Implementing an intervention to reduce use of antibiotics for suspected urinary tract infection in nursing homes - a qualitative study of barriers and enablers based on Normalization Process Theory.

BACKGROUND: Overuse of antibiotics in the elderly population is contributing to the global health problem of antibiotic resistance. Hence, it is important to improve prescribing practices in care facilities for elderly residents. In nursing homes, urinary tract infection (UTI) is the most common reason for antibiotic prescription but inappropriate prescriptions are frequent. In order to reduce the use of antibiotics for suspected urinary tract infection in this context, a complex intervention based on education as well as tools for reflection and communication had been developed and trialed in a group of nursing homes. The presents study explored the barriers and enablers in implementing this complex intervention. METHODS: After the intervention trial period, a qualitative interview study was performed in six of the nursing homes that had received the intervention. The study included 12 informants: One senior manager, four nurses, six healthcare assistants, and one healthcare helper. Normalization Process Theory was used to structure the interviews as well as the analysis. RESULTS: The intervention was well received among the informants in terms of its purpose and content. The initial educational session had altered the informants' perceptions of UTI and of the need for adopting a different approach to suspected UTIs. Also, the study participants generally experienced that the intervention had positively impacted their practice. The most important barrier was that some of the interventions' clinical content was difficult to understand for the staff. This contributed to some problems with engaging all relevant staff in the intervention and with using the observation tool correctly in practice. Here, nurses played a key role in the implementation process by regularly explaining and discussing the intervention with other staff. CONCLUSION: The results suggest that it is possible to implement more evidence-based practices concerning antibiotics use in nursing homes by employing a combination of educational activities and supportive tools directed at nursing home staff.

Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial.

BACKGROUND: When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI. METHODS: This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062. FINDINGS: Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33). INTERPRETATION: The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality. FUNDING: Danish Ministry of Health and the Velux Foundation.

Quality of the Diagnostic Process, Treatment Decision, and Predictors for Antibiotic Use in General Practice for Nursing Home Residents with Suspected Urinary Tract Infection.

Urinary tract infections (UTIs) are common in nursing home (NH) residents and Denmark is one of the countries with the highest antibiotic use in NHs. The aim of this study was to assess the quality of the diagnostic process and treatment decision on the day of the first contact from NHs to general practice and assess predictors for prescription of antibiotics in NH residents without an indwelling urinary catheter. The study was a prospective observational study in general practice in the Capital Region of Denmark; 490 patients were included; 158 out of 394 (40.1%, 95% CI 35; 45) patients with suspected UTI had urinary tract symptoms; 270 out of 296 (91.2%, 95% CI 87; 94) patients without urinary tract symptoms had a urine culture performed. Performing urine culture in the general practice was inversely associated to prescription of antibiotics on day one (OR 0.27, 95% CI 0.13; 0.56). It is imperative to support the implementation of interventions aimed at improving the quality of the diagnostic process on day one, as less than half of the patients given the diagnosis "suspected UTI" had urinary tract symptoms, and most patients without urinary tract symptoms had a urine culture performed.

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes.

AIM: The aim was to determine the association between healthcare workers' (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention. BACKGROUND: Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important. METHODS: This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ2 test and a linear mixed regression model were applied. FINDINGS: Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (-7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (-5.64, P < 0.01). Native HCWs' mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs' mean change in knowledge-of-antibiotic score. CONCLUSION: Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Urinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis. OBJECTIVE: The objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality. METHODS: The study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period. RESULTS: The trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020. CONCLUSIONS: The greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI. TRIAL REGISTRATION: ClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17710.