Antibiotic stewardship improved prescribing for suspected UTI in frail older adults

Inappropriate antibiotic prescribing for suspected urinary tract infections (UTIs) was reduced in practices and facilities assigned to use a decision tool instead of usual care, particularly for patients with dementia, a randomized trial in Europe found.

A multidisciplinary stewardship program helped reduce antibiotic prescribing for urinary tract infections (UTIs) in frail older adults, a study found.

Researchers performed a cluster-randomized controlled trial at 43 general practices and 43 elder care facilities in Poland, the Netherlands, Norway, and Sweden from September 2019 to June 2021 to evaluate whether antibiotic stewardship reduced antibiotic prescribing for suspected UTIs in frail older adults. The intervention included a decision tool for appropriate antibiotic use supported by a toolbox of educational materials and was implemented using a participatory-action-research approach, with sessions for education, evaluation, and intervention customization. The control group provided usual care. The study's primary outcome was the number of antibiotic prescriptions for suspected UTI per person-year, with secondary outcomes including complications, all-cause hospital referrals, all-cause hospital admissions, and all-cause mortality overall and within 21 days after suspected UTIs. The results were published Feb. 22 by BMJ.

The trial involved 38 clusters of practices or facilities and 1,041 frail patients ages 70 years and older, with 411 person-years of follow-up, a baseline period of five months, and a follow-up period of seven months. Five hundred two patients were in the intervention group, and 539 were in the usual care group. Mean age was 86 years, 71% were women, and 44% had dementia. During the follow-up period, there were 54 antibiotic prescriptions for suspected UTI in 202 person-years in the intervention group versus 121 prescriptions in 209 person-years in the usual care group (0.27 per person-year vs. 0.58 per person-year, respectively). Those in the intervention group were less likely than those in the usual care group to receive an antibiotic prescription for suspected UTI (rate ratio, 0.42; 95% CI, 0.26 to 0.68). Complications, hospital referrals and admissions, mortality within 21 days of suspected UTI, and all-cause mortality did not differ between the intervention and control groups. In a subgroup analysis, the intervention had a stronger effect in patients with dementia versus those without (rate ratios, 0.33 [95% CI, 0.17 to 0.64] and 0.56 [95% CI, 0.28 to 1.12], respectively) and in patients without urinary incontinence versus those with it (rate ratios, 0.24 [95% CI, 0.11 to 0.54] and 0.53 [95% CI, 0.29 to 0.96], respectively).

The authors noted that they did not evaluate patient-reported outcomes, microbiological outcomes, or cost-effectiveness and that the COVID-19 pandemic could have affected their results, among other limitations. They said it was promising that the intervention appeared effective in patients with dementia but noted that it was not as effective in those with urinary incontinence, possibly because it is more difficult to recognize urinary tract symptoms in this group. The authors concluded that the multifaceted antibiotic stewardship intervention used in their study safely reduced antibiotic prescribing for suspected UTIs in frail older adults. “Implementation across diverse older adult care settings requires the active participation of all healthcare professionals, as well as tailoring to the local situation,” they wrote.

Another recent article, published by Clinical Infectious Diseases on Feb. 20, looked at the current pyuria thresholds used to diagnose UTIs in older women. Researchers examined 164 women ages 65 years and older, 63 with at least two new-onset lower urinary tract symptoms and one uropathogen with at least 104 colony-forming units/mL (the UTI group) and 101 controls, who were asymptomatic and were classified as having asymptomatic bacteriuria (one uropathogen ≥105 colony-forming units/mL), a negative culture, or mixed flora.

Patients in the UTI group had higher median urinary leukocytes versus controls (900 versus 26 leukocytes/µL on microscopy; 1,575 vs. 23 leukocytes/µL on flowcytometry; P<0.001), and the area under the curve was 0.93 for both methods. Sensitivity and specificity of microscopy were 88% (positive and negative likelihood ratio, 7.2 and 0.1, respectively) at a cut-off of 264 leukocytes/µL. The commonly used cut-off for pyuria, 10 leukocytes/µL, had 36% specificity and 100% sensitivity.

The researchers concluded that degree of pyuria can help distinguish UTI from asymptomatic bacteriuria in older women. “Current pyuria cut-offs for UTI are too low and promote inappropriate UTI diagnosis in this population, affecting patient care, antimicrobial stewardship efforts and research,” they wrote. “The impact of higher cut-off values on prescription behavior and UTI related outcomes in older women deserves further study.”