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Original Investigation
May 11, 2020

A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents

Author Affiliations
  • 1Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
  • 3Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison
  • 4Medical Service, William S. Middleton Veterans Affairs Hospital, Madison, Wisconsin
  • 5Division of Internal Medicine and Geriatrics, University of Wisconsin, Madison
  • 6Infection Prevention Consultant, Saylorsburg, Pennsylvania
  • 7Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Intern Med. Published online May 11, 2020. doi:10.1001/jamainternmed.2020.1256
Key Points

Question  Can a multifaceted antimicrobial stewardship and quality improvement intervention reduce unnecessary treatment of unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) among noncatheterized nursing home residents?

Findings  This quality improvement study of 25 nursing homes, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, found that the intervention was associated with a reduction in the incidence of antibiotic use for unlikely cystitis cases by 27% and a reduction in overall antibiotic use for any type of urinary tract infection by 17% compared with the control group. There were no significant differences in all-cause hospitalizations or mortality.

Meaning  If implemented, these intervention tools may help nursing homes improve clinical care while meeting recently revised federal requirements for antimicrobial stewardship and quality improvement.

Abstract

Importance  Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections.

Objective  To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents.

Design, Setting, and Participants  A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018.

Interventions  Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care.

Main Outcomes and Measures  The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death.

Results  Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]).

Conclusions and Relevance  This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.

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