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BACKGROUND: According to the Centers for Disease Control and Prevention (CDC), 1 to 3 million infections occurs every year among long-term care (LTC) residents. Urinary tract infections (UTIs) are the most frequently reported by LTC facilities, accounting for 20-30%. However, a substantial portion of these UTIs actually may be asymptomatic bacteriuria, which has shown to be prevalent among LTC residents ranging from 15% to 50%. Because infections are diagnosed frequently in LTC facilities, residents are often exposed to antimicrobial agents, with the likelihood that 50% to 70% of residents will receive at least one course during a 1-year period. Due to this exposure and other risk factors, the prevalence of Clostridium difficile infections (CDI) has become an increasing problem in LTC facilities. Therefore, the Kentucky Department for Public Health (KDPH) conducted an infection prevention collaborative project with the primary goal to reduce the inappropriate use of antimicrobials and associated CDIs by 15%.
METHODS: A pre-post intervention study was conducted among a group of LTC facilities over 18 months (2012-2013). The National Healthcare Safety Network (NHSN) Surveillance definitions for CDI and UTI were selected and utilized. Multiple activities such as on-site visits, baseline survey, education, and implementation of evidence-based practices were completed. Tools such as policies, evidence-based protocols, checklists, and decision trees were created to address practices needing improvement. Data was collected utilizing a web-based SharePoint site.
RESULTS: Pre-intervention results included a total of 984 UTIs reported (2.8 per 1,000 resident days) and 80 CDIs (2.28 per 10,000 resident days). Of the UTIs reported and treated with antimicrobials, 70% did not meet the NHSN surveillance definitions for symptomatic UTI. Almost all of these asymptomatic cases had no clinical urinary symptoms reported. The most common reported non-urinary symptom was confusion or behavior change (27%). Post-intervention results included a total of 507 reported UTIs (rate of 2.05 per 1,000 resident days) and a total of 32 CDIs (rate of 1.3 per 10,000 resident days). These results demonstrated a 33% reduction in reported and treated cases of asymptomatic bacteriuria (p-value of <0.001) and a 43% reduction in CDI cases (p-value 0.01).
CONCLUSIONS: Overuse of antimicrobials in the LTC setting is well documented and confirmed with this study. This collaborative project demonstrated that improving the surveillance and implementation of evidence-based practices for urinary tract infections among long-term care residents, can lead to a reduction in inappropriate antibiotic use and have a significant impact on associated Clostridium difficile infections.