A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents.

Importance: Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections. Objective: To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents. Design, Setting, and Participants: A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018. Interventions: Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care. Main Outcomes and Measures: The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death. Results: Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]). Conclusions and Relevance: This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.

The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents.

OBJECTIVE: To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti-infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long-Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. DESIGN: Two-round modified Delphi survey. PARTICIPANTS: Expert panel of 19 clinical pharmacists. MEASUREMENTS: Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug-drug interactions to avoid, and duration of therapy by sex on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation-specific mean score. RESULTS: The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug-drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug-drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine). CONCLUSION: An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti-infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539-545, 2019.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents.

OBJECTIVES: To identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in noncatheterized nursing home residents ≥65 years of age using consensus-based methods informed by a literature review. DESIGN: Literature review and modified Delphi survey with strict inclusion criteria. SETTING AND PARTICIPANTS: Expert panel of 20 physicians certified in geriatric medicine and/or medical direction, actively practicing in post-acute and long-term care settings. METHODS: The authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including nonspecific "quality control" items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use. RESULTS: The literature review identified 16 signs and symptoms that were evaluated in 3 Delphi survey rounds. The response rate was 100% for round 1 and 95% for the second 2 rounds. Consensus agreement for inclusion was achieved for dysuria on round 1 with exclusion of the 3 quality controls, and "offensive smelling urine." Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round 3 evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached. CONCLUSIONS/IMPLICATIONS: The panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute/long-term care populations.

The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure.

OBJECTIVES: Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population. DESIGN: A Delphi consensus procedure. SETTING AND PARTICIPANTS: An international panel of practitioners recognized as experts in the field of UTI in frail older patients. MEASURES: In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool. RESULTS: Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter. CONCLUSIONS: A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.

Emergence of rimantadine-resistant virus within 6 days of starting rimantadine prophylaxis with oseltamivir treatment of symptomatic cases.

OBJECTIVES: To report on the detection of rimantadine resistance within 6 days of starting rimantadine prophylaxis. DESIGN: Observational prospective study. SETTING: Fifty-bed nursing unit during the 2004/05 influenza season. PARTICIPANTS: All residents. INTERVENTION: Clinical monitoring for new onset of respiratory illness followed by collection of nasopharyngeal swabs for Directigen AB testing and influenza culture. After outbreak identification, rimantadine was administered as prophylaxis, whereas oseltamivir was used to treat symptomatic cases. Laboratory monitoring for the emergence of rimantadine resistance was reinitiated on the fifth day of rimantadine prophylaxis. MEASUREMENTS: Tabulation of respiratory illnesses, rapid tests and cultures yielding influenza A, and rimantadine sensitivity determination in five index isolates. RESULTS: A total of 15 symptomatic cases were identified over 8 days. Amantadine sensitivity was determined in five cases. Three initial cases were sensitive to rimantadine, whereas two cases identified after 6 days of rimantadine prophylaxis were resistant to rimantadine. CONCLUSION: The Centers for Disease Control and Prevention reported that 91% of isolates collected early the following season (2005/06) were resistant to rimantadine. Rimantadine treatment is no longer recommended. This experience anticipated the new recommendations. If reemergence of sensitivity follows discontinuation of rimantadine use, using rimantadine as prophylaxis and oseltamivir for treatment of symptomatic cases might be efficacious and economical on a national scale.

Determinants of vitamin D levels in nursing home residents.

OBJECTIVE: To determine the effect of various doses of vitamin D(2) and D(3), as well as ambulatory status (a surrogate for sun exposure), on 25-OH-D levels. DESIGN: Cross-sectional study with multiple regression analysis. SETTING: A state veterans home for veterans and their spouses. PARTICIPANTS: Three hundred two of 609 eligible residents. MEASUREMENTS: Serum 25-OH-D and parathyroid hormone (PTH) level, supplemental dose of vitamins D(2) and D(3) per kilogram of body weight, and 3 levels of ambulatory status. RESULTS: The mean 25-OH-D level was 28.6 + 9.2 ng/mL; 6.6% of subjects had values of 16 ng/mL or below. Thirty-two percent of participants had 25-OH-D levels below 30 ng/mL and PTH elevation based on stage of kidney disease, evidence that the suboptimal 25-OH-D level had physiologic consequences. Residents unable to transfer independently had 25-OH-D levels 1.6 ng/mL lower than those able to transfer independently. A regression analysis performed in residents unable to transfer independently (less likely to be exposed to the sun) demonstrated that the average increase in 25-OH-D level per 100 IU of D(3) in a 70-kg resident was 2.1 ng/mL versus 1.8 ng/mL for vitamin D(2). CONCLUSION: Nursing home residents should receive at least 800-1000 IU of D(3) per day in an effort to maintain optimal vitamin D levels.

Pneumococcal Vaccination Guidance for Post-Acute and Long-Term Care Settings: Recommendations From AMDA's Infection Advisory Committee.

Efforts at preventing pneumococcal disease are a national health priority, particularly in older adults and especially in post-acute and long-term care settings The Advisory Committee on Immunization Practices recommends that all adults ≥65 years of age, as well as adults 18-64 years of age with specific risk factors, receive both the recently introduced polysaccharide-protein conjugate vaccine against 13 pneumococcal serotypes as well as the polysaccharide vaccine against 23 pneumococcal serotypes. Nursing facility licensure regulations require facilities to assess the pneumococcal vaccination status of each resident, provide education regarding pneumococcal vaccination, and administer the appropriate pneumococcal vaccine when indicated. Sorting out the indications and timing for 13 pneumococcal serotypes and 23 pneumococcal serotypes administration is complex and presents a significant challenge to healthcare providers. Here, we discuss the importance of pneumococcal vaccination for older adults, detail AMDA-The Society for Post-Acute and Long-Term Care Medicine (The Society)'s recommendations for pneumococcal vaccination practice and procedures, and offer guidance to postacute and long-term care providers supporting the development and effective implementation of pneumococcal vaccine policies.

Between-meal risedronate does not alter bone turnover in nursing home residents.

OBJECTIVES: To assess the effect of between-meal weekly risedronate and daily calcium 630 mg and vitamin D 400 IU on bone turnover markers. DESIGN: Randomized,double-blind,placebo-controlled trial. SETTING: Skilled nursing home (NH). PARTICIPANTS: Sixty skilled-NH residents (46 men, 14 women), mean age+/-standard deviation of 76+/-6, were randomized to receive risedronate 30 mg (n=31) or matching placebo (n=29) once weekly for 12 weeks. All received 315 mg calcium with 200 IU vitamin D twice daily. MEASUREMENTS: Bone-specific alkaline phosphatase (BSAP), N-telopeptide of type 1 collagen (NTx), 25-hydroxyvitamin D (25OHD), and parathyroid hormone were measured at baseline and 6 and 12 weeks. RESULTS: Risedronate reduced BSAP significantly more than placebo (P<.05) at 6 weeks but not at 12 weeks; no treatment effect on serum NTx was observed. Defining hypovitaminosis D as a serum 25OHD concentration below 32 ng/mL, 50 of 53 (94%) study participants were low at baseline (mean 25OHD 19 ng/mL). Vitamin D levels remained insufficient in 74% of participants after 12 weeks. CONCLUSION: In this NH population, weekly risedronate administered using a between-meal dosing schedule reduced serum BSAP at 6 weeks of treatment; this effect was not observed at 12 weeks. The overall lack of change in bone turnover markers suggests that this risedronate dose and schedule would not be expected to increase bone density or reduce fracture risk in this population. Hypovitaminosis D was common and not reliably corrected by 400 IU of vitamin D daily. Despite an extremely high osteoporotic fracture risk in NH residents, additional study is required to determine under which conditions pharmacological treatment is efficacious in this population and define approaches that assure vitamin D repletion.

Severe hypercalcemia after transition from calcium carbonate to calcium citrate in an elderly woman treated with ergocalciferol 50,000 IU per day.

BACKGROUND: Absorption of calcium carbonate in the fasting state has been reported to be significantly compromised in subjects with achlorhydria. Although calcium carbonate malabsorption in the fasting state cannot be predicted, it might be corrected if the compound is administered with meals. However, administering calcium carbonate with meals is logistically challenging in long-term care facilities. OBJECTIVE: The aim of this study was to report the case of a woman who was transitioned to calcium citrate and subsequently experienced symptomatic severe hypercalcemia. METHODS: An 89-year-old female resident of the Wisconsin Veterans Home, a skilled nursing facility in King, Wisconsin, was receiving long-term treatment with ergocalciferol (vitamin D2) 50,000 IU/d. The patient also was receiving calcium carbonate supplements in the morning, and she rarely ate breakfast (fasting state). The patient was transitioned from 2000 mg/d of elemental calcium as carbonate to 1230 mg/d as citrate. RESULTS: After being switched from calcium carbonate to calcium citrate, the patient developed severe symptomatic hypercalcemia (16.8 mg/dL), the primary cause of which was the administration of an inappropriately high dose of vitamin D. CONCLUSIONS: We report a case of symptomatic severe hypercalcemia in a skilled nursing facility resident treated with an inappropriately high daily dose of vitamin D. Hypercalcemia manifested when calcium carbonate was replaced with calcium citrate.

Experience with the rapid Directigen test for influenza.

OBJECTIVE: To determine the sensitivity and positive predictive value of the Becton-Dickson Directigen AB performed on-site in a nursing home compared to viral culture. SETTING: A 721-bed skilled nursing facility for veterans and spouses. DESIGN MEASUREMENTS: Nasopharyngeal specimens were obtained with a low clinical threshold from residents during 3 influenza seasons for rapid antigen testing in the nursing home. The specimens were then transported for viral culture by courier on ice to a laboratory 45 miles away. RESULTS: A total of 327 samples were obtained; 36 were positive for influenza A by rapid test, and all but 2 grew the organism on tissue culture with a positive predictive value of 94%. Nineteen specimens were negative by rapid test, but grew influenza A on tissue culture with a sensitivity of 64%. Influenza prophylaxis was usually initiated the day the first positive rapid test was encountered when influenza was active in the community. CONCLUSION: The Directigen AB is a reliable indicator of influenza when influenza has been culture-confirmed in the community. Although sensitivity is limited, a group of rapid tests provided early laboratory confirmation and facilitated the application of prophylaxis.

Complications of chronic indwelling urinary catheters.

Chronic indwelling catheters are used to manage urinary retention, especially in the presence of urethral obstruction, and to facilitate healing of incontinence-related skin breakdown. These indwelling foreign bodies become coated and sometimes obstructed by biofilm laden with bacteria and struvite crystals. Bacteria invariably colonize the system and may invade the blood stream following trauma or obstruction. Staff should maintain a closed, dependent system to avoid introducing new organisms and be vigilant for the development of obstruction, avoid trauma, and consider chronic catheters and drainage bags to be potential sources of antibiotic-resistant bacteria for secretion containment and when antibiotics are selected for empiric therapy. Suprapubic catheters should be considered when urethral catheters are associated with discomfort or periurethral suppurative complications, especially in males.

The importance of parathyroid hormone and vitamin D status in the treatment of osteoporosis and renal insufficiency.

Suboptimal vitamin D status is common in sick, elderly patients and is associated with secondary hyperparathyroidism, increased bone turnover, and accelerated bone loss. Nutritional supplementation of elderly patients with vitamin D and calcium has been associated with a reduction in fractures and falls. Recently, the National Kidney Foundation (NKF) recommended screening parathyroid hormone (PTH) levels in those with glomerular filtration rates (GFR) less than 60 mL/min. The PTH target range increases as renal failure progresses because of skeletal resistance. When PTH levels are above the target range, measurement of serum 25-hydroxyvitamin D (25-OH-D) is recommended. If the 25-OH-D level is less than 30 ng/mL, supplementation with vitamin D is recommended. Practitioners should consider supplementing most residents with vitamin D and calcium or follow NKF guidelines.

Clustering of multiple endemic strains of methicillin-resistant Staphylococcus aureus in a nursing home: an 8-year study.

PFGE was performed on residents' first clinical MRSA isolate (n=94) during 8 years. Sixty-one percent of the isolates were clustered in time (P < .05) and space (P < .05) (i.e., 2 separate statistically significant tests). Isolates from individual units were genetically related, with only the occasional unrelated isolate.

Delays in the application of outbreak control prophylaxis for influenza A in a nursing home.

OBJECTIVE: To identify delayed prophylaxis from a pre-existing database and strategies to improve performance. SETTING: A skilled nursing facility with 14 floors (4 buildings). The "outbreak unit" was a 50- to 60-bed floor. METHODS: We performed surveillance during six seasons using one protocol. Prophylaxis was started when influenza was cultured in the building and 10% of residents on the floor had a new respiratory illness within 7 days. We defined delayed prophylaxis as four or more residents on a floor with positive cultures whose specimens had been collected within 5 days before the application of prophylaxis. RESULTS: We identified 14 examples of delayed prophylaxis. In three, delayed prophylaxis was related to the 3.9-day delay between culture collection and culture report There was a high degree of commonality among building attack rates within a season. During six seasons, the first case in the last building occurred 27 to 64 days after the first case in the facility. The two seasons with the greatest activity (68 and 154 cases, respectively) began with explosive, multi-floor outbreaks in a single building. The match between the circulating strain and the vaccine was good, except in 1997-1998 when there were seven examples of delayed prophylaxis. CONCLUSIONS: Influenza may involve buildings sequentially with a commonality of building attack rates. Explosive, multi-floor outbreaks early in the season could lead to a lower threshold for prophylaxis within a larger area when initial cases are encountered later in the season. This strategy could have prevented five examples of delayed prophylaxis. Rapid testing of multiple specimens while waiting for culture confirmation could have prevented three examples of delayed prophylaxis.

Risk of acquiring influenza A in a nursing home from a culture-positive roommate.

Influenza A was cultured in 62 double rooms. The roommate was infected in 12 (19.4%). During 3,294 resident-seasons, influenza was cultured in 208 single rooms (6.3%). Those who lived in double rooms with a culture-positive roommate had a 3.07 relative risk (CI95, 1.61-5.78) of acquiring influenza.

The identification of genetically related bacterial isolates using pulsed field gel electrophoresis on nursing home units: a clinical experience.

OBJECTIVES: To describe a laboratory-based technique to track nursing home infections. DESIGN: Retrospective data analysis. SETTING: A 721-bed skilled care facility with 14 nursing units. PARTICIPANTS: Residents in a nursing home, average age 76+/-10, 78% male. MEASUREMENTS: Bacterial isolates were listed for each nursing unit. Clusters of identical species and antibiotic susceptibility were identified followed by pulsed-field gel electrophoresis (PFGE). If the genetic analysis yielded related strains, the director of nursing performed a clinical investigation. PFGE is available through reference laboratories at a cost of approximately 75 dollars/isolate. RESULTS: Twenty-four clinical clusters of phenotypically identical bacteria (species, antibiotic susceptibility) were identified. Fourteen included genetically related isolates. CONCLUSION: Approximately half of the phenotypically identical clusters contained genetically related isolates. The identification of genetically related bacterial isolates on nursing units by PFGE provides staff with a specific circumstance to review secretion precautions. Genetic analysis may also demonstrate that apparent clusters are unrelated.

The effect of culture-positive influenza type A on resource use and adverse events in nursing home residents.

OBJECTIVES: To determine adverse clinical events and resource utilization associated with culture-positive influenza A in nursing home residents. DESIGN: A retrospective cohort study with cases and controls. SETTING: Seven hundred twenty-one-bed skilled nursing facility. PARTICIPANTS: One hundred fifty-four residents (21% of all residents) from whom influenza A was isolated during the 1997/98 season and matched controls. MEASUREMENTS: Baseline parameters, staff interventions, diagnostic tests, and adverse events were recorded from 60 days before to 60 days after specimen collection. The difference between each individual's before and after measurements determined excess utilization secondary to influenza. Controls were studied to determine time series effects. RESULTS: Baseline Minimum Data Set and nutritional parameters demonstrated significantly greater (P <.05) feeding dependency and lower serum albumin in the control group. Time series effects in the control group were negligible. Among cases, there were nine deaths within 30 days; among controls, there were four (chi2 P =.26). Within 30 days of onset, an average excess of 18 notations by nursing staff, one phone call to the physician, and one to family was noted per case. In half of cases, a nonscheduled physician visit was required. There was a 20% excess in physician orders for oxygen and bronchodilators. Chest x-rays were performed in half of the cases, and antibiotics were prescribed to half. Sixteen percent of cases had radiographic pneumonia, and 2% had congestive heart failure. The average cost for excess chest x-rays, laboratory services, antimicrobials, ambulance calls, hospital days, and emergency room and physician visits was $943.44. This does not include efforts by nursing home staff who accommodate functional decline on-site. CONCLUSION: An unexpected finding was that there were more impaired individuals who were less likely to have influenza detected or less likely to acquire influenza in the control group than in the influenza group. The morbidity, mortality, excess staff effort, and measured expenditure justify efforts to prevent influenza.

Mechanisms of unexplained anemia in the nursing home.

OBJECTIVES: To characterize anemia in elderly nursing home residents. DESIGN: Prospective multiinstitutional cohort study. SETTING: Five nursing homes. PARTICIPANTS: From retrospective analysis, residents found to be anemic using chart review were prospectively randomized. Of the 81 residents enrolled, 60 were anemic. MEASUREMENTS: Chart review for medical history and factors related to treatment or history of anemia, extensive laboratory evaluation for causes of anemia, and classification of anemia by two hematologists. RESULTS: Among the 60 anemic residents, the causes of anemia were idiopathic (n=27), iron-deficiency (n=14), anemia associated with chronic disease (n=8), anemia of renal insufficiency (n=6), and other (n=5). The eryrthropoietin (EPO) response to anemia was lower in residents with idiopathic anemia (IA) than in those with iron-deficiency anemia, and this correlated with renal function as estimated using calculated creatinine clearance. In this elderly population, advancing age was not correlated with lower EPO response. CONCLUSION: IA is common in nursing home residents. A lower EPO response contributes to the high prevalence of anemia in this setting and may be due, in part, to occult renal dysfunction.