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Urine Culture Testing in Community Nursing Homes: Gateway to Antibiotic Overprescribing

Published online by Cambridge University Press:  31 January 2017

Philip D. Sloane ,
Christine E. Kistler ,
David Reed ,
David J. Weber ,
Kimberly Ward  and
Sheryl Zimmerman
Philip D. Sloane*
Affiliation:
Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
Christine E. Kistler
Affiliation:
Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
David Reed
Affiliation:
Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
David J. Weber
Affiliation:
Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, North Carolina
Kimberly Ward
Affiliation:
Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
Sheryl Zimmerman
Affiliation:
Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina School of Social Work, University of North Carolina, Chapel Hill, North Carolina
*
*Address correspondence to Philip D. Sloane, 590 Manning Drive, Chapel Hill, NC 27599 (psloane@med.unc.edu).
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Abstract

OBJECTIVE

To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs)

DESIGN

Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period

SETTING

31 NHs in North Carolina

PARTICIPANTS

254 NH residents who had a urine culture ordered within the 1-month study period

METHODS

We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs.

RESULTS

Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000–99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%).

CONCLUSIONS

Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available.

Infect Control Hosp Epidemiol 2017;38:524–531

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 5 , May 2017 , pp. 524 - 531
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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References

REFERENCES

1. Medicare and Medicaid programs: reform of requirements for long-term care facilities. Office of the Federal Register website. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reformof-requirements-for-long-term-care-facilities. Published 2016. Accessed November 7, 2016.Google Scholar
2. The core elements of antibiotic stewardship in nursing homes. Centers for Disease Control and Prevention website. http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html. Published 2015. Accessed August 9, 2016.Google Scholar
3. Daneman, N, Gruneir, A, Bronskill, SE, et al. Prolonged antibiotic treatment in long-term care: role of the prescriber. JAMA Intern Med 2013;173:673–682.CrossRefGoogle ScholarPubMed
4. Zimmerman, S, Sloane, P, Bertrand, R, et al. Successfully reducing antibiotic prescribing in nursing homes. J Am Geriatr Soc 2014;62:907–912.Google Scholar
5. Eikelenboom-Boskamp, A, Cox-Claessens, J, Boom-Poels, P, Drabbe, M, Koopmans, R, Voss, A.. Three-year prevalence of healthcare-associated infections in Dutch nursing homes. J Hosp Infect 2011;78:59–62.CrossRefGoogle ScholarPubMed
6. Nace, D, Drinka, P, Crnich, C. Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. J Am Med Dir Assoc 2014;15:133–139.Google Scholar
7. The national action plan to prevent health care-associated infections: road map to elimination; Chapter 8: Long-term care facilities. US Department of Health and Human Services website. http://health.gov/hcq/pdfs/hai-action-plan-ltcf.pdf. Published 2013. Accessed August 9, 2016.Google Scholar
8. Trautner, B, Grigoryan, L. Approach to a positive urine culture in a patient without urinary symptoms. Infect Dis Clin North Am 2014;28:15–31.CrossRefGoogle Scholar
9. Phillips, C, Adepoju, O, Stone, N, et al. Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes. BMC Geriatr 2012;12:73.Google Scholar
10. Nicolle, L, Bradley, S, Colgan, R, Rice, J, Schaeffer, A, Hooton, T. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.Google Scholar
11. Cai, T, Nesi, G, Mazzoli, S, et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis 2015;61:1655–1661.Google Scholar
12. Eke-Usim, AC, Rogers, MA, Gibson, KE, Crnich, C, Mody, L. Targeted infection prevention study team. Constitutional symptoms trigger diagnostic testing before antibiotic prescribing in high-risk nursing home residents. J Am Geriatr Soc 2016;64:1975–1980.CrossRefGoogle Scholar
13. High, K, Bradley, S, Gravenstein, S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc 2009;57:375–394.CrossRefGoogle ScholarPubMed
14. Loeb, M, Bentley, D, Bradley, S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol 2001;22:120–124.Google Scholar
15. Loeb, M, Brazil, K, Lohfeld, L, et al. Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial. BMC Health Serv Res 2002;2:17.Google Scholar
16. Genao, L, Buhr, G. Urinary tract infections in older adults residing in long-term care facilities. Ann Long Term Care 2012;20:33–38.Google Scholar
17. Stone, N, Ashraf, M, Calder, J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965–977.Google Scholar
18. Sloane, PD, Kistler, C, Mitchell, CM, et al. Role of body temperature in diagnosing bacterial infection in nursing home residents. J Am Geriatr Soc 2014;62:135–140.Google Scholar
19. Fever temperatures: accuracy and comparison—topic overview. WebMD website. http://www.webmd.com/children/tc/fever-temperatures-accuracy-and-comparison-topic-overview. Published 2015. Accessed December 1, 2015.Google Scholar
20. Nursing Home Compare. US Government Medicare website. https://www.medicare.gov/NursingHomeCompare/search.html. Accessed August 31, 2015.Google Scholar
21. Rafii, F, Sutherland, J, Cerniglia, C. Effects of treatment with antimicrobial agents on the human colonic microflora. Therapeut Clin Risk Manag 2008;4:1343–1358.Google Scholar
22. Loeb, M, Brazil, K, Lohfeld, L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ 2005;331:669–670.Google Scholar
23. Boscia, J, Abrutyn, E, Kaye, D. Asymptomatic bacteriuria in elderly persons: treat or do not treat? Ann Intern Med 1987;106:764–766.Google Scholar
24. Wagenlehner, F, Naber, K, Weidner, W. Asymptomatic bacteriuria in elderly patients: significance and implications for treatment. Drugs Aging 2005;22:801–807.Google Scholar
25. Inouye, S. Delirium in older persons. N Engl J Med 2006;354:1157–1165.CrossRefGoogle ScholarPubMed
26. Borsje, P, Wetzels, R, Lucassen, P, Pot, A, Koopmans, R. The course of neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review. Int Psychogeriatr 2015;27:385–405.Google Scholar
27. Balogun, S, Philbrick, J. Delirium, a symptom of UTI in the elderly: fact or fable? A systematic review. Canad Geriatr J 2013;17:22–26.Google Scholar
28. Juthani-Mehta, M, Quagliarello, V, Perrelli, E, Towle, V, Van Ness, P, Tinetti, M. Clinical features to identify urinary tract infection in nursing home residents: a cohort study. J Am Geriatr Soc 2009;57:963–970.Google Scholar
29. Midthun, S, Paur, R, Lindseth, G. Urinary tract infections. Does the smell really tell? J Gerontol Nurs 2004;30:4–9.Google Scholar
30. Vaisman, A, Gold, W, Leis, J. A 78-year-old woman with lethargy and a positive urine culture. CMAJ 2013;185:679–680.Google Scholar
31. Pandey, S, Kim, H, Choi, S, Sa, I, Oh, S. Major odorants released as urinary volatiles by urinary incontinent patients. Sensors (Basel) 2013;13:8523–8533.Google Scholar
32. Nicolle, L, Bradley, S, Colgan, R, Rice, J, Schaeffer, A, Hooton, T. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.CrossRefGoogle Scholar
33. Wald, H. Challenging the “Culture of Culturing”: the case for less testing and more clinical assessment. JAMA Intern Med 2016;176:587–588.Google Scholar
34. Pettersson, E, Vernby, A, Mölstad, S, Lundborg, CS. Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial. J Antimicrob Chemother 2011;66:2659–2666.Google Scholar
35. Trautner, BW, Grigoryan, L, Petersen, NJ, Hysong, S, Cadena, J, Patterson, JE, Naik, AD. Effectiveness of an antimicrobial stewardship approach for urinary catheter-associated asymptomatic bacteriuria. JAMA Intern Med 2015;175:1120–1127.Google Scholar
36. Zabarsky, TF, Sethi, AK, Donskey, CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control 2008;36:476–480.Google Scholar
37. Juthani-Mehta, M, Datunashvili, A, Tinetti, M. Tests for urinary tract infection in nursing home residents. JAMA 2014;312:1687–1688.CrossRefGoogle ScholarPubMed