Reviewed by: Rebekah Moehring, MD, MPH, FSHEA, Duke University Hospital
In the July issue of JAMA Internal Medicine, Nace et al. present their AHRQ-funded implementation study of antimicrobial stewardship focused on urinary tract infections (UTIs) in long-term care facilities. UTIs are the most frequently treated infection in nursing homes. Most UTI-targeted antibiotic use is for “unlikely” cystitis, or cases for which empirical antibiotics would be unnecessary due to non-specific symptoms. Investigators implemented a multifaceted intervention targeting avoidance of treatment for unlikely cystitis among non-catheterized residents. The study included 25 US nursing homes or assisted living facilities randomized to intervention (N=12) or standard care (N=13). The analysis included data from a 2017 baseline and intervention period from 5/2017 to 4/2018.
I think “multifaceted” is an understatement. The intervention included a 1-hour educational webinar; pocket cards and posters with education and treatment guidelines; standardized UTI management order forms; an active monitoring sheet to track symptoms instead of immediately pulling the trigger on antibiotics; tools for system change; 1-pager documents that outlined diagnosis and treatment of UTIs in clinical vignettes; coaching calls for staff every 6 weeks; quarterly data feedback reports that included facility-level data on UTI rates, compliance with guidelines, and antibiotic use outcomes; and a 1:1 call with a nursing leader to review data in the last quarter of the study. Participating sites also had to report their own data, including monthly summary data and case report forms for each potential UTI case. Participation was voluntary, driven by motivation to show adherence to new regulations for stewardship in nursing facilities. Although 46 sites showed initial interest, 22 sites fully completed the project. Over half of the initially interested sites dropped out and one site closed operations altogether. Of those sites that completed the study, intervention sites had a reduction in antibiotic use for unlikely cystitis compared with control sites (adjusted incidence rate ratio 0.73, 0.59-0.91), and also a reduction in treatment for any UTI overall (adjusted odds ratio 0.83, 0.70-0.99). The reductions were not seen in the raw numbers; the effects were not evident until the analysis was adjusted for baseline antibiotic use. These rates varied quite widely by site and were higher in the control group at baseline, suggesting that by chance the intervention sites had less “juice to squeeze” with the intervention than control sites, which may have resulted in less robust effects – an issue that could be addressed by stratified randomization strategies in future studies.
This study was a big undertaking, involving multi-level interventions that ultimately were effective in reducing antibiotic use for UTI. More importantly, this study illustrates why stewardship in the long-term care setting is so hard and why implementation studies like this one are so important to do. Data collection requires local resources to achieve, maintaining engagement is tough, uncertainty about financial solvency, competing priorities, high staff turnover, and the list goes on. What investigators accomplished here was amazing! However, it may be hard to achieve outside of a structured research setting without highly motivated leadership. Good news though—all the tools developed for this study are available on the AMDA website.
Nace DA, Hanlon JT, Crnich CJ, et al. A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents. JAMA Intern Med. 2020;180(7):944–951. doi:10.1001/jamainternmed.2020.1256 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764860