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Clinical Reasoning Underlying Guideline Nonadherence in Urinary Tract Infections in Nursing Homes

Published:October 20, 2021DOI:https://doi.org/10.1016/j.jamda.2021.09.032
      Suspected urinary tract infections (UTIs) are the main reason for antimicrobial use in nursing homes, but prescriptions are often inappropriate, risking antimicrobial resistance development.
      • van Buul L.W.
      • Veenhuizen R.B.
      • Achterberg W.P.
      • et al.
      Antibiotic prescribing in Dutch nursing homes: How appropriate is it?.
      Diagnosing UTIs in this population is complex because of a lack of reliable diagnostic tests to distinguish UTI from asymptomatic bacteriuria, and the frequent occurrence of nonspecific symptoms for which an association with UTI remains unclear.
      • Caterino J.M.
      • Kline D.M.
      • Leininger R.
      • et al.
      Nonspecific symptoms lack diagnostic accuracy for infection in older patients in the emergency department.
      International guidelines
      • Ashraf M.S.
      • Gaur S.
      • Bushen O.Y.
      • et al.
      Diagnosis, treatment, and prevention of urinary tract infections in post-acute and long-term care settings: A consensus statement from AMDA's Infection Advisory Subcommittee.
      • Stone N.D.
      • Ashraf M.S.
      • Calder J.
      • et al.
      Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria.
      • van Buul L.W.
      • Vreeken H.L.
      • Bradley S.F.
      • et al.
      The development of a decision tool for the empiric treatment of suspected urinary tract infection in frail older adults: A Delphi Consensus Procedure.
      recommend to (1) diagnose UTIs based on solely specific urinary symptoms, (2) to identify specific urinary symptoms by observation and physical examination, and (3) to prevent the use of urine dipsticks or to only use dipsticks for ruling out UTI. Despite these recommendations, nonspecific symptoms are still frequently attributed to UTIs in practice, and positive urine testing results are the most important factor driving antimicrobial prescriptions in suspected UTI.
      • Kistler C.E.
      • Beeber A.S.
      • Zimmerman S.
      • et al.
      Nursing home clinicians' decision to prescribe antibiotics for a suspected urinary tract infection: Findings from a discrete choice experiment.
      The aim of the current study was to examine the clinical reasoning underlying nonadherence to guidelines that contributes to inappropriate antibiotic use.
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      References

        • van Buul L.W.
        • Veenhuizen R.B.
        • Achterberg W.P.
        • et al.
        Antibiotic prescribing in Dutch nursing homes: How appropriate is it?.
        J Am Med Dir Assoc. 2015; 16: 229-237
        • Caterino J.M.
        • Kline D.M.
        • Leininger R.
        • et al.
        Nonspecific symptoms lack diagnostic accuracy for infection in older patients in the emergency department.
        J Am Geriatr Soc. 2019; 67: 484-492
        • Ashraf M.S.
        • Gaur S.
        • Bushen O.Y.
        • et al.
        Diagnosis, treatment, and prevention of urinary tract infections in post-acute and long-term care settings: A consensus statement from AMDA's Infection Advisory Subcommittee.
        J Am Med Dir Assoc. 2020; 21: 12-24.e12
        • Stone N.D.
        • Ashraf M.S.
        • Calder J.
        • et al.
        Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria.
        Infect Control Hosp Epidemiol. 2012; 33: 965-977
        • van Buul L.W.
        • Vreeken H.L.
        • Bradley S.F.
        • et al.
        The development of a decision tool for the empiric treatment of suspected urinary tract infection in frail older adults: A Delphi Consensus Procedure.
        J Am Med Dir Assoc. 2018; 19: 757-764
        • Kistler C.E.
        • Beeber A.S.
        • Zimmerman S.
        • et al.
        Nursing home clinicians' decision to prescribe antibiotics for a suspected urinary tract infection: Findings from a discrete choice experiment.
        J Am Med Dir Assoc. 2020; 21: 675-682.e671
        • Kuil S.D.
        • Hidad S.
        • Fischer J.C.
        • et al.
        Sensitivity of point-of-care testing C reactive protein and procalcitonin to diagnose urinary tract infections in Dutch nursing homes: PROGRESS study protocol.
        BMJ Open. 2019; 9: e031269
        • Damschroder L.J.
        • Aron D.C.
        • Keith R.E.
        • et al.
        Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
        Implement Sci. 2009; 4: 50
      1. Urinary tract infections: To dip or not to dip Available at: https://www.dorsetccg.nhs.uk/Downloads/aboutus/medicines-management/Other%20Guidelines/Urine%20dipsticks%20leaflet%20-%20To%20Dip%20or%20Not%20to%20Dip.pdf. Accessed June 6, 2021.

        • Bartholomew L.K.
        • Parcel G.S.
        • Kok G.
        • et al.
        Planning Health Promotion Programs: An Intervention Mapping Approach.
        3rd ed. Jossey-Bass, San Fransisco2011