The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents

Kistler, Christine E.; Zimmerman, Sheryl; Scales, Kezia; Ward, Kelly; Weber, David J.; Reed, David; McClester, Mallory; Sloane, Philip D.

doi:10.1111/jgs.14857

Cited by 35 publications

(36 citation statements)

References 47 publications

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“…Although based on a small number of isolates (n ϭ 17), our finding of 35% CIP susceptibility in SNF patients is alarming and is considerably lower than results of a recent study of patients from 31 nursing facilities across North Carolina that documented a 56% CIP susceptibility rate (17), again highlighting the utility of local surveillance data to guide therapy selection for UTI. Furthermore, because prior FQ use is a known risk factor for FQ-resistant E. coli infection (18), our findings underscore the need to extend antimicrobial stewardship interventions in SNFs to limit unnecessary FQ exposure.…”

Section: Discussioncontrasting

confidence: 44%

Emergency Department Urinary Antibiograms Differ by Specific Patient Group

et al. 2017

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Patients presenting to the emergency department (ED) represent a heterogeneous population comprised of all ages, various backgrounds, such as from the community and skilled-nursing facilities (SNFs), and at various risks for resistant pathogens. The aim of this study was to compare patient group-specific urinary antibiograms in the ED. Adults presented to the ED with an ICD 9/10 code urinary tract infection (UTI) diagnosis during July 2015 to June 2016 were randomly selected (n ϭ 500) to extract relevant demographic, laboratory, and clinical data from the medical record. Urinary Escherichia coli antibiograms were compared between institutional versus ED and among ED patients (male versus female; age of 18 to 64 years versus Ն65 years; female aged 18 to 50 years versus Ͼ50 years; home versus SNF; and admitted versus discharged). E. coli grew from 56% (145/259) of the positive urine cultures. Overall ciprofloxacin (CIP), trimethoprim-sulfamethoxazole (SXT), and cefazolin (CFZ) susceptibilities were Ͻ71%. Differences in antibiograms were the following: lower CFZ and SXT susceptibilities in ED versus institutional (CFZ, 67% versus 86% [P ϭ 0.001]; SXT, 66% versus 74% [P ϭ 0.02]), lower ampicillin and gentamicin susceptibilities in females aged 18 to 50 years versus Ͼ50 years (32% versus 52% [P ϭ 0.04]; 78% versus 93% [P ϭ 0.02]), lower CIP susceptibilities in the elderly (64% versus 81%; P ϭ 0.03), SNF versus home (35% versus 77%; P Ͻ 0.001), admitted versus discharged (63% versus 78%; P ϭ 0.04), and lower SXT susceptibilities in patients aged Ͻ65 years versus the elderly (58% versus 71%; P ϭ 0.01). Nitrofurantoin showed Ͼ80% susceptibility in all groups. Patient group-specific urinary antibiograms revealed distinct differences in E. coli susceptibility and should be developed to better inform empirical UTI therapy selection in the ED.KEYWORDS antibiogram, antimicrobial stewardship, emergency department, urinary tract infection U rinary tract infections (UTIs) are among the top 3 infections encountered in the emergency department (ED), accounting for nearly 2 million visits for females of all ages and 160,000 visits for males aged 65 years and older in the United States (1). Selection of antibiotic therapy for UTIs in the ED is challenging due to the absence of microbiologic data at the time of clinical decision and patient discharge or transfer. Furthermore, the increasing emergence of antimicrobial resistance among uropathogens in both the community and inpatient settings (2, 3) presents a significant challenge for ED clinicians to balance prompt initiation of effective empirical antibiotics without overprescribing broad-spectrum antibiotics. Incorporating local antibiograms into clinical decision-making can assist in the selection of appropriate empirical therapy (4, 5). Institution-wide antibiograms, however, may not accurately reflect susceptibility

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Section: Discussioncontrasting

confidence: 44%

Emergency Department Urinary Antibiograms Differ by Specific Patient Group

et al. 2017

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“…To the Editor: We read with interest the recent article from Kistler and colleagues, an analysis of the antibiotic prescribing pathway for presumed urinary tract infection (UTI) in 260 nursing home (NH) residents. 1 This article is critically important because it's aim was to identify target areas for antibiotic stewardship strategies in NHs related to treatment of suspected UTI, which is the largest contributor to antibiotic use in this setting and much of which is unnecessary or inappropriate. Although the need for antibiotic stewardship in NHs is well recognized, effective and financially resourceful interventions specific to NHs are largely unknown and absent.…”

Section: Antibiotic Prescribing Pathway For Urinary Tract Infections:mentioning

confidence: 99%

“…2 We applaud the authors for describing the prescribing pathway with regard to "upstream events" related to the diagnosis of the UTI and "downstream events" related to the appropriate treatment of the presumed UTI. 1 As the authors describe, diagnosing a UTI and deciding when to treat older adults is challenging and is often based on nonspecific signs and symptoms. 1,3 4 In their own analysis, Kistler and colleagues found that nonspecific signs and symptoms (acute mental status change) influenced prescribing more than urinary symptoms.…”

Section: Antibiotic Prescribing Pathway For Urinary Tract Infections:mentioning

confidence: 99%

Integrating Frailty Research into the Medical Specialties—Report from a U13 Conference

Walston

Robinson

Zieman

et al. 2017

J American Geriatrics Society

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Although the field of frailty research has expanded rapidly, it is still a nascent concept within the clinical specialties. Frailty, conceptualized as increased vulnerability to stressors because of significant depletion of physiological reserves, predicts poorer outcomes in several medical specialties, including cardiology, HIV care, nephrology, and in the behavioral and social sciences. Incorporation of frailty assessment and frailty research into the specialties is hindered by a lack of a consensus definition, by the proliferation of measurement tools, inadequate understanding of the biology of frailty, and lack of validated clinical algorithms for patients who have frailty. In 2015, the American Geriatrics Society, the National Institute on Aging (NIA) and the Alliance for Academic Internal Medicine held a conference for awardees of the NIA sponsored ‘Grants for Early Medical/Surgical Specialists Transition into Aging Research (GEMSSTAR)’1 program to review the current state of the knowledge regarding frailty in the sub-specialties, as well as to highlight key examples of integrating frailty research into the medical specialties. Key research questions to advance frailty research into specialty medicine are proposed.

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“…As noted in Dr. Finucane's commentary, ambiguity over the types of clinical symptoms that should trigger suspicion of UTI is a major determinant of this problem. It is widely believed that UTI in older adults can manifest atypically, which has led to the practice of testing for UTI and initiating treatment when these tests are positive after a fall or change in cognitive or physical function . Nevertheless, there is little evidence that these nonspecific symptoms, when present in isolation, are reliable indicators of UTI .…”

Section: Factors Driving Overdiagnosis and Overtreatment Of Utimentioning

confidence: 99%