Syndromic Antibiograms and Nursing Home Clinicians’ Antibiotic Choices for Urinary Tract Infections

This survey study evaluates whether providing nursing home clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections.


Informed Consent
Participation in this study is anonymous and voluntary.Participating in this study may not benefit you directly, but it will help us learn more about antibiotic prescribing in the nursing home setting and develop a tool to support empiric antibiotic decisions.
If you participate in the study, you will receive a $50.00 Amazon gift card for your time.The information you will share with us will be kept confidential.
If you have any questions about this study, please contact Lindsay Taylor at ltaylor4@uwhealth.org.
There are qualifications to participate in this study: (1) you must be a clinician, either a NP, PA, MD, or DO, and (2) you must currently treat residents of a nursing home.By checking the "I approve" box below, you are indicating that you meet the qualifications above and that you consent to take part in our study.

Start of Block: WISCA Intro Page
Please read in its entirety: Following this screen there will be four clinical vignettes.Each will ask you to pick an antibiotic.Please approach them like you would for any resident of the facilities in which you work.We want this to replicate your practices as closely as possible.
Each case will be presented alongside a novel weighted-incidence syndromic combination antibiogram (WISCA) for your facility pictured here.The WISCA is an alternative to the standard antibiogram format.Rather than presenting antibiotic susceptibilities by bacterial species, a WISCA combines the susceptibilities across all bacteria recovered from a common source (e.g., urine) to predict the activity of individual antibiotics to treat a specific syndrome (e.g., urinary tract infection [UTI]).In the prior four cases, which additional materials or tools did you reference while making your antibiotic decisions?(Select all that apply) ▢ Online References (4) ▢ Local Antibiogram (5) ▢ National Guidelines (6) ▢ Locally Prepared Guidelines (7) ▢ Other (please specify) (8) __________________________________________________ ▢ I don't use other reference materials (9) In your practice, which materials or tools do you reference when making UTI treatment decisions for nursing home residents?(Select all that apply) Overall, you found interpreting information conveyed in the weighted-incidence syndromic combination antibiogram to be: Her temperature is 98.4°F.Her blood pressure is 118/72 with a heart rate of 64, normal respiratory rate and oxygen saturation of 100% on room air.Her physical exam is notable only for slightly masked facies, mild cogwheel rigidity, a shuffling gait, and benign abdominal exam.Urinalysis shows 3+ pyuria, 2+ nitrites.The urine culture is pending.A 78-year-old female with obesity, chronic obstructive pulmonary disease, heart failure, and peripheral vascular disease required an urgent below-knee amputation for limb-threatening ischemia.Her surgery was 2 weeks ago.She has been getting wound care and physical therapy in your building for the previous 10 days.She reports new pain with urination and urgency that developed in the last 48 hours.
Her temperature is 99.2°F.Her blood pressure is 122/82 with a heart rate of 74, normal respiratory rate and oxygen saturation of 100% on room air.Her physical exam is notable for costovertebral angle tenderness to percussion.Based on labs prior to transfer, creatinine clearance was 65 ml/min.Urinalysis shows 3+ pyuria, 2+ nitrites, and white blood cell clumps.Urine culture is pending.
She reports having had swollen lips and difficulty breathing after receiving cephalexin 3 years ago.Beside perioperative antibiotics, she has not taken antibiotics in the prior 3 months.
Assuming you have already decided to treat this patient for UTI, which antibiotic would you prescribe?Pick a single antibiotic.Dose and length of therapy are not required.A 73-year-old woman with a history of insulin-dependent diabetes, stroke with associated right sided weakness, and vascular dementia is a resident of your dementia unit.She developed increased urinary urgency, incontinence, and dysuria over the prior 2 days.She does not have a urinary catheter and has no known antibiotic allergies.
You recall that 3 months ago she was on contact precautions for an extended-spectrum beta-lactamase (ESBL)producing Klebsiella species in her urine, and she was treated with ciprofloxacin.Review of that culture shows that the prior Klebsiella isolate was resistant to cefazolin and ceftriaxone, and sensitive to fluoroquinolones, trimethoprimsulfamethoxazole, nitrofurantoin, cefepime, and carbapenems.
Her temperature is 99.3°F.Her blood pressure is 140/83 with a heart rate of 89, normal respiratory rate and oxygen saturation of 97% on room air.Her physical exam is notable for stable right sided weakness, discomfort with applied suprapubic pressure, and no costovertebral angle tenderness.The urinalysis shows 2+ pyuria and 3+ nitrites.Recent creatinine clearance is 55 mL/min.The urine culture is pending.
Assuming that you have already decided to treat this patient, which antibiotic would you prescribe?Pick a single antibiotic.Dose and length of therapy are not required.

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Please provide a brief description of your rationale for the antibiotic selection, including reason(s) for the antibiotic selected.An 83 year-old man with non-insulin dependent diabetes mellitus, hypertension, and benign prostatic hypertrophy with a chronic indwelling urinary catheter has been living in your facility for the last 3 months.This morning, staff noted he was newly confused and did not eat his breakfast but was able to take his morning pills.He has not had any sick contacts and there are no known COVID-19 cases in the facility.The patient has no known antibiotic allergies and has not taken antibiotics in the prior 3 months.His temperature is 100.4°F.His blood pressure is 135/90 with heart rate of 89, normal respiratory rate and oxygen saturation of 96% on room air.His physical exam is notable for normal cardiac and respiratory exam.He grimaces with applied suprapubic pressure and does not appear to have costovertebral angle tenderness.The chronic indwelling urinary catheter is in place with cloudy urine in the bag.His foley catheter is replaced and urinalysis from a fresh urine sample shows white blood cell clumps, 3+ leukocyte esterase, 3+ nitrites, and many red blood cells.SARS-CoV-2 PCR testing is negative.His most recent creatinine clearance is 65 mL/min.

Assuming that you have already decided to treat this patient for UTI, which antibiotic would you prescribe?
Pick a single antibiotic.Dose and length of therapy are not required.

________________________________________________________________
Please provide a brief description of your rationale for the antibiotic selection, including reason(s) for the antibiotic selected.Please read in its entirety: Following this screen there will be four vignettes presented as patient cases.Please approach them like you would for any resident of the facilities in which you work.We want this to replicate your practices as closely as possible.

Start of Block: Control Abx Choice 1. Cystitis
An 87 year-old female with mild dementia, Parkinson's disease on levodopa, diet-controlled diabetes, and stage 3 chronic kidney disease (recent creatine clearance of 50 mL/min) reports new onset dysuria for the last 48 hours.The staff also notes an increase in urinary incontinence.She has no known drug allergies and is able to take pills orally.She had a Clostridioides difficile infection about 9 months ago.She has not had any antibiotics in the most recent 3 months.100% on room air.Her physical exam is notable for costovertebral angle tenderness to percussion.Based on labs prior to transfer, creatinine clearance was 65 ml/min.Urinalysis shows 3+ pyuria, 2+ nitrites, and white blood cell clumps.Urine culture is pending.
She reports having had swollen lips and difficulty breathing after receiving cephalexin 3 years ago.Beside perioperative antibiotics, she has not taken antibiotics in the prior 3 months.
Assuming you have already decided to treat this patient for UTI, which antibiotic would you prescribe?Pick a single antibiotic.Dose and length of therapy are not required.

________________________________________________________________
Please provide a brief description of your rationale for the antibiotic selection, including reason(s) for the antibiotic selected.An 83 year-old man with non-insulin dependent diabetes mellitus, hypertension, and benign prostatic hypertrophy with a chronic indwelling urinary catheter has been living in your facility for the last 3 months.This morning, staff noted he was newly confused and did not eat his breakfast but was able to take his morning pills.He has not had any sick contacts and there are no known COVID-19 cases in the facility.The patient has no known antibiotic allergies and has not taken antibiotics in the prior 3 months.His temperature is 100.4°F.His blood pressure is 135/90 with heart rate of 89, normal respiratory rate and oxygen saturation of 96% on room air.His physical exam is notable for normal cardiac and respiratory exam.He grimaces with applied suprapubic pressure and does not appear to have costovertebral angle tenderness.The chronic indwelling urinary catheter is in place with cloudy urine in the bag.His foley catheter is replaced and urinalysis from a fresh urine sample shows white blood cell clumps, 3+ leukocyte esterase, 3+ nitrites, and many red blood cells.SARS-CoV-2 PCR testing is negative.His most recent creatinine clearance is 65 mL/min.
Assuming you have already decided to treat this patient for UTI, which antibiotic would you prescribe?Pick a single antibiotic.Dose and length of therapy are not required.

________________________________________________________________
Please provide a brief description of your rationale for the antibiotic selection, including reason(s) for the antibiotic selected.A 73-year-old woman with a history of insulin-dependent diabetes, stroke with associated right sided weakness, and vascular dementia is a resident of your dementia unit.She developed increased urinary urgency, incontinence, and dysuria over the prior 2 days.She does not have a urinary catheter and has no known antibiotic allergies.You recall that 3 months ago she was on contact precautions for an extended-spectrum beta-lactamase (ESBL)-producing Klebsiella species in her urine, and she was treated with ciprofloxacin.Review of that culture shows that the prior Klebsiella isolate was resistant to cefazolin and ceftriaxone, and sensitive to fluoroquinolones, trimethoprim-sulfamethoxazole, nitrofurantoin, cefepime, and carbapenems.
Her temperature is 99.3°F.Her blood pressure is 140/83 with a heart rate of 89, normal respiratory rate and oxygen saturation of 97% on room air.Her physical exam is notable for stable right sided weakness, discomfort with applied suprapubic pressure, and no costovertebral angle tenderness.The urinalysis shows 2+ pyuria and 3+ nitrites.Recent creatinine clearance is 55 mL/min.The urine culture is pending.
Assuming you have already decided to treat this patient for UTI, which antibiotic would you prescribe?Pick a single antibiotic.Dose and length of therapy are not required.

________________________________________________________________
Please provide a brief description of your rationale for the antibiotic selection, including reason(s) for the antibiotic selected.Thank you for your time and responses!As noted in the informed consent section, your personal information will not be linked to any survey responses.Please follow the email link below to Corrine Kowal and state your first and last name as well as preferred mailing address to receive the gift card.
The gift card may take 1-2 weeks to arrive.

End of Block: Conclusion eTable 1. Matrix of Active and Optimal Therapy
Matrix of active and optimal therapy for case 1.
Case 1 presents a female nursing home resident with a history of C. difficile infection and signs/symptoms consistent with simple cystitis.Isolate-antibiotic combinations are coded in the matrix as follows: inactive antibiotic treatment is indicated by a 0, active but not optimal antibiotic treatment is indicated by a 1, and active and optimal antibiotic treatment is indicated by a 2.
Matrix of active and optimal therapy for case 2.
Case 2 presents a female nursing home resident with history of severe allergy to cephalosporins (angioedema) and signs and symptoms consistent with an upper urinary tract infection (pyelonephritis).Isolate-antibiotic combinations are coded in the matrix as follows: inactive antibiotic treatment is indicated by a 0, active but not optimal antibiotic treatment is indicated by a 1, and active and optimal antibiotic treatment is indicated by a 2.  Matrix of active and optimal therapy for case 3.
Case 3 presents a male nursing home resident with a chronic indwelling urinary catheter and signs and symptoms consistent with a catheterassociated urinary tract infection.Additionally, he has fever, raising concern for possible upper urinary tract involvement.Isolate-antibiotic combinations are coded in the matrix as follows: inactive antibiotic treatment is indicated by a 0, active but not optimal antibiotic treatment is indicated by a 1, and active and optimal antibiotic treatment is indicated by a 2.  The antibiograms differ from no antibiogram and from each other.
TA and WISCA higher vs. no antibiogram (p < 0.001) but not different from each other TA and WISCA higher vs. no antibiogram (p < 0.01) but not different from each other The differences in outcomes between arms is not the same for all 4 cases.Significant case-by-arm interaction effect detected (p < 0.001) Significant case-by-arm interaction effect detected (p < 0.001) Adjusting for demographic factors improves the model fit.
No significant improvement in model fit with addition of demographics (Likelihood ratio p = 0.91) No significant improvement in model fit with addition of demographics (Likelihood ratio p = 0.12) : Control Abx Choice 4. Cystitis, history of MDRO

o
Nurse Practitioner (NP) (1) o Physician Assistant (PA) (2) o Doctor of Medicine (MD) (3) o Doctor of Osteopathy (DO) (4) Display This Question: If What are your credentials?= Doctor of Medicine (MD) Or What are your credentials?= Doctor of Osteopathy (DO) What is your specialty and/or sub-specialty training?(Mark all that apply) LN et al.JAMA Network Open.How long have you been practicing in long term care?

End of Block: Additional Materials Questions Start of Block: Questions Evaluating Tool Use-WISCA Across
the four vignettes, how helpful was the provided weighted-incidence syndromic combination antibiogram in making your antibiotic choice?

you have already decided to treat this patient for UTI, which antibiotic would you prescribe?
Pick a single antibiotic.Dose and length of therapy are not required.
A B © 2023 Taylor LN et al.JAMA Network Open.Assuming ________________________________________________________________ Please provide a brief description of your rationale for the antibiotic selection, including reason(s) for the antibiotic selected.________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ End of Block:

Traditional Antibiogram Abx Choice 3. Catheter associated urinary tract infection Start of Block: Questions Evaluating Tool Use-Antibiogram
________________________________________________________________A B ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ End of Block: Across the four vignettes, how helpful was the provided antibiogram in making your antibiotic choice?o Not At All Helpful (1) o Slightly Helpful (2) o Moderately Helpful (3) o Very Helpful (4) o Extremely Helpful (5) o Very Easy (6) End of Block: Questions Evaluating Tool Use-Antibiogram Start of Block: Control Block Introduction

of Block: Control Abx Choice 1. Cystitis Start of Block: Control Abx Choice 2. Pyelonephritis, cephalosporin allergy A
Her temperature is 98.4°F.Her blood pressure is 118/72 with a heart rate of 64, normal respiratory rate and oxygen saturation of 100% on room air.Her physical exam is notable only for slightly masked facies, mild cogwheel rigidity, a shuffling gait, and benign abdominal exam.Urinalysis shows 3+ pyuria, 2+ nitrites.The urine culture is pending.78-year-old female with obesity, chronic obstructive pulmonary disease, heart failure, and peripheral vascular disease required an urgent below-knee amputation for limb-threatening ischemia.Her surgery was 2 weeks ago.She has been getting wound care and physical therapy in your building for the previous 10 days.She reports new pain with urination and urgency that developed in the last 48 hours.
________________________________________________________________Please provide a brief description of your rationale for antibiotic selection, including reason(s) for the antibiotic selected.________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ End Her temperature is 99.2°F.Her blood pressure is 122/82 with a heart rate of 74, normal respiratory rate and oxygen saturation of © 2023 Taylor LN et al.JAMA Network Open.