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DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
Deferring Prescribing in Nursing Home Residents with Asymptomatic Bacteriuria:
A Pilot Study
Emilie Kennedy MSN, CRNP, FNP-C
Clarion University and Edinboro University
Doctor of Nursing Practice Project
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DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
Table of Contents
Title ............................................................................................................................................ 3
Abstract ...................................................................................................................................... 3
Introduction ................................................................................................................... 4
Problem Description ...................................................................................................... 4
Available Knowledge ...................................................................................................... 5
Rationale……………………………………………………………………………………………………………….….6
Specific Aims……………………………………………………………………………………………………………..8
Methods ..................................................................................................................................... 9
Context………………………………………………………………………………………………………………………9
Interventions ................................................................................................................. 11
Study of the Interventions ............................................................................................. 12
Measures………………………………………………………………………………………………….……………….12
Analysis……………………………………………………………………………………………..……………………...14
Ethical Considerations.................................................................................................... 14
Results……………………………………………………………………………………………………..……………………………14
Discussion……………………………………………………………………………………………………………………………..16
Summary……………………………………………………………………………………………………………………16
Limitations…………………………………………………………………………………………..…………………….19
Conclusions ……………………………………………………………………………………………………………...19
References………………………………………………………………………………………………………..…………………..20
Appendix A………………………………………………………………………….………………………………………………..23
Appendix B……………………………………………………………………………………………………..…………………….32
Appendix C………………………………………………………………………………………………………..………………….33
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DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
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Title and Abstract
Title
The purpose of this research study is to identify risk factors for unnecessary
antibiotic use by prescribers and to assess the impact of educational interventions impact
for nursing home residents that have asymptomatic bacteriuria (ASB). Antibiotic use in
nursing homes creates several harmful patient outcomes including; the emergence of
multi-drug resistant bacteria, adverse drug events, polypharmacy, and higher health care
costs.
Abstract
Urinary tract infections (UTIs) are the most commonly treated infection among
nursing home residents; patients are commonly treated even in the absence of signs or
symptoms of a UTI being present. This research study’s objective is to reduce the amount
of unnecessary antibiotic prescribing and assess the impact of educational interventions in
nursing home residents that have asymptomatic bacteriuria (ASB). The design of this
research study is quasi-experimental. The setting is Butler Memorial Hospital, a non-profit
organization and an independent community hospital with 296 beds located in rural
Pennsylvania. Population of interest includes nursing home residents that present to Butler
Memorial Hospital’s Emergency Department with consecutive positive urine cultures. A
multifaceted educational intervention will be provided to Emergency Department staff to
reduce the number of unnecessary antibiotic prescribing in ASB cases.
There were 105 in the sample population that resided in an institutional facility for
the elderly that were seen in Butler Health System’s Emergency Department. Out of the
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
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105-sample population, 73 were encountered before educational intervention. Twelve out
of the 73 pre-educational sample population met the study’s inclusion criteria. Out of the
105 sample population, 32 were encountered after educational intervention. 4 out of the
32 post-educational sample population met the study’s inclusion criteria. In conclusion,
this pilot study showed that there was a 3.9 percent overall reduction in nursing home
residents that were being inappropriately diagnosed with a UTI and placed on unnecessary
antibiotics when in fact they had ASB and met the criteria to defer prescription. While this
was a small change the potential for changing prescribing habits with educational
programs is encouraging and more studies should be done with larger samples sizes.
Introduction
Problem Description
Nursing home residents frequently suffer from ASB; often this is mistreated as a
urinary tract infection. Providers therefore place patients on unnecessary antibiotic
therapy that can have harmful patient effects. Butler Health System’s Emergency
Department along with nursing home providers have voiced the need for antibiotic
stewardship in nursing home residents that enter for treatment showing signs and
symptoms of ASB. Neighboring nursing homes have expressed concern due to all of the
antibiotic complications they have encountered after ASB patient cases were mistreated
with an antibiotic. Researchers identified that unnecessary treatment of ASB in a common
clinical practice and seen in nearly 50% of ASB cases, and this indicates a significant
problem (Irfan, Brooks, Mithoowani, Celetti, Main & Mertz, 2015). Antibiotic use in nursing
homes creates several harmful patient outcomes including: the emergence of multi-drug
resistant bacteria; adverse drug events; polypharmacy; and higher health care costs.
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
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A knowledge gap exists between emergency department providers and healthcare
staff regarding the treatment of ASB. Education on this topic is crucial for positive patient
outcomes. Educational interventions implemented in this study include: an overview of the
evidence; clarification of misconceptions related to ASB management; discussion of cases
that residents had recently encountered and appropriate indication for urine cultures;
specifically, for patients with symptoms of UTI the presentation of asymptomatic
bacteriuria education. The primary investigator distributed pocket cards to emergency
department staff highlighting the Infectious Diseases Society of America guidelines for ASB
treatment to reinforce the program and offer references for future review. Implementing
educational interventions aim is to help reduce the amount of unnecessary antibiotics
prescribed to nursing home residents with ASB.
The research question for this study is, “Will educational interventions reduce the
amount of unnecessary antibiotic prescribing in nursing home residents that have
asymptomatic bacteriuria that present to Butler Health System’s Emergency Department?”
The following hypotheses will be tested in this research study.
H0: There is no reduction in the amount of antibiotics prescribed to nursing home residents
that have asymptomatic bacteriuria that present to Butler Health System’s Emergency
Department.
H1: There is a reduction in the amount of antibiotics prescribed to nursing home residents
that have asymptomatic bacteriuria that present to Butler Health System’s Emergency
Department.
Available Knowledge
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BACTERIURIA
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UTIs are the most commonly treated infection among nursing home residents. Even
in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms,
residents frequently receive an antibiotic for a suspected infection (Phillips et al., 2012). In
the absence of urinary symptoms, a diagnosis of ASB is given to patients. The 2005
Infectious Diseases Society of America guidelines define ASB as the specified quantitative
number of bacteria in the urine without any typical symptoms of a UTI (Nicolle, et. al., 2005).
These guidelines recommend no antimicrobial treatment for ASB unless the patient is
pregnant or anticipating a urologic interventional procedure. ASB is common and often
leads to unnecessary antibiotic use. Reducing antibiotic overuse for ASB is therefore an
important issue for antimicrobial stewardship (Lee et al., 2015). A need for antibiotic
stewardship in regard to ASB in Butler Health System’s Emergency Department has been
expressed from the health system itself as well as the nursing home providers. Antibiotic
therapy for ASB in the institutionalized elderly population has not been shown to be of
benefit and may in fact be harmful; however, antibiotics are still frequently used to treat
ASB in this population (Walker et al., 2000).
Rationale
ASB is prevalent in the elderly institutionalized population and there have been
various studies conducted involving the inappropriate treatment of ASB. A study conducted
by Irfan, Brooks, Mithoowani, Celetti, Main & Mertz (2015) regarding ASB was to reduce
risk factors and assess the impact of educational interventions. Variables included
appropriateness of ASB management, physicians’ knowledge and practice regarding ASB.
The sample population of interest was defined as consecutive patients with positive urine
cultures and the study was conducted in two tertiary teaching adult care hospitals.
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
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Educational sessions were implemented that provided a) an overview of the evidence, b)
feedback of findings during baseline assessment c) clarification of misconceptions related
to ASB management (i.e. risk factors associated with inappropriate treatment of ASB
identified during the period of baseline data collection), d) feedback about the initiative, e)
discussion of cases that residents had recently encountered and f) appropriate indication
for urine cultures, specifically, for patients with symptoms of UTI (Irfan et al., 2015).
Educational session interventions were effective in reducing inappropriate use of
antibiotics in ASB cases to less than 10%. Researchers demonstrated that their educational
interventions were not only successful in reducing inappropriate use of antimicrobials for
ASB cases in short studies but also in a long term follow up over two years (Irfan et al.,
2015).
Another study conducted by Walker, McGeer, Simor, Armstrong-Evans & Loeb
(2000) aimed to explore the perceptions, attitudes and opinions of physicians and nurses
involved in the process of prescribing antibiotics for ASB in institutionalized elderly people.
Focus groups were conducted among physicians and nurses who cared for to residents of
long term care facilities. The focus group discussions were tape recorded and the
transcripts for each session were analyzed to determine the uses and themes emerging
from the text (Walker et al., 2000). It was observed that the ordering of urine cultures and
the prescribing of antibiotics for residents with ASB were influenced by a wide range of
nonspecific symptoms or signs in residents. The physicians believed that the presence of
these signs justified a decision to order antibiotics. Nurses played a central role in both the
ordering of urine cultures and the decision to prescribe antibiotics through their
awareness of changes in residents’ status and communication of this to physicians. The
study concluded that education about ASB was viewed as an important priority for both
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BACTERIURIA
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physicians and nurses (Walker et al., 2000). The presence of non-urinary symptoms and
signs was an important factor in the prescription of antibiotics for ASB in the
institutionalized elderly population. However, ASB doesn’t necessarily warrant antibiotic
treatment (Walker et al., 2000).
These studies show the significance of inappropriately treated ASB and how
prevalent it is in the institutionalized elderly population. Two theories explained below can
be applied to the healthcare providers behavior in treating ASB.
One theory that supports this research study’s focus is Albert Bandura’s Social
Learning Theory. Albert Bandura’s social learning theory hypothesizes that individuals
learn from one another by means of observing, imitating, and modeling. Bandura (1977)
stated, “Most human behavior is learned observationally through modeling: from observing
others, one forms an idea of how new behaviors are performed, and on later occasions this
coded information serves as a guide for action” (p. 22).
Another theory that could be applied is Rodgers’ Diffusion of Innovations
Theory. Rogers (2003) discussed the innovation-diffusion process as “the process through
which an individual (or other decision-making unit) passes from gaining initial knowledge
of an innovation, to forming an attitude toward the innovation, to making a decision to
adopt or reject, to implementation of the new idea, and to confirmation of this decision” (p.
168). Both of these theories can directly relate to a healthcare providers’ approach in the
treatment or deferment of prescribing in ASB cases.
Specific Aims
The purpose of this research study is to reduce the amount of unnecessary antibiotic
prescribing and assess the impact of educational interventions in nursing home residents
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
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that have ASB that present to Butler Health System’s Emergency Department. This research
aims to improve patient outcomes and therefore increase quality care delivered by Butler
Memorial Hospital’s Emergency Department. An assumption can be made that patients will
benefit from this research study by being accurately treated for ASB and avoid harmful side
effects from mistreatment.
Methods
Context
UTI’s are the most common bacterial infection in elderly people, causing more than
50% of all infection episodes requiring treatment during institutional care (Hedin, Petersson,
Widebäck, Kahlmeter, & Mölstad, 2002). However, ASB is also prevalent and commonly
mistreated as a UTI with inappropriate antibiotics. Institutions for the elderly most commonly
include nursing homes, sheltered homes, and service houses of various sizes. Due to the
prevalence of ASB in the institutionalized elderly appropriate treatment is essential in delivering
quality patient care. Other differential diagnoses other than a UTI should be considered before
antibiotic treatment is given (Hedin, et. al., 2002).
Although current guidelines suggest screening for ASB and treating it in specific
circumstances such as during pregnancy or before invasive urologic procedures, antibiotic
overuse for ASB seems to be overwhelming in clinical practice, as supported by several
studies reporting that 20–80 % of cases of ASB are inappropriately treated (Lee et al.,
2015). The overuse of antibiotics in nursing home settings leads to the various
complications and potential harm to patients. Treatment of ASB has been shown to have no
clinical benefit in lowering the frequency of symptomatic UTI or ASB, whereas it
predisposes the patient to increased risk of development of resistant organisms or adverse
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BACTERIURIA
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effects (Kelley, Aaronson, Poon, McCarter, Bato, & Jankowski, 2014). The American
Geriatrics Society, (2013) has emphasized the importance of not treating elderly people
with ASB with antibiotics (Leduc, 2014). ASB can be harmful because of the possibility of
adverse drug reactions, especially in the frail elderly population with frequent
comorbidities.
Up to 70 percent of nursing home residents may receive at least one antibiotic agent
a year (McMaughan et al., 2016). This statistic is staggering and can lead to unwarranted
negative patient outcomes. The emergence of multidrug resistant organisms in nursing
homes and consequent spread to the community combined with other negative outcomes of
antibiotic overuse, such as adverse drug events, hospital admissions, and higher health care costs,
calls for optimizing antibiotic stewardship in nursing homes (McMaughan et al., 2016).
ASB is often times mistreated due to a lack of knowledge on the part of the
healthcare providers and staff. This knowledge is crucial in accurately diagnosing and
treating patients. National guidance indicates that men and women over 65 years should
not receive antibiotic treatment for ASB (McNulty, 2014). Providing educational sessions
regarding published guidelines to healthcare providers will help to eliminate any
mistreatment of ASB cases. According to Lee et. al., (2015), “Physicians’ lack of knowledge
and misperceptions contribute to the misuse of antibiotics” (p. 2). Inappropriate treatment
methods need to be addressed to improve patient outcomes and avoid any harm in
patients.
Zabarsky, Sethi, & Donskey (2008), found that 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.
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
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Antibiotic stewardship is a necessity to decrease bacterial drug resistance and is significant
in this research setting.
Interventions
This study uses observational methods, a chart review will be conducted preeducational intervention and post-educational intervention. A multifaceted educational
intervention will be provided for Emergency Department staff at Butler Memorial Hospital.
Educational interventions implemented in this study include; an overview of the evidence,
clarification of misconceptions related to ASB management, discussion of cases that
residents had recently encountered and appropriate indication for urine cultures,
specifically, for patients with symptoms of UTI the presentation of asymptomatic
bacteriuria education. Pocket cards for emergency department staff highlighting the
Infectious Diseases Society of America guidelines for ASB treatment will be provided to
staff for practice reference. Appendix A & B.
The Infectious Diseases Society of America guidelines state that ASB is defined as
two consecutive voided urine specimens with isolation of the same organism in
quantitative counts ≥105 cfu/mL in women with no signs or symptoms of UTI, or a single,
clean catch voided urine specimen with one bacterial species isolated in quantitative count
≥105 cfu/mL without any signs or symptoms of UTI in men (Nicolle, et. al., 2005). In both
men and women, a single catheterized urine specimen with one bacterial species isolated
in a quantitative count ≥102 cfu/mL were defined as having bacteriuria (Nicolle, et. al.,
2005). The pocket cards include an algorithm of when to screen and treat ASB patients and
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
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the Infectious Diseases Society of America guidelines and criteria for the diagnosis of
bacteriuria. Appendix B. The primary investigator created an algorithm as part of the
study assist providers with a clear and concise method to help guide treatment.
The educational presentation and materials were provided to the emergency
department staff to emphasize the importance of not treating the institutionalized elderly
population or patients that meet the Infectious Disease Society of America’s criteria for no
treatment.
Study of the Interventions
Data for the research was collected over ten months’ pre-educational intervention
to obtain baseline observation. Educational interventions were provided for emergency
department providers and healthcare staff and, then post-educational intervention data
was collected over 3 months’ time. Next, data was collected based upon the inclusion and
exclusion criteria listed. This data was then analyzed to determine the outcome of the pilot
study.
Measures
Butler Memorial Hospital served as the setting for my research project and research
will be conducted specifically in the Emergency Department. Butler Memorial Hospital is
an independent community, 296 bed hospital that opened in 1898. It is a non-profit
organization located in the rural community of Butler Pennsylvania. Butler Memorial
Hospital’s Emergency Department encounters several nursing home residents from the
surrounding community.
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Population of interest in this study include patients that reside in institutional
facilities for the elderly. The sample population must meet these inclusion criteria:
asymptomatic of urinary symptoms, discharged back to the nursing home, patients with a
first positive urine culture, defined as growth of greater than or equal to 105 colony
forming units per milliliter (CFU/mL) of bacteria. Urinary symptoms are defined by any
one of the following: urgency, dysuria, frequency, suprapubic tenderness, flank pain,
costovertebral angle pain and tenderness, rigors, gross hematuria, delirium, and new or
worsening fever (High, Bradley, Gravenstein, Mehr, Quagliarello, Richards, & Yoshikawa
2009).
General demographic data was collected on sample population including: age,
gender and if they have an indwelling catheter present. Inclusion criteria for the sample
population includes; the sample population must be a nursing home resident, discharged
back to the nursing home, patients with a first positive urine culture, defined as growth of
greater than or equal to 105 colony forming units per milliliter (CFU/mL) of bacteria, and
asymptomatic of urinary symptoms. Urinary symptoms are defined by any one of the
following: urgency, dysuria, frequency, suprapubic tenderness, flank pain, costovertebral
angle pain and tenderness, rigors, gross hematuria, delirium, and new or worsening fever
(High, et. al., 2009).
Exclusion criteria for the sample population includes; non-nursing home residents,
admission to the hospital and the presence of signs and symptoms of a UTI. A UTI is defined
by any one of the following: urgency, dysuria, frequency, suprapubic tenderness, flank pain,
costovertebral angle pain and tenderness, rigors, gross hematuria, delirium, and new or
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worsening fever, patients with a first positive urine culture of mixed growth, defined as
greater than 3 organisms (High, et. al., 2009).
Additional data collected will include if the patient was discharged on an antibiotic
for urinary symptoms both before and after educational interventions.
Analysis
The most accurate research design for this project is a quasi-experimental design.
There will be manipulation of the independent variable or the healthcare providers by
providing educational sessions for ED staff. The study shows a comparison of treated ASB
patients prior to educational sessions and then after education sessions. There will be no
control over what nursing home residents present to the emergency department or how
the provider treats the patient.
Ethical Considerations
The Institutional Review Boards at Edinboro University of Pennsylvania and Butler
Health System both approved the on-site data collection procedures for this study. Both
boards gave the research team a waiver of written consent. There were no physical,
psychological, financial, social/economic or legal risks, or harm from confidentiality to
population of interest in this study.
Results
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There were 105 of the sample population that resided in numerous institutional
facilities for the elderly that were seen in Butler Health System’s Emergency Department.
Out of the 105 sample population, 73 were encountered before educational intervention.
Data was collected between the dates of 2/1/18 through 7/31/18 for pre-educational
intervention. Twelve out of the 73 pre-educational sample population met the following
inclusion criteria; asymptomatic of urinary symptoms, discharged back to the nursing
home, patients with a first positive urine culture, defined as growth of greater than or equal
to 105 colony forming units per milliliter (CFU/mL) of bacteria. 8 of the 12-sample
population were females ranging in the age of 67-96. 4 of the 12-sample population were
males ranging in the age of 75-97. 3 of the 12-sample population had indwelling foley
catheters in place.
Additional data, collected between 8/10/18 through 11/10/18 comprised posteducational intervention observations. Out of the 105 sample population, 32 were
encountered after educational intervention. Four out of the 32 post-educational sample
population met the following inclusion criteria; asymptomatic of urinary symptoms,
discharged back to the nursing home, patients with a first positive urine culture, defined as
growth of greater than or equal to 105 colony forming units per milliliter (CFU/mL) of
bacteria. 4 of the 4-sample population were females ranging in the age of 74-93. 1of the 4
sample population had indwelling foley catheter in place.
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Institutionalized Elderly Sample Population
Size
80
70
60
50
40
30
20
10
0
Series1
PRE-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
PRE-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
THAT MET INCLUSION
CRITERIA
POST-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
POST-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
THAT MET INCLUSION
CRITERIA
Gender of Sample Population with
Indwelling Foley Catheters Present
POST-EDUCATIONAL INTERVENTION SAMPLE
POPULATION WITH INDWELLING FOLEY CATHETERS
PRE-EDUCATIONAL INTERVENTION SAMPLE
POPULATION WITH INDWELLING FOLEY CATHETERS
1
3
POST-EDUCATIONAL INTERVENTION MALES
0
POST-EDUCATIONAL INTERVENTION FEMALES
4
PRE-EDUCATIONAL INTERVENTION MALES
4
PRE-EDUCATIONAL INTERVENTION FEMALES
8
0
1
2
3
4
5
6
7
8
9
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Age of Sample Population
120
100
80
60
40
20
0
0
Series1
2
Series2
4
Series3
6
Series4
Series5
8
Series6
Series7
10
Series8
Discussion
Summary
The data analysis validated that nursing home residents that meet the Infectious
Disease Society of America’s guidelines for ASB do frequent Butler Health System’s
Emergency Department. Patients have been found discharged with UTI’s when in fact they
meet the criteria of ASB. This pilot study reveals that unnecessary antibiotics are being
prescribed to nursing home residents that exhibit ASB.
Interpretation
Out of the 73 pre-educational intervention sample population that met inclusion
criteria, 16.4% were inappropriately treated. This group of individuals were discharged
back to the nursing home facility on an antibiotic for an inaccurate diagnosis of a UTI.
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Pre-Educational Sample Population
16%
84%
Pre-Educational Intervention Sample Population
Pre-Educational Intervention Sample Population That Met Inclusion Criteria
Out of the 32 post-educational intervention sample population that met inclusion criteria,
12.5% were inappropriately treated. This group of individuals were discharged back to the
nursing home facility on an antibiotic for an inaccurate diagnosis of a UTI.
Post-Educational Sample Population
13%
87%
Pre-Educational Intervention Sample Population
Pre-Educational Intervention Sample Population That Met Inclusion Criteria
The pre- and post-educational intervention data revealed that there was a total of an
overall 3.9% reduction in patients that were inappropriately treated. Validating that the
educational interventions that were implemented in Butler Health System’s Emergency
Department were effective for reducing the amount of potential harmful patient outcomes.
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Overall Reduction
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Pre-Educational
Post-Educational
Intervention % of Sample Intervention % of Sample
Population
Population
Overall Reduction
Limitations
One limitation to this study is the setting only includes one hospital; comparison to
another comparable hospital would increase the interventional validity and
generalizability. Another limitation is the small sample size of population interests based
upon census.
Conclusions
This pilot study can conclude that there was a 3.9% overall reduction in nursing
home residents that were being inappropriately diagnosed with a UTI and placed on
unnecessary antibiotics when in fact they had ASB and met the criteria to defer
prescription.
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Further research needs to be conducted to assess the magnitude of inappropriate
ASB treatment in the inpatient hospital setting. Researchers speculate that future research
with a larger population of interest sample will yield a more validated study. Research
findings were shared with Butler Health System’s Infectious Disease Group, Emergency
Department and the Pennsylvania Safety Advisory Committee. This research data will be
beneficial to antibiotic stewardship initiatives.
References
Bandura, A. (1977). Social learning theory. New York, NY: Gernal Learning Press.
Chowdhury, F., Sarkar, K., Branche, A., Kim, J., Dwek, P., Nangit, A., … Visconti, E. (2012).
Preventing the inappropriate treatment of asymptomatic bacteriuria at a
community teaching hospital. Journal of Community Hospital Internal Medicine
Perspectives, 2(2), 10.3402/jchimp.v2i2.17814.
http://doi.org/10.3402/jchimp.v2i2.17814
Hedin, K., Petersson, C., Widebäck, K., Kahlmeter, G., & Mölstad, S. (2002). Asymptomatic
bacteriuria in a population of elderly in municipal institutional care. Scandinavian
Journal Of Primary Health Care, 20(3), 166-168.
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
21
High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT.,
(2009). Clinical practice guideline for the evaluation of fever and infection in older
adult residents of long‐term care facilities: 2008 update by the Infectious Diseases
Society of America. J Am Geriatr Soc. 2009;57(3):375–94.
Irfan, N., Brooks, A., Mithoowani, S., Celetti, S. J., Main, C., & Mertz, D. (2015). A Controlled
Quasi-Experimental Study of an Educational Intervention to Reduce the
Unnecessary Use of Antimicrobials For Asymptomatic Bacteriuria. Plos ONE, 10(7),
1-11. doi:10.1371/journal.pone.0132071
Kandel, R., Pallin, D., & Doron, S. Massachusetts Infection Prevention Partnership.
Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts
Department of Public Health, Massachusetts Senior Care Association, Masspro.
Kelley, D., Aaronson, P., Poon, E., McCarter, Y., Bato, B., & Jankowski, C. (2014). Evaluation of
an Antimicrobial Stewardship Approach to Minimize Overuse of Antibiotics in
Patients with Asymptomatic Bacteriuria. Infection Control & Hospital Epidemiology,
35(2), 193-195. doi:10.1086/674848
Leduc, A. (2014). Reducing the Treatment of Asymptomatic Bacteriuria in Seniors in a
Long-Term Care Facility. Canadian Nurse, 110(7), 25-30.
Lee, M. J., Kim, M., Kim, N., Kim, C., Song, K., Choe, P. G., & ... Kim, H. B. (2015). Why is
asymptomatic bacteriuria overtreated?: A tertiary care institutional survey of
resident physicians. BMC Infectious Diseases, 15289. doi:10.1186/s12879-0151044-3
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
22
McMaughan, D. K., Nwaiwu, O., Zhao, H., Frentzel, E., Mehr, D., Imanpour, S., & Phillips, C. D.
(2016). Impact of a decision-making aid for suspected urinary tract infections on
antibiotic overuse in nursing homes. BMC Geriatrics, 1681. doi:10.1186/s12877016-0255-9
McNulty, C. (2014). Managing asymptomatic bacteriuria in the elderly. Practice Nursing,
25(1), 11-15.
Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society
of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria
in adults. Clin Infect Dis. 2005; 40(5):643–54. Epub 2005/02/17. doi:
10.1086/427507 PMID: 15714408.
Phillips, C. D., Adepoju, O., Stone, N., Moudouni, D. M., Nwaiwu, O., Zhao, H., & Garfinkel, S.
(2012). Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract
infections in four nursing homes. BMC Geriatrics, 12(1), 73. doi:10.1186/1471
Rogers, E.M. (2003). Diffusion of Innovations (5th Ed.). New York: The Free Press.
Walker, S., McGeer, A., Simor, A. E., Armstrong-Evans, M., & Loeb, M. (2000). Why are
antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly
people? A qualitative study of physicians' and nurses' perceptions. CMAJ: Canadian
Medical Association Journal = Journal De L'association Medicale Canadienne, 163(3),
273-277.
Zabarsky, T. F., Sethi, A. K., & Donskey, C. J. (2008). Sustained reduction in inappropriate
treatment of asymptomatic bacteriuria in a long-term care facility through an
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educational intervention. American Journal Of Infection Control, 36(7), 476-480.
doi:10.1016/j.ajic.2007.11.007
Appendix A
23
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Appendix B
Pocket Card:
25
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Appendix C
26
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BACTERIURIA
Deferring Prescribing in Nursing Home Residents with Asymptomatic Bacteriuria:
A Pilot Study
Emilie Kennedy MSN, CRNP, FNP-C
Clarion University and Edinboro University
Doctor of Nursing Practice Project
1
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Table of Contents
Title ............................................................................................................................................ 3
Abstract ...................................................................................................................................... 3
Introduction ................................................................................................................... 4
Problem Description ...................................................................................................... 4
Available Knowledge ...................................................................................................... 5
Rationale……………………………………………………………………………………………………………….….6
Specific Aims……………………………………………………………………………………………………………..8
Methods ..................................................................................................................................... 9
Context………………………………………………………………………………………………………………………9
Interventions ................................................................................................................. 11
Study of the Interventions ............................................................................................. 12
Measures………………………………………………………………………………………………….……………….12
Analysis……………………………………………………………………………………………..……………………...14
Ethical Considerations.................................................................................................... 14
Results……………………………………………………………………………………………………..……………………………14
Discussion……………………………………………………………………………………………………………………………..16
Summary……………………………………………………………………………………………………………………16
Limitations…………………………………………………………………………………………..…………………….19
Conclusions ……………………………………………………………………………………………………………...19
References………………………………………………………………………………………………………..…………………..20
Appendix A………………………………………………………………………….………………………………………………..23
Appendix B……………………………………………………………………………………………………..…………………….32
Appendix C………………………………………………………………………………………………………..………………….33
2
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Title and Abstract
Title
The purpose of this research study is to identify risk factors for unnecessary
antibiotic use by prescribers and to assess the impact of educational interventions impact
for nursing home residents that have asymptomatic bacteriuria (ASB). Antibiotic use in
nursing homes creates several harmful patient outcomes including; the emergence of
multi-drug resistant bacteria, adverse drug events, polypharmacy, and higher health care
costs.
Abstract
Urinary tract infections (UTIs) are the most commonly treated infection among
nursing home residents; patients are commonly treated even in the absence of signs or
symptoms of a UTI being present. This research study’s objective is to reduce the amount
of unnecessary antibiotic prescribing and assess the impact of educational interventions in
nursing home residents that have asymptomatic bacteriuria (ASB). The design of this
research study is quasi-experimental. The setting is Butler Memorial Hospital, a non-profit
organization and an independent community hospital with 296 beds located in rural
Pennsylvania. Population of interest includes nursing home residents that present to Butler
Memorial Hospital’s Emergency Department with consecutive positive urine cultures. A
multifaceted educational intervention will be provided to Emergency Department staff to
reduce the number of unnecessary antibiotic prescribing in ASB cases.
There were 105 in the sample population that resided in an institutional facility for
the elderly that were seen in Butler Health System’s Emergency Department. Out of the
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4
105-sample population, 73 were encountered before educational intervention. Twelve out
of the 73 pre-educational sample population met the study’s inclusion criteria. Out of the
105 sample population, 32 were encountered after educational intervention. 4 out of the
32 post-educational sample population met the study’s inclusion criteria. In conclusion,
this pilot study showed that there was a 3.9 percent overall reduction in nursing home
residents that were being inappropriately diagnosed with a UTI and placed on unnecessary
antibiotics when in fact they had ASB and met the criteria to defer prescription. While this
was a small change the potential for changing prescribing habits with educational
programs is encouraging and more studies should be done with larger samples sizes.
Introduction
Problem Description
Nursing home residents frequently suffer from ASB; often this is mistreated as a
urinary tract infection. Providers therefore place patients on unnecessary antibiotic
therapy that can have harmful patient effects. Butler Health System’s Emergency
Department along with nursing home providers have voiced the need for antibiotic
stewardship in nursing home residents that enter for treatment showing signs and
symptoms of ASB. Neighboring nursing homes have expressed concern due to all of the
antibiotic complications they have encountered after ASB patient cases were mistreated
with an antibiotic. Researchers identified that unnecessary treatment of ASB in a common
clinical practice and seen in nearly 50% of ASB cases, and this indicates a significant
problem (Irfan, Brooks, Mithoowani, Celetti, Main & Mertz, 2015). Antibiotic use in nursing
homes creates several harmful patient outcomes including: the emergence of multi-drug
resistant bacteria; adverse drug events; polypharmacy; and higher health care costs.
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A knowledge gap exists between emergency department providers and healthcare
staff regarding the treatment of ASB. Education on this topic is crucial for positive patient
outcomes. Educational interventions implemented in this study include: an overview of the
evidence; clarification of misconceptions related to ASB management; discussion of cases
that residents had recently encountered and appropriate indication for urine cultures;
specifically, for patients with symptoms of UTI the presentation of asymptomatic
bacteriuria education. The primary investigator distributed pocket cards to emergency
department staff highlighting the Infectious Diseases Society of America guidelines for ASB
treatment to reinforce the program and offer references for future review. Implementing
educational interventions aim is to help reduce the amount of unnecessary antibiotics
prescribed to nursing home residents with ASB.
The research question for this study is, “Will educational interventions reduce the
amount of unnecessary antibiotic prescribing in nursing home residents that have
asymptomatic bacteriuria that present to Butler Health System’s Emergency Department?”
The following hypotheses will be tested in this research study.
H0: There is no reduction in the amount of antibiotics prescribed to nursing home residents
that have asymptomatic bacteriuria that present to Butler Health System’s Emergency
Department.
H1: There is a reduction in the amount of antibiotics prescribed to nursing home residents
that have asymptomatic bacteriuria that present to Butler Health System’s Emergency
Department.
Available Knowledge
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UTIs are the most commonly treated infection among nursing home residents. Even
in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms,
residents frequently receive an antibiotic for a suspected infection (Phillips et al., 2012). In
the absence of urinary symptoms, a diagnosis of ASB is given to patients. The 2005
Infectious Diseases Society of America guidelines define ASB as the specified quantitative
number of bacteria in the urine without any typical symptoms of a UTI (Nicolle, et. al., 2005).
These guidelines recommend no antimicrobial treatment for ASB unless the patient is
pregnant or anticipating a urologic interventional procedure. ASB is common and often
leads to unnecessary antibiotic use. Reducing antibiotic overuse for ASB is therefore an
important issue for antimicrobial stewardship (Lee et al., 2015). A need for antibiotic
stewardship in regard to ASB in Butler Health System’s Emergency Department has been
expressed from the health system itself as well as the nursing home providers. Antibiotic
therapy for ASB in the institutionalized elderly population has not been shown to be of
benefit and may in fact be harmful; however, antibiotics are still frequently used to treat
ASB in this population (Walker et al., 2000).
Rationale
ASB is prevalent in the elderly institutionalized population and there have been
various studies conducted involving the inappropriate treatment of ASB. A study conducted
by Irfan, Brooks, Mithoowani, Celetti, Main & Mertz (2015) regarding ASB was to reduce
risk factors and assess the impact of educational interventions. Variables included
appropriateness of ASB management, physicians’ knowledge and practice regarding ASB.
The sample population of interest was defined as consecutive patients with positive urine
cultures and the study was conducted in two tertiary teaching adult care hospitals.
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7
Educational sessions were implemented that provided a) an overview of the evidence, b)
feedback of findings during baseline assessment c) clarification of misconceptions related
to ASB management (i.e. risk factors associated with inappropriate treatment of ASB
identified during the period of baseline data collection), d) feedback about the initiative, e)
discussion of cases that residents had recently encountered and f) appropriate indication
for urine cultures, specifically, for patients with symptoms of UTI (Irfan et al., 2015).
Educational session interventions were effective in reducing inappropriate use of
antibiotics in ASB cases to less than 10%. Researchers demonstrated that their educational
interventions were not only successful in reducing inappropriate use of antimicrobials for
ASB cases in short studies but also in a long term follow up over two years (Irfan et al.,
2015).
Another study conducted by Walker, McGeer, Simor, Armstrong-Evans & Loeb
(2000) aimed to explore the perceptions, attitudes and opinions of physicians and nurses
involved in the process of prescribing antibiotics for ASB in institutionalized elderly people.
Focus groups were conducted among physicians and nurses who cared for to residents of
long term care facilities. The focus group discussions were tape recorded and the
transcripts for each session were analyzed to determine the uses and themes emerging
from the text (Walker et al., 2000). It was observed that the ordering of urine cultures and
the prescribing of antibiotics for residents with ASB were influenced by a wide range of
nonspecific symptoms or signs in residents. The physicians believed that the presence of
these signs justified a decision to order antibiotics. Nurses played a central role in both the
ordering of urine cultures and the decision to prescribe antibiotics through their
awareness of changes in residents’ status and communication of this to physicians. The
study concluded that education about ASB was viewed as an important priority for both
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8
physicians and nurses (Walker et al., 2000). The presence of non-urinary symptoms and
signs was an important factor in the prescription of antibiotics for ASB in the
institutionalized elderly population. However, ASB doesn’t necessarily warrant antibiotic
treatment (Walker et al., 2000).
These studies show the significance of inappropriately treated ASB and how
prevalent it is in the institutionalized elderly population. Two theories explained below can
be applied to the healthcare providers behavior in treating ASB.
One theory that supports this research study’s focus is Albert Bandura’s Social
Learning Theory. Albert Bandura’s social learning theory hypothesizes that individuals
learn from one another by means of observing, imitating, and modeling. Bandura (1977)
stated, “Most human behavior is learned observationally through modeling: from observing
others, one forms an idea of how new behaviors are performed, and on later occasions this
coded information serves as a guide for action” (p. 22).
Another theory that could be applied is Rodgers’ Diffusion of Innovations
Theory. Rogers (2003) discussed the innovation-diffusion process as “the process through
which an individual (or other decision-making unit) passes from gaining initial knowledge
of an innovation, to forming an attitude toward the innovation, to making a decision to
adopt or reject, to implementation of the new idea, and to confirmation of this decision” (p.
168). Both of these theories can directly relate to a healthcare providers’ approach in the
treatment or deferment of prescribing in ASB cases.
Specific Aims
The purpose of this research study is to reduce the amount of unnecessary antibiotic
prescribing and assess the impact of educational interventions in nursing home residents
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9
that have ASB that present to Butler Health System’s Emergency Department. This research
aims to improve patient outcomes and therefore increase quality care delivered by Butler
Memorial Hospital’s Emergency Department. An assumption can be made that patients will
benefit from this research study by being accurately treated for ASB and avoid harmful side
effects from mistreatment.
Methods
Context
UTI’s are the most common bacterial infection in elderly people, causing more than
50% of all infection episodes requiring treatment during institutional care (Hedin, Petersson,
Widebäck, Kahlmeter, & Mölstad, 2002). However, ASB is also prevalent and commonly
mistreated as a UTI with inappropriate antibiotics. Institutions for the elderly most commonly
include nursing homes, sheltered homes, and service houses of various sizes. Due to the
prevalence of ASB in the institutionalized elderly appropriate treatment is essential in delivering
quality patient care. Other differential diagnoses other than a UTI should be considered before
antibiotic treatment is given (Hedin, et. al., 2002).
Although current guidelines suggest screening for ASB and treating it in specific
circumstances such as during pregnancy or before invasive urologic procedures, antibiotic
overuse for ASB seems to be overwhelming in clinical practice, as supported by several
studies reporting that 20–80 % of cases of ASB are inappropriately treated (Lee et al.,
2015). The overuse of antibiotics in nursing home settings leads to the various
complications and potential harm to patients. Treatment of ASB has been shown to have no
clinical benefit in lowering the frequency of symptomatic UTI or ASB, whereas it
predisposes the patient to increased risk of development of resistant organisms or adverse
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effects (Kelley, Aaronson, Poon, McCarter, Bato, & Jankowski, 2014). The American
Geriatrics Society, (2013) has emphasized the importance of not treating elderly people
with ASB with antibiotics (Leduc, 2014). ASB can be harmful because of the possibility of
adverse drug reactions, especially in the frail elderly population with frequent
comorbidities.
Up to 70 percent of nursing home residents may receive at least one antibiotic agent
a year (McMaughan et al., 2016). This statistic is staggering and can lead to unwarranted
negative patient outcomes. The emergence of multidrug resistant organisms in nursing
homes and consequent spread to the community combined with other negative outcomes of
antibiotic overuse, such as adverse drug events, hospital admissions, and higher health care costs,
calls for optimizing antibiotic stewardship in nursing homes (McMaughan et al., 2016).
ASB is often times mistreated due to a lack of knowledge on the part of the
healthcare providers and staff. This knowledge is crucial in accurately diagnosing and
treating patients. National guidance indicates that men and women over 65 years should
not receive antibiotic treatment for ASB (McNulty, 2014). Providing educational sessions
regarding published guidelines to healthcare providers will help to eliminate any
mistreatment of ASB cases. According to Lee et. al., (2015), “Physicians’ lack of knowledge
and misperceptions contribute to the misuse of antibiotics” (p. 2). Inappropriate treatment
methods need to be addressed to improve patient outcomes and avoid any harm in
patients.
Zabarsky, Sethi, & Donskey (2008), found that 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.
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Antibiotic stewardship is a necessity to decrease bacterial drug resistance and is significant
in this research setting.
Interventions
This study uses observational methods, a chart review will be conducted preeducational intervention and post-educational intervention. A multifaceted educational
intervention will be provided for Emergency Department staff at Butler Memorial Hospital.
Educational interventions implemented in this study include; an overview of the evidence,
clarification of misconceptions related to ASB management, discussion of cases that
residents had recently encountered and appropriate indication for urine cultures,
specifically, for patients with symptoms of UTI the presentation of asymptomatic
bacteriuria education. Pocket cards for emergency department staff highlighting the
Infectious Diseases Society of America guidelines for ASB treatment will be provided to
staff for practice reference. Appendix A & B.
The Infectious Diseases Society of America guidelines state that ASB is defined as
two consecutive voided urine specimens with isolation of the same organism in
quantitative counts ≥105 cfu/mL in women with no signs or symptoms of UTI, or a single,
clean catch voided urine specimen with one bacterial species isolated in quantitative count
≥105 cfu/mL without any signs or symptoms of UTI in men (Nicolle, et. al., 2005). In both
men and women, a single catheterized urine specimen with one bacterial species isolated
in a quantitative count ≥102 cfu/mL were defined as having bacteriuria (Nicolle, et. al.,
2005). The pocket cards include an algorithm of when to screen and treat ASB patients and
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the Infectious Diseases Society of America guidelines and criteria for the diagnosis of
bacteriuria. Appendix B. The primary investigator created an algorithm as part of the
study assist providers with a clear and concise method to help guide treatment.
The educational presentation and materials were provided to the emergency
department staff to emphasize the importance of not treating the institutionalized elderly
population or patients that meet the Infectious Disease Society of America’s criteria for no
treatment.
Study of the Interventions
Data for the research was collected over ten months’ pre-educational intervention
to obtain baseline observation. Educational interventions were provided for emergency
department providers and healthcare staff and, then post-educational intervention data
was collected over 3 months’ time. Next, data was collected based upon the inclusion and
exclusion criteria listed. This data was then analyzed to determine the outcome of the pilot
study.
Measures
Butler Memorial Hospital served as the setting for my research project and research
will be conducted specifically in the Emergency Department. Butler Memorial Hospital is
an independent community, 296 bed hospital that opened in 1898. It is a non-profit
organization located in the rural community of Butler Pennsylvania. Butler Memorial
Hospital’s Emergency Department encounters several nursing home residents from the
surrounding community.
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Population of interest in this study include patients that reside in institutional
facilities for the elderly. The sample population must meet these inclusion criteria:
asymptomatic of urinary symptoms, discharged back to the nursing home, patients with a
first positive urine culture, defined as growth of greater than or equal to 105 colony
forming units per milliliter (CFU/mL) of bacteria. Urinary symptoms are defined by any
one of the following: urgency, dysuria, frequency, suprapubic tenderness, flank pain,
costovertebral angle pain and tenderness, rigors, gross hematuria, delirium, and new or
worsening fever (High, Bradley, Gravenstein, Mehr, Quagliarello, Richards, & Yoshikawa
2009).
General demographic data was collected on sample population including: age,
gender and if they have an indwelling catheter present. Inclusion criteria for the sample
population includes; the sample population must be a nursing home resident, discharged
back to the nursing home, patients with a first positive urine culture, defined as growth of
greater than or equal to 105 colony forming units per milliliter (CFU/mL) of bacteria, and
asymptomatic of urinary symptoms. Urinary symptoms are defined by any one of the
following: urgency, dysuria, frequency, suprapubic tenderness, flank pain, costovertebral
angle pain and tenderness, rigors, gross hematuria, delirium, and new or worsening fever
(High, et. al., 2009).
Exclusion criteria for the sample population includes; non-nursing home residents,
admission to the hospital and the presence of signs and symptoms of a UTI. A UTI is defined
by any one of the following: urgency, dysuria, frequency, suprapubic tenderness, flank pain,
costovertebral angle pain and tenderness, rigors, gross hematuria, delirium, and new or
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worsening fever, patients with a first positive urine culture of mixed growth, defined as
greater than 3 organisms (High, et. al., 2009).
Additional data collected will include if the patient was discharged on an antibiotic
for urinary symptoms both before and after educational interventions.
Analysis
The most accurate research design for this project is a quasi-experimental design.
There will be manipulation of the independent variable or the healthcare providers by
providing educational sessions for ED staff. The study shows a comparison of treated ASB
patients prior to educational sessions and then after education sessions. There will be no
control over what nursing home residents present to the emergency department or how
the provider treats the patient.
Ethical Considerations
The Institutional Review Boards at Edinboro University of Pennsylvania and Butler
Health System both approved the on-site data collection procedures for this study. Both
boards gave the research team a waiver of written consent. There were no physical,
psychological, financial, social/economic or legal risks, or harm from confidentiality to
population of interest in this study.
Results
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There were 105 of the sample population that resided in numerous institutional
facilities for the elderly that were seen in Butler Health System’s Emergency Department.
Out of the 105 sample population, 73 were encountered before educational intervention.
Data was collected between the dates of 2/1/18 through 7/31/18 for pre-educational
intervention. Twelve out of the 73 pre-educational sample population met the following
inclusion criteria; asymptomatic of urinary symptoms, discharged back to the nursing
home, patients with a first positive urine culture, defined as growth of greater than or equal
to 105 colony forming units per milliliter (CFU/mL) of bacteria. 8 of the 12-sample
population were females ranging in the age of 67-96. 4 of the 12-sample population were
males ranging in the age of 75-97. 3 of the 12-sample population had indwelling foley
catheters in place.
Additional data, collected between 8/10/18 through 11/10/18 comprised posteducational intervention observations. Out of the 105 sample population, 32 were
encountered after educational intervention. Four out of the 32 post-educational sample
population met the following inclusion criteria; asymptomatic of urinary symptoms,
discharged back to the nursing home, patients with a first positive urine culture, defined as
growth of greater than or equal to 105 colony forming units per milliliter (CFU/mL) of
bacteria. 4 of the 4-sample population were females ranging in the age of 74-93. 1of the 4
sample population had indwelling foley catheter in place.
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Institutionalized Elderly Sample Population
Size
80
70
60
50
40
30
20
10
0
Series1
PRE-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
PRE-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
THAT MET INCLUSION
CRITERIA
POST-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
POST-EDUCATIONAL
INTERVENTION
SAMPLE POPULATION
THAT MET INCLUSION
CRITERIA
Gender of Sample Population with
Indwelling Foley Catheters Present
POST-EDUCATIONAL INTERVENTION SAMPLE
POPULATION WITH INDWELLING FOLEY CATHETERS
PRE-EDUCATIONAL INTERVENTION SAMPLE
POPULATION WITH INDWELLING FOLEY CATHETERS
1
3
POST-EDUCATIONAL INTERVENTION MALES
0
POST-EDUCATIONAL INTERVENTION FEMALES
4
PRE-EDUCATIONAL INTERVENTION MALES
4
PRE-EDUCATIONAL INTERVENTION FEMALES
8
0
1
2
3
4
5
6
7
8
9
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Age of Sample Population
120
100
80
60
40
20
0
0
Series1
2
Series2
4
Series3
6
Series4
Series5
8
Series6
Series7
10
Series8
Discussion
Summary
The data analysis validated that nursing home residents that meet the Infectious
Disease Society of America’s guidelines for ASB do frequent Butler Health System’s
Emergency Department. Patients have been found discharged with UTI’s when in fact they
meet the criteria of ASB. This pilot study reveals that unnecessary antibiotics are being
prescribed to nursing home residents that exhibit ASB.
Interpretation
Out of the 73 pre-educational intervention sample population that met inclusion
criteria, 16.4% were inappropriately treated. This group of individuals were discharged
back to the nursing home facility on an antibiotic for an inaccurate diagnosis of a UTI.
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Pre-Educational Sample Population
16%
84%
Pre-Educational Intervention Sample Population
Pre-Educational Intervention Sample Population That Met Inclusion Criteria
Out of the 32 post-educational intervention sample population that met inclusion criteria,
12.5% were inappropriately treated. This group of individuals were discharged back to the
nursing home facility on an antibiotic for an inaccurate diagnosis of a UTI.
Post-Educational Sample Population
13%
87%
Pre-Educational Intervention Sample Population
Pre-Educational Intervention Sample Population That Met Inclusion Criteria
The pre- and post-educational intervention data revealed that there was a total of an
overall 3.9% reduction in patients that were inappropriately treated. Validating that the
educational interventions that were implemented in Butler Health System’s Emergency
Department were effective for reducing the amount of potential harmful patient outcomes.
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Overall Reduction
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Pre-Educational
Post-Educational
Intervention % of Sample Intervention % of Sample
Population
Population
Overall Reduction
Limitations
One limitation to this study is the setting only includes one hospital; comparison to
another comparable hospital would increase the interventional validity and
generalizability. Another limitation is the small sample size of population interests based
upon census.
Conclusions
This pilot study can conclude that there was a 3.9% overall reduction in nursing
home residents that were being inappropriately diagnosed with a UTI and placed on
unnecessary antibiotics when in fact they had ASB and met the criteria to defer
prescription.
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Further research needs to be conducted to assess the magnitude of inappropriate
ASB treatment in the inpatient hospital setting. Researchers speculate that future research
with a larger population of interest sample will yield a more validated study. Research
findings were shared with Butler Health System’s Infectious Disease Group, Emergency
Department and the Pennsylvania Safety Advisory Committee. This research data will be
beneficial to antibiotic stewardship initiatives.
References
Bandura, A. (1977). Social learning theory. New York, NY: Gernal Learning Press.
Chowdhury, F., Sarkar, K., Branche, A., Kim, J., Dwek, P., Nangit, A., … Visconti, E. (2012).
Preventing the inappropriate treatment of asymptomatic bacteriuria at a
community teaching hospital. Journal of Community Hospital Internal Medicine
Perspectives, 2(2), 10.3402/jchimp.v2i2.17814.
http://doi.org/10.3402/jchimp.v2i2.17814
Hedin, K., Petersson, C., Widebäck, K., Kahlmeter, G., & Mölstad, S. (2002). Asymptomatic
bacteriuria in a population of elderly in municipal institutional care. Scandinavian
Journal Of Primary Health Care, 20(3), 166-168.
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT.,
(2009). Clinical practice guideline for the evaluation of fever and infection in older
adult residents of long‐term care facilities: 2008 update by the Infectious Diseases
Society of America. J Am Geriatr Soc. 2009;57(3):375–94.
Irfan, N., Brooks, A., Mithoowani, S., Celetti, S. J., Main, C., & Mertz, D. (2015). A Controlled
Quasi-Experimental Study of an Educational Intervention to Reduce the
Unnecessary Use of Antimicrobials For Asymptomatic Bacteriuria. Plos ONE, 10(7),
1-11. doi:10.1371/journal.pone.0132071
Kandel, R., Pallin, D., & Doron, S. Massachusetts Infection Prevention Partnership.
Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts
Department of Public Health, Massachusetts Senior Care Association, Masspro.
Kelley, D., Aaronson, P., Poon, E., McCarter, Y., Bato, B., & Jankowski, C. (2014). Evaluation of
an Antimicrobial Stewardship Approach to Minimize Overuse of Antibiotics in
Patients with Asymptomatic Bacteriuria. Infection Control & Hospital Epidemiology,
35(2), 193-195. doi:10.1086/674848
Leduc, A. (2014). Reducing the Treatment of Asymptomatic Bacteriuria in Seniors in a
Long-Term Care Facility. Canadian Nurse, 110(7), 25-30.
Lee, M. J., Kim, M., Kim, N., Kim, C., Song, K., Choe, P. G., & ... Kim, H. B. (2015). Why is
asymptomatic bacteriuria overtreated?: A tertiary care institutional survey of
resident physicians. BMC Infectious Diseases, 15289. doi:10.1186/s12879-0151044-3
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
22
McMaughan, D. K., Nwaiwu, O., Zhao, H., Frentzel, E., Mehr, D., Imanpour, S., & Phillips, C. D.
(2016). Impact of a decision-making aid for suspected urinary tract infections on
antibiotic overuse in nursing homes. BMC Geriatrics, 1681. doi:10.1186/s12877016-0255-9
McNulty, C. (2014). Managing asymptomatic bacteriuria in the elderly. Practice Nursing,
25(1), 11-15.
Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society
of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria
in adults. Clin Infect Dis. 2005; 40(5):643–54. Epub 2005/02/17. doi:
10.1086/427507 PMID: 15714408.
Phillips, C. D., Adepoju, O., Stone, N., Moudouni, D. M., Nwaiwu, O., Zhao, H., & Garfinkel, S.
(2012). Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract
infections in four nursing homes. BMC Geriatrics, 12(1), 73. doi:10.1186/1471
Rogers, E.M. (2003). Diffusion of Innovations (5th Ed.). New York: The Free Press.
Walker, S., McGeer, A., Simor, A. E., Armstrong-Evans, M., & Loeb, M. (2000). Why are
antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly
people? A qualitative study of physicians' and nurses' perceptions. CMAJ: Canadian
Medical Association Journal = Journal De L'association Medicale Canadienne, 163(3),
273-277.
Zabarsky, T. F., Sethi, A. K., & Donskey, C. J. (2008). Sustained reduction in inappropriate
treatment of asymptomatic bacteriuria in a long-term care facility through an
DEFERRING ANTIBIOTIC PRESCRIBING IN NURSING HOME RESIDENTS WITH ASYMPTOMATIC
BACTERIURIA
educational intervention. American Journal Of Infection Control, 36(7), 476-480.
doi:10.1016/j.ajic.2007.11.007
Appendix A
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Appendix B
Pocket Card:
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Appendix C
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