Major article
Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention

https://doi.org/10.1016/j.ajic.2007.11.007Get rights and content

Background

In long-term care facilities, treatment of asymptomatic bacteriuria (ASB) is common. However, randomized, controlled trials suggest that such treatment offers no benefit and may promote antimicrobial resistance.

Methods

For 3 months before and 30 months after instituting an educational intervention, we monitored the appropriateness of urine culture collection and antibiotic treatment based on published guidelines and examined the effect on total antimicrobial use. The intervention included education of nursing staff to discourage the collection of urine cultures in the absence of symptoms suggestive of urinary tract infection and of primary care practitioners to not treat ASB.

Results

In preintervention period, 23 of 38 (61%) antibiotic regimens prescribed for urinary tract indications were for ASB. In the 6 months after the intervention, inappropriate submission of urine cultures decreased from 2.6 to 0.9 per 1000 patient-days (P < .0001), overall rate of treatment of ASB was reduced from 1.7 to 0.6 per 1000 patient-days (P = .0017), and total antimicrobial days of therapy were reduced from 167.7 to 117.4 per 1000 patient-days (P < .001). These reductions were maintained for 30 months after beginning the intervention.

Conclusion

Educational interventions requiring minimal resources can result in sustained reductions in inappropriate treatment of ASB in long-term care and decreased total antimicrobial use. Education of the nursing staff regarding appropriate criteria for requesting urine cultures should be a component of such interventions. (Am J Infect Control 2008;36:000-0.)

Section snippets

Methods

A 33-month prospective study from February 1, 2002, to October 31, 2004, was conducted in the long-term care facility of the Cleveland Department of Veterans Affairs Medical Center. The long-term care facility contains 190 beds on 5 separate wards and is separate from the acute care hospital. The facility is staffed with 1 infection control nurse, approximately 80 licensed nurses, and 6 full-time primary care providers. The educational intervention and monitoring of ASB rates were conducted by

Results

Interviews conducted at the beginning of the educational intervention revealed several factors that could contribute to unnecessary treatment of ASB. Many of the nurses reported that urine specimens were routinely sent for culture for a variety of reasons in the absence of signs or symptoms of infection. Such reasons included foul-smelling or cloudy urine, after urethral catheter changes, upon admission to the ward, after treatment of UTI to document cure, and for nonspecific symptoms unrelated

Discussion

Prior to an educational intervention, we found that most antibiotic prescriptions for urinary indications in our long-term care facility were for ASB. An educational intervention directed at nursing staff and primary care providers resulted in significant reductions in inappropriate submission of urine cultures and in the overall rate of treatment of ASB. Interestingly, when inappropriate urine cultures were sent and ASB was identified during the initial 6 months of the intervention, there was

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    There is a need for information to be made readily available to nurses, for clear policies to support nurses to provide appropriate care, and for nurses to be actively involved in the planning and in the implementation of antimicrobial stewardship activities, to ensure that expectations are practical, and that practice changes reflect nursing workflow. Applying behaviour change theory to inform implementation of local antimicrobial stewardship interventions has been recommended, (Lorencatto et al., 2018; Davey, 2015; Charani et al., 2011) and interventions that encompassed behaviour strategies, were associated with improvements that were impactful on antimicrobial use, (Zabarsky et al., 2008; Messina et al., 2015; Saha et al., 2017) suggesting this may provide the foundation of an effective approach for encouraging nurse involvement. Clearly, implementation needs to assess both context, and potential impact on nursing workflow.

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Supported by the Infection Control Department, Louis Stokes Cleveland VA Medical Center, and by an Advanced Research Career Development Award from the Department of Veterans Affairs (to C.J.D.).

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