An intervention that incorporated educational materials and a dialogue tool for nursing home staff to use when discussing suspected urinary tract infections (UTIs) in residents with physicians was beneficial in reducing antibiotic prescriptions and inappropriate treatments, a randomized trial from Denmark found.
“In the intervention group, the antibiotic prescription rate for UTI was halved and the rate of inappropriateness of the treatment decision was lower, without substantial increases in all-cause hospitalizations or all-cause mortality compared with the control [group], which was to continue standard practice,” Sif Helen Arnold, PhD, from the Department of Public Health, University of Copenhagen, Denmark, and colleagues wrote in Lancet Infectious Diseases.
Jacob Bodilsen, MD, from the Department of Infectious Diseases at Aalborg University Hospital in Denmark, noted that this open-label, parallel group randomized controlled trial is important because antimicrobial resistance is often driven by inappropriate antibiotic treatment; and, he added, “[i]n Denmark, the primary care sector is responsible for 87% of all antibiotics prescribed for humans (approximately 75% of these prescriptions are filled out by general practitioners) and UTIs are among the most frequent indications.”
Bodilsen, who was not affiliated with the study, wrote in an accompanying editorial that diagnosing UTIs in older patients is often difficult.
“Older patients frequently present with unclear symptoms, a reduced capability of providing a detailed medical history, and a long list of existing comorbidities and medications that might need to be considered,” Bodilsen wrote. “To further complicate matters, noninfectious causes of urogenital symptoms among older people are also common—e.g., urethral irritation due to atrophic vaginal mucosa in postmenopausal women. For individual patients, inappropriate antimicrobial treatment confers unnecessary risks of side-effects and toxic effects, Clostridioides difficile associated diarrhea, and antimicrobial resistance. However, the potential delay in time to correct a diagnosis attributable to inappropriate antibiotic prescribing and associated fixation on erroneous diagnoses in older frail patients is perhaps even more important.”
In their study, which was conducted in 22 nursing homes, Arnold and colleagues randomized nursing home facilities 1:1 to either receive the intervention or to continue with standard practice. Eligibility requirements were residents 65 years or old who were permanent residents in the facility and “resided in a living space designated for those with dementia or somatic health care needs,” the study authors noted.
The primary outcome of the study was the number of antibiotic prescriptions filled for acute UTI per resident per days at risk. They researchers counted prescriptions for separate suspected UTIs and antibiotic adjustments for the same suspected UTI in the same individual as separate events. They defined days at risk as the number of days the resident has been in the nursing home during the trial period.
“Secondary outcomes were the appropriateness of antibiotic treatments for UTI, all-cause hospitalizations, and all-cause mortality during the trial per resident per days at risk,” Arnold and colleagues wrote. “When signs and symptoms matched the flowchart in the reflection tool, UTI was likely and the antibiotic treatment was considered appropriate.”
The Intervention consisted of two parts—an interactive educational session for the nursing home staff and a two-part dialogue tool:
“Interactive educational session for nursing home staff
- Consequences of antibiotic resistance.
- Communication pathway between the resident with a suspected urinary tract infection (UTI) and the physician.
- Discussion of UTI definitions in nursing home residents and asymptomatic bacteriuria.
- Discussion on how to evaluate a resident with non-specific symptoms.
- Case 1: the facilitator showed how to use the dialogue tool.
- Case 2: the participants used the dialogue tool.
“The dialogue tool
- Checklist of observed signs and symptoms.
- Flowchart to determine if UTI is likely.
- Four key questions for reflection:
- Have other diagnostic possibilities been explored before suspecting UTI?
- Is there new onset and substantial change?
- Is it possible to wait, and see?
- Will preventive hygienic measures help?
- Identification: identify the patient and the contacting staff member.
- Situation: describe the event, the duration, and the patient’s vital signs.
- Background: describe any measures taken, use of urinary catheter, and prophylactic treatment of UTI.
- Assessment: describe symptoms.
- Recommendation: ask for advice.”
The educational sessions were conducted in 75 minute sessions over 8 weeks and staff learned “how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool,” Arnold and colleagues wrote.
In all, 22 facilities were randomized—11 in the intervention arm (770 [92.2%] of 835 allocated residents) and 11 in the control group (705 [89.2%] of 790 allocated residents). There were 572 and 535 nursing home staff in the intervention and control groups, respectively. The trial was completed by all nursing home facilities, but there were 65 residents in the intervention group and 85 in the control group excluded from the trial, with 1,470 residents—765 in the intervention group and 705 in the control group—available for analysis for the primary endpoint.
The findings were as follows:
- There were 134 antibiotic prescriptions per resident per 84,035 days at risk in the intervention group versus 228 per 77,817 days at risk in the control group.
- The rate ratio (RR) of receiving an antibiotic for UTI was 0.51 (95% CI 0.37-0.71) in the unadjusted model and 0.42 (0.31-0.57) in the adjusted model.
- No deaths were reported.
- Of the 1,475 residents in the study, 412 (28.5%) were admitted to the hospital.
- All-cause hospitalization risk was increased in the intervention group (adjusted model RR 1.28, 95% CI 0.95-1.74), but all-cause mortality was lower (0.91, 0.62-1.33).
Arnold and colleagues noted that the increase of hospitalization in the intervention group could have two explanations.
“First, the uncertainty of an unknown diagnosis could lead to nursing home staff increasingly recommending hospitalization to the physician or emergency services,” they wrote. “Second, nursing home staff in the intervention group could have been more likely to discover diseases requiring hospitalization, because a broader range of somatic and non-somatic explanations was considered for the observed signs and symptoms.”
Of the participants, 67.7% were female and more than 67% were mobile, with just over 28% wheelchair bound and 2% bedbound. Most of the residents were between 75 and 94 years old.
Limitations of the study include that the “only statistical analysis was blinded, which could result in ascertainment bias by outcome assessors,” and the findings may not be generalizable outside of nursing homes “with an interest in antibiotic stewardship.” Additionally, the study authors noted, antibiotic resistance or long-term effects were not measured in this study.
An intervention that incorporated educational materials and a dialogue tool for nursing home staff to use when discussing suspected urinary tract infections (UTIs) in residents with physicians was beneficial in reducing antibiotic prescriptions and inappropriate treatments.
While there was an increase in hospitalizations in the intervention arm of the trial, mortality was lower.
Candace Hoffmann, Managing Editor, BreakingMED™
The study was funded by the Danish Ministry of Health and The Velux Foundation.
Arnold and co-authors had no relevant relationships to declare.
Bodilsen had no relevant relationships to declare.
Cat ID: 494
Topic ID: 398,494,282,494,730,192,255,241,925