The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents.

Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections (UTIs) in nursing home (NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship. Chart review of 260 randomly-selected cases from 247 NH residents treated with an antibiotic for a presumed UTI in 31 NHs in North Carolina. We examined the prescribing pathway from presenting illness, to the prescribing event, illness work-up and subsequent clinical events including emergency department use, hospitalization, and death. Analyses described the decision-making processes and outcomes and compared decisions made with Loeb criteria for initiation of antibiotics. Of 260 cases, 60% had documented signs/symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). NH providers (81%) were the most common prescribers and ciprofloxacin (32%) was the most commonly prescribed antibiotic. Fourteen percent of presumed UTI cases included a white blood cell count, 71% included a urinalysis, and 72% had a urine culture. Seventy-five percent of cultures grew at least one organism with ≥100,000 colony-forming units/milliliter and 12% grew multi-drug resistant organisms; 28% of antibiotics were prescribed for more than 7 days, and 7% of cases had a subsequent death, emergency department visit, or hospitalization within 7 days. Non-specific signs/symptoms appeared to influence prescribing more often than urinary tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide the decision-making process to reduce antibiotic overuse and antibiotic resistance.

Kistler CE ，Zimmerman S ，Scales K ，Ward K ，Weber D ，Reed D ，McClester M ，Sloane PD ... -  《-》

Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis.

Pulia M ，Kern M ，Schwei RJ ，Shah MN ，Sampene E ，Crnich CJ ... -  《Antimicrobial Resistance and Infection Control》

Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial.

Rutten JJS ，van Buul LW ，Smalbrugge M ，Geerlings SE ，Gerritsen DL ，Natsch S ，Sloane PD ，Veenhuizen RB ，van der Wouden JC ，Hertogh CMPM ... -  《BMC Geriatrics》

Does adherence to the Loeb minimum criteria reduce antibiotic prescribing rates in nursing homes?

The Loeb minimum criteria (LMC), developed by a 2001 consensus conference, are minimum standards for initiation of antibiotics in long term care settings, intended to reduce inappropriate prescribing. This study examined the relationship between nursing home prescriber adherence to the LMC and antibiotic prescribing rates, overall and for each of three specific conditions (urinary tract infections, respiratory infections, and skin and soft tissue infections). We performed a cross-sectional analysis at the resident-day level. We estimated multivariate models adjusting for nursing home characteristics via multilevel Poisson regression, with robust standard errors to account for clustering of prescriptions within residents within nursing homes. Data were collected through medical record abstraction in 12 North Carolina nursing homes between March and May 2011. In total, we identified 3381 antibiotic prescriptions across the 3-month observation period, representing 110,810 nursing home resident-days. In addition, we performed chart audits for a random sample of 653 prescriptions for urinary tract, respiratory, and skin and soft tissue infections to create measures of LMC adherence. The primary outcome was a count of prescriptions per resident per day, and the key explanatory variable was a nursing home-level estimate of the proportion of antibiotic prescriptions that adhered to the LMC. Only 12.7% of prescriptions were classified as LMC adherent, although there was substantial variation across study nursing homes (range: 4.8% to 22.0%) and by infection type (1.9% adherence for respiratory infections, 10.2% for urinary tract infections, and 42.7% for skin and soft tissue infections). We found no statistically significant relationship between adherence to the LMC and total prescribing rates (IRR 1.00, 95% CI 0.98-1.03; P = .84). Similarly, there was no significant relationship between LMC adherence and prescribing rates for treating urinary tract infections (IRR 0.99, 95% CI 0.96-1.02; P = .49), respiratory infections (IRR 0.91, 95% CI 0.76-1.08; P = .28), or skin and soft tissue infections (IRR 0.99, 95% CI 0.98-1.01; P = .39) considered alone. We found little evidence that prescribers in study nursing homes considered the LMC when making prescribing decisions. Further, we found no evidence that greater adherence to the LMC was associated with lower rates of antibiotic prescribing. Evidence-based guidelines for antibiotic initiation must be adopted more widely before any substantial gains from adherence are likely to be recognized.

Olsho LE ，Bertrand RM ，Edwards AS ，Hadden LS ，Morefield GB ，Hurd D ，Mitchell CM ，Sloane PD ，Zimmerman S ... -  《-》

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

Sloane PD ，Kistler CE ，Reed D ，Weber DJ ，Ward K ，Zimmerman S ... -  《-》