A tailored intervention for nursing care facility (NCF) staff aimed at improving their knowledge and communication skills regarding urinary tract infections (UTI) was associated with a decrease in both antibiotic prescriptions and inappropriate UTI treatment, according to results of a study published in Lancet Infectious Diseases.
Researchers performed an open-label, parallel-group, cluster randomized controlled trial at NCF across Denmark (ClinicalTrials.gov, NCT03715062). Eligible participants were aged 65 years and older who either resided in a NCF, had a NCF listed as their permanent address, or resided in a facility designated for those with dementia or somatic healthcare needs. . A total of 22 nursing care facilities were randomly assigned in a 1:1 fashion to either receive interactive educational sessions and a dialogue tool or continue standard practice. Educational sessions were 75 minutes over a period of 8 weeks in which NCF staff learned to distinguish between UTI and asymptomatic bacteriuria, evaluate non-specific UTI 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 a resident was present at a NCF during the trial period.
A total of 1625 patients from 22 NCFs were included in the trial, of whom 765 and 705 were analyzed for the primary endpoint in the 11 intervention and 11 control facilities, respectively. The standardized number of staff in the intervention and control facilities were 572 and 535, respectively.
A total of 362 antibiotic prescriptions for UTI were issued during the study. Among participants in the intervention group, the number of prescriptions was 134 per 84,035 days at risk vs 228 per 77,817 days at risk among those in the control group. In the unadjusted and adjusted model, the rate ratio (RR) of receiving an antibiotic prescription was 0.51 (95% CI, 0.37-0.71) and 0.42 (95% CI, 0.31-0.57), respectively.
No deaths were reported among 140 participants with suspected UTI, 28.5% of whom were hospitalized during the trial. In the intervention group, the researchers found that the risk for all-cause hospitalization was increased (adjusted model RR, 1.28; 95%, CI 0.95-1.74) and the risk for all-cause mortality was decreased (adjusted model RR, 0.91; 95% CI, 0.62-1.33).
The study limitations included its blinding of only the statistical analysis, potential ascertainment or inclusion bias for outcomes with data originating from electronic health records or UTI diaries of NCF residents, and limited generalizability due to convenience sampling and voluntary participation. In addition, resistance rates and long-term effects were not measured and the potential contamination of the control group by NCF staff or general practitioners was unknown. Finally, the actual number of staff in each NCF could not be determined.
According to the researchers, “our results imply that a broader range of health professionals should be engaged in antibiotic stewardship and that programmes should be tailored to address potential barriers to implementation and should focus on education, reflection, and a structured professional dialogue.”
Arnold SH, Jensen JN, Bjerrum L, et al. Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial. Lancet Infect Dis. Published online July 22, 2021. doi: 10.1016/S1473-3099(21)00001-3