Joseph T Hanlon1, Subashan Perera2, Steven Schweon3, Paul Drinka4, Christopher Crnich5, David A Nace6. 1. Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Geriatic Research Education and Clinical Center/Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, PA, USA. Electronic address: jth14@pitt.edu. 2. Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA. 3. Infection Prevention Consultant, Saylorsburg, PA, USA. 4. Division of Internal Medicine and Geriatrics, University of Wisconsin, Madison, WI, USA. 5. Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; William S. Middleton VA Hospital, Madison, WI, USA. 6. Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
Abstract
OBJECTIVE: To determine the impact of an educational quality improvement initiative on the appropriateness of antibiotic prescribing restricted to uncomplicated cystitis in older noncatheterized nursing home residents. DESIGN: Quality improvement study with randomized assignment. SETTINGS AND PARTICIPANTS: Twenty-five nursing homes in United States were randomized to the intervention or usual care group by strata that included state, urban/rural status, bed size, and geographic separation. METHODS: A 12-month trial of a low-intensity multifaceted antimicrobial stewardship intervention focused on uncomplicated cystitis in nursing home residents vs usual care. The outcome was the modified Medication Appropriateness Index as assessed by a blinded geriatric clinical pharmacist and consisted of an assessment of antibiotic effectiveness, dosage, drug-drug interactions, and duration. RESULTS: There were 75 cases (0.15/1000 resident days) in intervention and 92 (0.22/1000 resident days) in control groups with a probable cystitis per consensus guidelines. Compared with controls, there was a statistically nonsignificant 21% reduction in the risk of inappropriate antibiotic prescribing (nonzero Medication Appropriateness Index score rate 0.13 vs 0.21/1000 person days; adjusted incident rate ratio 0.79; 95% confidence interval 0.45‒1.38). There was a favorable comparison in inappropriateness of duration (77% vs 89% for intervention vs control groups, respectively; P = .0394). However, the intervention group had more problems with drug-drug interactions than the control group (8% vs 1%, respectively; P = .0463). Similarly, the intervention group had a nonsignificant trend toward more problems with dosage (primarily because of the lack of adjustment for decreased renal function) than the control group (32% vs 25%, respectively; P = .3170). Both groups had similar rates of problems with choice/effectiveness (44% vs 45%; P = .9417). The most common class of antibiotics prescribed inappropriately was quinolones (25% vs 23% for intervention versus control groups, respectively; P = .7057). CONCLUSIONS AND IMPLICATIONS: A low-intensity intervention showed a trend toward improved appropriate antibiotic prescribing in nursing home residents with likely uncomplicated cystitis. Efforts to improve antibiotic prescribing in addition to the low-intensity intervention might include a consultant pharmacist in a nursing home to identify inappropriate prescribing practices. Published by Elsevier Inc.
OBJECTIVE: To determine the impact of an educational quality improvement initiative on the appropriateness of antibiotic prescribing restricted to uncomplicated cystitis in older noncatheterized nursing home residents. DESIGN: Quality improvement study with randomized assignment. SETTINGS AND PARTICIPANTS: Twenty-five nursing homes in United States were randomized to the intervention or usual care group by strata that included state, urban/rural status, bed size, and geographic separation. METHODS: A 12-month trial of a low-intensity multifaceted antimicrobial stewardship intervention focused on uncomplicated cystitis in nursing home residents vs usual care. The outcome was the modified Medication Appropriateness Index as assessed by a blinded geriatric clinical pharmacist and consisted of an assessment of antibiotic effectiveness, dosage, drug-drug interactions, and duration. RESULTS: There were 75 cases (0.15/1000 resident days) in intervention and 92 (0.22/1000 resident days) in control groups with a probable cystitis per consensus guidelines. Compared with controls, there was a statistically nonsignificant 21% reduction in the risk of inappropriate antibiotic prescribing (nonzero Medication Appropriateness Index score rate 0.13 vs 0.21/1000 person days; adjusted incident rate ratio 0.79; 95% confidence interval 0.45‒1.38). There was a favorable comparison in inappropriateness of duration (77% vs 89% for intervention vs control groups, respectively; P = .0394). However, the intervention group had more problems with drug-drug interactions than the control group (8% vs 1%, respectively; P = .0463). Similarly, the intervention group had a nonsignificant trend toward more problems with dosage (primarily because of the lack of adjustment for decreased renal function) than the control group (32% vs 25%, respectively; P = .3170). Both groups had similar rates of problems with choice/effectiveness (44% vs 45%; P = .9417). The most common class of antibiotics prescribed inappropriately was quinolones (25% vs 23% for intervention versus control groups, respectively; P = .7057). CONCLUSIONS AND IMPLICATIONS: A low-intensity intervention showed a trend toward improved appropriate antibiotic prescribing in nursing home residents with likely uncomplicated cystitis. Efforts to improve antibiotic prescribing in addition to the low-intensity intervention might include a consultant pharmacist in a nursing home to identify inappropriate prescribing practices. Published by Elsevier Inc.
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Authors: Joseph T Hanlon; Subashan Perera; Paul J Drinka; Christopher J Crnich; Steven J Schweon; Michele Klein-Fedyshin; Charles B Wessel; Stacey Saracco; Gulsum Anderson; Mary Mulligan; David A Nace Journal: J Am Geriatr Soc Date: 2018-12-24 Impact factor: 5.562
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