistance, and Pat Mayo for statistical mentorship.
Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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