- Email: [email protected]
Re: Impact of a Decision-Making Aid for Suspected Urinary Tract Infections on Antibiotic Overuse in Nursing Homes
Urological Survey 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57
Geriatrics Re: Inappropriate Use of Urinary Catheters among Hospitalized Elderly Patients: Clinician Awareness is Key F. W. Hu, D. C. Yang, C. C. Huang, C. H. Chen and C. M. Chang Institute of Allied Health Sciences, College of Medicine, Division of Geriatrics and Gerontology, Department of Internal Medicine and Department of Nursing, National Cheng Kung University, Tainan City, Taiwan Geriatr Gerontol Int 2015; 15: 1235e1241. doi: 10.1111/ggi.12431
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25496666 Editorial Comment: Although indwelling urinary catheters can be useful for a number of urological conditions in a variety of clinical settings, use is also associated with well-known risks, including urinary tract infections (UTIs), stones and tissue erosion. Clinical pathways and policy initiatives have been implemented in the United States and other countries in an effort to decrease overall rates of urinary catheter use and facilitate early removal when possible. These efforts have helped to reduce rates of catheter associated UTIs. However, there are still many cases of inappropriate catheter use in acute and long-term care settings. This study examined rates of catheter use including the number of days for each individual. Inappropriate catheter use, based on lack of clinical necessity, was documented in 52.8% of catheter days in an acute care hospital setting. Convenience of care was the most commonly cited reason for catheter use. Prolonged indwelling catheter use was associated with several negative clinical outcomes including greater length of hospital stay and increased rates of UTI, discharge from the facility with the catheter in place and impairment in activities of daily living. These results highlight the ongoing need to fully evaluate the medical necessity of catheter placement and ongoing use in an effort to decrease inappropriate catheter utilization. Tomas L. Griebling, MD, MPH
Suggested Reading Leuck AM, Wright D, Ellingson L et al: Complications of Foley cathetersdis infection the greatest risk? J Urol 2012; 187: 1662.
Re: Impact of a Decision-Making Aid for Suspected Urinary Tract Infections on Antibiotic Overuse in Nursing Homes D. K. McMaughan, O. Nwaiwu, H. Zhao, E. Frentzel, D. Mehr, S. Imanpour, S. Garfinkel and C. D. Phillips Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas, American Institutes for Research, Washington, D.C., and University of Missouri School of Medicine, Columbia, Missouri BMC Geriatr 2016; 16: 81. doi: 10.1186/s12877-016-0255-9
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27084340 Editorial Comment: Antibiotic use for treatment of culture documented or presumed urinary tract infections (UTIs) is extremely common in geriatric clinical care. Despite strong evidence that antibiotics should not be routinely prescribed in cases of symptomatic bacteriuria, the practice remains
0022-5347/17/1973-0001/0 THE JOURNAL OF UROLOGY® Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2016.12.049 Vol. 197, 1-3, March 2017 Printed in U.S.A.
www.jurology.com Dochead: Urological Survey
LIT 5.4.0 DTD JURO14267_proof 16 December 2016 4:55 pm EO:
j
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 1 113 114
GERIATRICS
2
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171
widespread and can lead to negative outcomes, including increased development of bacterial antibiotic resistance, increased rates of adverse drug events and increased costs. There has been recent interest in enhancing antibiotic stewardship. including dissemination of guideline and policy statements about avoiding antibiotic use in cases of symptomatic bacteriuria. One of the main problems is differentiating this condition from true symptomatic UTI. It must be remembered that older adults may not experience the typical UTI symptoms of dysuria, fever and pelvic pain, but rather atypical symptoms such as mental status change or anorexia. This study examined the effects of a standardized decision aid using evidence-based guidelines on rates of antibiotic prescribing in 574 residents in regional nursing homes in a single state. Overall rates of asymptomatic bacteriuria were used to dichotomize nursing homes into high and low intensity for the condition, and the degree of success or fidelity of using decision aids was considered another predictor variable. Rates of inappropriate antibiotic prescription decreased, particularly for nursing homes with better fidelity following decision aid methods. Although they did not reach statistical significance, there were trends noted between high and low intensity homes for asymptomatic bacteriruia. These findings demonstrate the potential usefulness of standard decision tools to reduce unnecessary antibiotic prescriptions. Tomas L. Griebling, MD, MPH
Re: Constitutional Symptoms Trigger Diagnostic Testing before Antibiotic Prescribing in High-Risk Nursing Home Residents A. C. Eke-Usim, M. A. Rogers, K. E. Gibson, C. Crnich and L. Mody; Targeted Infection Prevention Study Team School of Public Health, Department of Internal Medicine, and Division of Geriatric and Palliative Care Medicine, University of Michigan School of Medicine, and Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin J Am Geriatr Soc 2016; 64: 1975e1980. doi: 10.1111/jgs.14286
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27655061 Editorial Comment: Given epidemiological data showing a dramatic increase in rates of antibiotic resistance for many common bacteria, there has recently been increased interest in research aimed at improving antibiotic stewardship. The topic is of particular concern in geriatrics, where urinary tract infections (UTIs) and pneumonia are especially common. This study examined how symptoms and other clinical triggers prompted antibiotic prescribing patterns for residents at 6 nursing homes in a region of 1 state. A total of 162 residents with an indwelling urinary catheter, an enteral feeding tube or both were studied. Rate of incident infection was high at 62%. Change in mental status was a significant predictor of ordering urinalysis, chest x-ray and blood cultures in this group. Empirical antibiotic therapy was used in 21.5% and 30.2% of suspected UTI and pneumonia cases, respectively. However, more concerning was the fact antibiotics were prescribed in 17% of patients with no clinical or laboratory evidence of infection, and antibiotic treatments were commonly continued despite subsequent negative culture results. Differentiation between asymptomatic bacteriuria, which generally does not require treatment, and true UTI is important. The findings support the use of objective clinical data including culture results to optimize antibiotic use in this population and improve antibiotic stewardship. Tomas L. Griebling, MD, MPH
Suggested Reading Griebling TL: Urologic Diseases in America project: trends in resource use for urinary tract infections in women. J Urol 2005; 173: 1281. Griebling TL: Urologic Diseases in America project: trends in resource use for urinary tract infections in men. J Urol 2005; 173: 1288.
Dochead: Urological Survey
LIT 5.4.0 DTD JURO14267_proof 16 December 2016 4:55 pm EO:
172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228
Geriatrics Re: Inappropriate Use of Urinary Catheters among Hospitalized Elderly Patients: Clinician Awareness is Key F. W. Hu, D. C. Yang, C. C. Huang, C. H. Chen and C. M. Chang Institute of Allied Health Sciences, College of Medicine, Division of Geriatrics and Gerontology, Department of Internal Medicine and Department of Nursing, National Cheng Kung University, Tainan City, Taiwan Geriatr Gerontol Int 2015; 15: 1235e1241. doi: 10.1111/ggi.12431
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25496666 Editorial Comment: Although indwelling urinary catheters can be useful for a number of urological conditions in a variety of clinical settings, use is also associated with well-known risks, including urinary tract infections (UTIs), stones and tissue erosion. Clinical pathways and policy initiatives have been implemented in the United States and other countries in an effort to decrease overall rates of urinary catheter use and facilitate early removal when possible. These efforts have helped to reduce rates of catheter associated UTIs. However, there are still many cases of inappropriate catheter use in acute and long-term care settings. This study examined rates of catheter use including the number of days for each individual. Inappropriate catheter use, based on lack of clinical necessity, was documented in 52.8% of catheter days in an acute care hospital setting. Convenience of care was the most commonly cited reason for catheter use. Prolonged indwelling catheter use was associated with several negative clinical outcomes including greater length of hospital stay and increased rates of UTI, discharge from the facility with the catheter in place and impairment in activities of daily living. These results highlight the ongoing need to fully evaluate the medical necessity of catheter placement and ongoing use in an effort to decrease inappropriate catheter utilization. Tomas L. Griebling, MD, MPH
Suggested Reading Leuck AM, Wright D, Ellingson L et al: Complications of Foley cathetersdis infection the greatest risk? J Urol 2012; 187: 1662.
Re: Impact of a Decision-Making Aid for Suspected Urinary Tract Infections on Antibiotic Overuse in Nursing Homes D. K. McMaughan, O. Nwaiwu, H. Zhao, E. Frentzel, D. Mehr, S. Imanpour, S. Garfinkel and C. D. Phillips Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas, American Institutes for Research, Washington, D.C., and University of Missouri School of Medicine, Columbia, Missouri BMC Geriatr 2016; 16: 81. doi: 10.1186/s12877-016-0255-9
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27084340 Editorial Comment: Antibiotic use for treatment of culture documented or presumed urinary tract infections (UTIs) is extremely common in geriatric clinical care. Despite strong evidence that antibiotics should not be routinely prescribed in cases of symptomatic bacteriuria, the practice remains
0022-5347/17/1973-0001/0 THE JOURNAL OF UROLOGY® Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2016.12.049 Vol. 197, 1-3, March 2017 Printed in U.S.A.
www.jurology.com Dochead: Urological Survey
LIT 5.4.0 DTD JURO14267_proof 16 December 2016 4:55 pm EO:
j
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 1 113 114
GERIATRICS
2
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171
widespread and can lead to negative outcomes, including increased development of bacterial antibiotic resistance, increased rates of adverse drug events and increased costs. There has been recent interest in enhancing antibiotic stewardship. including dissemination of guideline and policy statements about avoiding antibiotic use in cases of symptomatic bacteriuria. One of the main problems is differentiating this condition from true symptomatic UTI. It must be remembered that older adults may not experience the typical UTI symptoms of dysuria, fever and pelvic pain, but rather atypical symptoms such as mental status change or anorexia. This study examined the effects of a standardized decision aid using evidence-based guidelines on rates of antibiotic prescribing in 574 residents in regional nursing homes in a single state. Overall rates of asymptomatic bacteriuria were used to dichotomize nursing homes into high and low intensity for the condition, and the degree of success or fidelity of using decision aids was considered another predictor variable. Rates of inappropriate antibiotic prescription decreased, particularly for nursing homes with better fidelity following decision aid methods. Although they did not reach statistical significance, there were trends noted between high and low intensity homes for asymptomatic bacteriruia. These findings demonstrate the potential usefulness of standard decision tools to reduce unnecessary antibiotic prescriptions. Tomas L. Griebling, MD, MPH
Re: Constitutional Symptoms Trigger Diagnostic Testing before Antibiotic Prescribing in High-Risk Nursing Home Residents A. C. Eke-Usim, M. A. Rogers, K. E. Gibson, C. Crnich and L. Mody; Targeted Infection Prevention Study Team School of Public Health, Department of Internal Medicine, and Division of Geriatric and Palliative Care Medicine, University of Michigan School of Medicine, and Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin J Am Geriatr Soc 2016; 64: 1975e1980. doi: 10.1111/jgs.14286
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27655061 Editorial Comment: Given epidemiological data showing a dramatic increase in rates of antibiotic resistance for many common bacteria, there has recently been increased interest in research aimed at improving antibiotic stewardship. The topic is of particular concern in geriatrics, where urinary tract infections (UTIs) and pneumonia are especially common. This study examined how symptoms and other clinical triggers prompted antibiotic prescribing patterns for residents at 6 nursing homes in a region of 1 state. A total of 162 residents with an indwelling urinary catheter, an enteral feeding tube or both were studied. Rate of incident infection was high at 62%. Change in mental status was a significant predictor of ordering urinalysis, chest x-ray and blood cultures in this group. Empirical antibiotic therapy was used in 21.5% and 30.2% of suspected UTI and pneumonia cases, respectively. However, more concerning was the fact antibiotics were prescribed in 17% of patients with no clinical or laboratory evidence of infection, and antibiotic treatments were commonly continued despite subsequent negative culture results. Differentiation between asymptomatic bacteriuria, which generally does not require treatment, and true UTI is important. The findings support the use of objective clinical data including culture results to optimize antibiotic use in this population and improve antibiotic stewardship. Tomas L. Griebling, MD, MPH
Suggested Reading Griebling TL: Urologic Diseases in America project: trends in resource use for urinary tract infections in women. J Urol 2005; 173: 1281. Griebling TL: Urologic Diseases in America project: trends in resource use for urinary tract infections in men. J Urol 2005; 173: 1288.
Dochead: Urological Survey
LIT 5.4.0 DTD JURO14267_proof 16 December 2016 4:55 pm EO:
172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228