Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes

Charles D Phillips, Omolola Adepoju, Nimalie Stone, Darcy K McMaughan Moudouni, Obioma Nwaiwu, Hongwei Zhao, Elizabeth Frentzel, David Mehr, Steven Garfinkel, Charles D Phillips, Omolola Adepoju, Nimalie Stone, Darcy K McMaughan Moudouni, Obioma Nwaiwu, Hongwei Zhao, Elizabeth Frentzel, David Mehr, Steven Garfinkel

Abstract

Background: Urinary tract infections (UTIs) are the most commonly treated infection among nursing home residents. Even in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms, residents frequently receive an antibiotic for a suspected infection. This research investigates factors associated with the use of antibiotics to treat asymptomatic bacteriuria (ASB) among nursing home residents.

Methods: This was a cross-sectional study involving multi-level multivariate analyses of antibiotic prescription data for residents in four nursing homes in central Texas. Participants included all nursing home residents in these homes who, over a six-month period, received an antibiotic for a suspected UTI. We investigated what factors affected the likelihood that a resident receiving an antibiotic for a suspected UTI was asymptomatic.

Results: The most powerful predictor of antibiotic treatment for ASB was the presence of an indwelling urinary catheter. Over 80 percent of antibiotic prescriptions written for catheterized individuals were written for individuals with ASB. For those without a catheter, record reviews identified 204 antibiotic prescriptions among 151 residents treated for a suspected UTI. Almost 50% of these prescriptions were for residents with no documented UTI symptoms. Almost three-quarters of these antibiotics were ordered after laboratory results were available to clinicians. Multivariate analyses indicated that resident characteristics did not affect the likelihood that an antibiotic was prescribed for ASB. The only statistically significant factor was the identity of the nursing home in which a resident resided.

Conclusions: We confirm the findings of earlier research indicating frequent use of antibiotics for ASB in nursing homes, especially for residents with urinary catheters. In this sample of nursing home residents, half of the antibiotic prescriptions for a suspected UTI in residents without catheters occurred with no documented signs or symptoms of a UTI. Urine studies were performed in almost all suspected UTI cases in which an antibiotic was prescribed. Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI.

References

    1. Breitenbucher RB. UTI: managing the most common nursing home infection. Geriatrics. 1990;45(5):68–70. 75.
    1. Warren JW, Palumbo FB, Fitterman L, Speedie SM. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr Soc. 1991;39(10):963–972.
    1. Nicolle LE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic-resistance in nursing homes. Clin Microbiol Rev. 1996;9:1–17.
    1. Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guidelines for evaluation of fever and infection in long term care facilities. J Am Med Dir Assoc. 2001;2:246–258. doi: 10.1016/S1525-8610(04)70213-3.
    1. Kamel H. Managing urinary tract infections: guide for nursing home practitioners. Ann Long Term Care. 2005;13:21–28.
    1. Tsan L, Langberg R, Davis C, Phillips Y, Pierce J, Hojlo C, Gibert C, Gaynes R, Montgomery O, Bradley S, Danko L, Roselle G. Nursing home-associated infections in department of veterans affairs community living centers. AJIC. 2010;38(6):461–466.
    1. Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol. 1993;14:220–225. doi: 10.1086/646719.
    1. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am. 1997;11:647–662. doi: 10.1016/S0891-5520(05)70378-0.
    1. Nicolle LE. SHEA long-term–care committee. Urinary tract infections in long-term–care facilities. Infect Control Hosp Epidemiol. 2001;22(3):167–175. doi: 10.1086/501886.
    1. Nicolle LE, Bjornson J, Harding GK, MacDonell JA. Bacteriuria in elderly institutionalized men. N Engl J Med. 1983;309:1420–1425. doi: 10.1056/NEJM198312083092304.
    1. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987;83:27–33.
    1. Nicolle LE. Asymptomatic bacteriuria – important or not? N Engl J Med. 2000;343:1037–1039. doi: 10.1056/NEJM200010053431409.
    1. Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med. 1994;120(10):827–833.
    1. Ouslander JG, Schapira M, Schnelle JF, Uman G, Fingold S, Tuico E, Nigam JG. Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents? Ann Intern Med. 1995;122(10):749–754.
    1. Yoshikawa TT. VRE, MRSA, PRP, and DRGNB in LTCF: lessons to be learned from this alphabet. J Am Geriatr Soc. 1998;46(2):241–243.
    1. Denis O, Jans B, Deplano A, Nonhoff C, De Ryck R, Suetens C, Struelens MJ. Epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) among residents of nursing homes in Belgium. J Antimicrob Chemother. 2009;64(6):1299–1306. doi: 10.1093/jac/dkp345.
    1. Vromen M, van der Ven AJ, Knols A, Stobberingh EE. Antimicrobial resistance patterns in urinary isolates from nursing home residents. Fifteen years of data reviewed. J Antimicrob Chemother. 1999;44(1):113–116. doi: 10.1093/jac/44.1.113.
    1. Wiener J, Quinn JP, Bradford PA, Goering RV, Nathan C, Bush K, Weinstein RA. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA. 1999;281(6):517–523. doi: 10.1001/jama.281.6.517.
    1. Lautenbach E, Marsicano R, Tolomeo P, Heard M, Serrano S, Stieritz DD. Epidemiology of antimicrobial resistance among gram-negative organisms recovered from patients in a multistate network of long-term care facilities. Infect Control Hosp Epidemiol. 2009;30(8):790–793. doi: 10.1086/599070.
    1. Sandoval C, Walter SD, McGeer A, Simor AE, Bradley SF, Moss LM, Loeb MB. Nursing home residents and Enterobacteriaceae resistant to third-generation cephalosporins. Emerg Infect Dis. 2004;10(6):1050–1055. doi: 10.3201/eid1006.030662.
    1. Matheï C, Niclaes L, Suetens C, Jans B, Butinix F. Infections in residents of nursing homes. Infect Dis Clin North Am. 2007;21(3):761–772. doi: 10.1016/j.idc.2007.07.005.
    1. Rotjanapan P, Dosa D, Thomas KS. Potentially inappropriate treatment of urinary tract infections in two rhode island nursing homes. Arch Intern Med. 2011;171(5):438–443. doi: 10.1001/archinternmed.2011.13.
    1. High K, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long term care facilities. Clin Infect Dis. 2009;48:149–171. doi: 10.1086/595683.
    1. Loeb M, Bentley DW, Bradley S, Crossley K, Garibaldi R, Gantz N, McGeer A, Muder RR, Mylotte J, Nicolle LE, Nurse B, Paton S, Simor AE, Smith P, Strausbaugh L. 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(2):120–124. doi: 10.1086/501875.
    1. Hawes C, Morris JN, Phillips CD, Mor V, Fries BE, Nonemaker S. Reliability estimates for the minimum data set for nursing home resident assessment and care screening (MDS) Gerontologist. 1995;35(2):172–178. doi: 10.1093/geront/35.2.172.
    1. Mylotte JM, Keagle J. Benchmarks for antibiotic use and cost in long-term care. J Am Geriatr Soc. 2005;53(7):1117–1122. doi: 10.1111/j.1532-5415.2005.53351.x.
    1. Mylotte JM, Neff M. Trends in antibiotic use and cost and influence of case-mix and infection rate on antibiotic-prescribing in a long-term care facility. Am J Infect Control. 2003;31:18–25. doi: 10.1067/mic.2003.47.
    1. Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci. 1999;54(11):M546–M553. doi: 10.1093/gerona/54.11.M546.
    1. Morris JN, Fries BE, Mehr DR, Hawes C, Phillips C, Mor V, Lipsitz LA. MDS cognitive performance scale. J Gerontol. 1994;49(4):M174–M182. doi: 10.1093/geronj/49.4.M174.
    1. Hartmaier SL, Sloane PD, Guess HA, Koch GG. The MDS cognition scale: a valid instrument for identifying and staging nursing home residents with dementia using the minimum data set. J Am Geriatr Soc. 1994;42(11):1173–1179.
    1. Hartmaier SL, Sloane PD, Guess HA, Koch GG, Mitchell CM, Phillips CD. Validation of the minimum data set cognitive performance scale: agreement with the mini-mental state examination. J Gerontol A Biol Sci Med Sci. 1995;50(2):M128–M133.
    1. Mezey MD, Mitty EL, Bottrell MM, Ramsey GC, Fisher T. Advance directives: older adults with dementia. Clin Geriatr Med. 2000;16(2):255–268. doi: 10.1016/S0749-0690(05)70056-2.
    1. Paquay L, De Lepeleire J, Schoenmakers B, Ylieff M, Fontaine O, Butinix F. Comparison of the diagnostic accuracy of the cognitive performance scale (Minimum Data Set) and the mini-mental state exam for the detection of cognitive impairment in nursing home residents. Int J Geriatr Psychiatry. 2007;22:286–293. doi: 10.1002/gps.1671.
    1. Brown MN, Lapane KL, Luisi AF. The Management of depression in older nursing home residents. J Am Geriatr Soc. 2002;50(1):69–76. doi: 10.1046/j.1532-5415.2002.50010.x.
    1. Burrows A, Morris JN, Simon SE, Hirdes JP, Phillips CD. Development of a minimum data set-based depression rating scale for use in nursing homes. Age Ageing. 2000;29(2):165–172. doi: 10.1093/ageing/29.2.165.
    1. Dey AN. Characteristics of elderly nursing home residents: data from the 1995 national nursing home survey. Adv Data. 1996;279:1–12.
    1. Richards CL Jr, Darradji M, Weinberg A, Ouslander JG. Antimicrobial use in post-acute care: a retrospective descriptive analysis in seven long-term care facilities in Georgia. J Am Med Dir Assoc. 2005;6(2):109–112. doi: 10.1016/j.jamda.2004.12.021.
    1. Nicolle LE. Urinary infections in the elderly: symptomatic or asymptomatic? Int J Antimicrob Agents. 1999;11(3–4):265–268.
    1. Bonnal C, Baune B, Mion M, Armand-Lefevre L, L’Heriteau F, Wolmark Y, Lucet JC. Bacteriuria in a geriatric hospital: impact of an antibiotic improvement program. J Am Med Dir Assoc. 2008;9(8):605–609. doi: 10.1016/j.jamda.2008.04.004.
    1. Katz PR, Beam TR Jr, Brand F, Boyce K. Antibiotic use in the nursing home. Physician practice patterns. Arch Intern Med. 1990;150(7):1465–1468. doi: 10.1001/archinte.1990.00390190111017.
    1. Yoshikawa T. T: Antimicrobial resistance and aging: Beginning of the end of the antibiotic era? J Am Geriatr Soc. 2002;50(7 SUPPL):S226–S229.
    1. Zimmer JG, Bentley DW, Valenti WM, Watson NM. Systemic antibiotic use in nursing homes. A quality assessment. J Am Geriatr Soc. 1986;34:703–710.
    1. Benoit SR, Nsa W, Richards CL, Bratzler DW, Shefer AM, Steele LM, Jernigan JA. Factors associated with antimicrobial use in Nursing homes. A multilevel model. J Am Geriatr Soc. 2008;56:2039–2044. doi: 10.1111/j.1532-5415.2008.01967.x.
    1. McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang EE. Definitions of infection surveillance in long-term care facilities. Am J Infect Control. 1991;19:1–7. doi: 10.1016/0196-6553(91)90154-5.
    1. Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986;81:979–982. doi: 10.1016/0002-9343(86)90391-8.
    1. Berman P, Hogan DB, Fox RA. The atypical presentation of infection in old age. Age Ageing. 1987;16:201–207. doi: 10.1093/ageing/16.4.201.
    1. Jarrett PG, Rockwood K, Carver D, Stolee P, Cosway S. Illness presentation in elderly patients. Arch Intern Med. 1995;155:1060–1064. doi: 10.1001/archinte.1995.00430100086010.
    1. Juthani-Mehta M, Quagliarello V, Perrelli E, Towle V, Van Ness PH, Tinetti M. Clinical features to identify urinary tract infection in nursing home residents: a cohort study. J Am Geriatr Soc. 2009;57(6):963–970. doi: 10.1111/j.1532-5415.2009.02227.x.
    1. Juthani-Mehta M, Drickamer MA, Towle V, Zhang Y, Tinetti ME, Quagliarello VJ. Nursing home practitioner survey of diagnostic criteria for urinary tract infections. J Am Geriatr Soc. 2005;53(11):1986–1990. doi: 10.1111/j.1532-5415.2005.00470.x.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir