Impress you much? Results of randomised trial to improve antibiotic prescribing for suspected UTIs in frail older adults (ImpresU)

Reviewed by Dr. Michael Payne, MD; London Health Sciences Centre and Dr. Barry Rittmann, MD, MPH; Virginia Commonwealth University Health Systems 

Because asymptomatic bacteriuria is common in older adults, non-specific symptoms can frequently drive antibiotic (mis)use. Existing guidelines recommend against treatment in these cases, but practically this can be a challenging issue for providers. This study aimed to assess the impact of a multifaceted antibiotic stewardship intervention on prescribing practices in suspected urinary tract infections in frail older adults. 

This was a cluster randomized control trial of 38 adult care organizations in Poland, the Netherlands, Norway, and Sweden.  Participants were 70 years old or older, had significant physical or mental disabilities, and ADL dependencies.  It was conducted from September 2019 to June 2021. The intervention included a decision tool to guide appropriate antibiotic use, educational material including pocket cards, posters, and information leaflets that targeted healthcare professionals, patients, and caregivers. These were implemented through a participatory-action-research model.  The primary outcome was the number of antibiotics prescribed for suspected UTIs per person-year within 21 days of a suspected UTI. Secondary outcomes included the number of antibiotic prescriptions during office hours on the day of suspected UTIs, the number of inappropriate prescriptions, and the number of suspected UTIs. Adverse outcomes, all-cause hospital admissions, and all-cause mortality were also monitored.  

The study included 1041 patients within 38 clusters. The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42. No differences between intervention and control group were observed in the incidence of complications, hospital referrals, admissions to hospital, and mortality. 

This intervention was found to significantly decrease antibiotic prescribing in adult care settings for suspect UTIs, without an increase in negative outcomes.  There are some key limitations to the study.  First, they didn’t track antibiotic usage for other causes.  It is possible that this intervention led to an increase in antibiotic rates for other indications. Second, the study was interrupted due to the COVID-19 pandemic during a time that antibiotic rates had dropped in general.  Third, a longer evaluation time may be useful to assess if prescribing practices continued to be improved, or if they would regress back to previous levels. Despite these limitations, this study support supports the use of multifaceted antibiotic stewardship interventions to improve prescribing practices in frail older adults. 

Hartman et al., Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries.  BMJ 2023; 380 doi:

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