Antibiotic prescribing for urinary tract infections at three nursing homes following implementation of an antibiotic stewardship program: A quantitative evaluation of the Emory Antibiotic Stewardship in Long Term Care (EASIL) Initiative Open Access

Abstract

Introduction: Unnecessary use of antibiotics is common in nursing homes and can contribute to the emergence of antibiotic resistant organisms and increased rates of associated adverse events, such as C. difficile infections. As of November 2017, nursing homes are required to implement antibiotic stewardship programs to improve antibiotic prescribing practices. Three independent nursing homes collaborated with the Emory Antibiotic Stewardship in Long Term Care (EASIL) Initiative Team to start activities to reduce unnecessary antibiotic use for presumed urinary tract infections (UTIs). Activities included a stewardship gap analysis, launch of best practice guidance for UTI antibiotic prescribing shared with prescribing staff, and start of a data feedback system.

Objective/Aim: This study examines changes in antibiotic prescribing metrics for UTIs over the course of an antibiotic stewardship intervention in 3 Atlanta-based nursing homes enrolled in the EASIL Initiative. 

Methods: Quantitative methods were used to analyze antibiotic prescribing for UTIs over the course of the intervention by comparing antibiotic prescribing metrics between a peri-intervention period to an early intervention and late intervention period. Comparative metrics included facility-specific proportions of UTI antibiotic prescriptions over the recommended duration and days of therapy (DOT) per 1,000 resident days (RD).

Results: Average monthly RD at the three nursing homes ranged from 3,535 to 5,981. During the peri-intervention period, 96 (28.2%) antibiotic prescriptions were for UTIs, of which, 51 (53.1%) were new antibiotic starts. Metrics did not differ significantly between peri- and early intervention periods; however, one facility reported a significant reduction in new UTI prescriptions over recommended duration in late-intervention compared to peri-intervention period (Risk Ratio = 0.35, 95% CI 0.13-0.93, p = 0.033), while the other two reported non-significant declines. One facility reported a significant reduction in DOT/1000 RD between late-intervention period compared to peri-intervention period (Rate Ratio = 0.52, 95% CI 0.40-0.67, p < .001), while another experienced a significant increase in DOT/1,000 RD (Rate Ratio = 2.05, 95% CI 1.52-2.76, p < .001).

Conclusion: While this study found some significant improvements in antibiotic prescribing metrics over the study period, changes were inconsistent across facilities. Exploring how effects of the intervention may vary due to differences in implementation or facility staffing between facilities is warranted.

Table of Contents

INTRODUCTION 1

Introduction and Rationale 1

Problem Statement 2

Theoretical Framework 2

Purpose Statement 3

Research Question 4

Significance Statement 4

Definition of Terms 4

LITERATURE REVIEW 5

Antibiotic Resistance 5

Antibiotic Stewardship 6

Antibiotic Prescribing in Nursing Homes 7

Acute Care vs. Long-Term Care 14

Theoretical Framework 15

Current Problem/Study Relevance 18

STUDENT CONTRIBUTION 19

JOURNAL ARTICLE 24

Title Page 24

Abstract 25

Introduction 27

Methods 29

Results 33

Discussion 34

Conclusions and Implications 37

References 39

Tables and Figures 43

Appendix 48

PUBLIC HEALTH IMPLICATIONS51

REFERENCES 55

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	prescribing stewardship urinary tract infection antibiotic nursing home program evaluation
Committee Chair / Thesis Advisor	Regine Haardörfer, Emory University
Committee Members	Scott Fridkin, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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