National trends in the treatment of urinary tract infections among Veterans’ Affairs Community Living Center residents

Objective: To describe urinary tract infection (UTI) treatment among Veterans’ Affairs (VA) Community Living Centers (CLCs) nationally and to assess related trends in antibiotic use. Design: Descriptive study. Setting and participants: All UTI episodes treated from 2013 through 2017 among residents in 110 VA CLCs. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. UTI episodes were stratified into culture-positive and culture-negative episodes. Methods: Frequency and rate of antibiotic use were assessed for all UTI episodes overall and were stratified by culture-positive and culture-negative episodes. Joinpoint software was used for regression analyses of trends over time. Results: We identified 28,247 UTI episodes in 14,983 Veterans. The average age of Veterans was 75.7 years, and 95.9% were male. Approximately half of UTI episodes (45.7%) were culture positive and 25.7% were culture negative. Escherichia coli was recovered in 34.1% of culture-positive UTI episodes, followed by Proteus mirabilis and Klebsiellaspp, which were recovered in 24.5% and 17.4% of culture-positive UTI episodes, respectively. The rate of total antibiotic use in days of therapy (DOT) per 1,000 bed days decreased by 10.1% per year (95% CI, −13.6% to −6.5%) and fluoroquinolone use (ciprofloxacin or levofloxacin) decreased by 14.5% per year (95% CI, −20.6% to −7.8%) among UTI episodes overall. Similar reductions in rates of total antibiotic use and fluoroquinolone use were observed among culture-positive UTI episodes and among culture-negative UTI episodes. Conclusion: Over a 5-year period, antibiotic use for UTIs significantly decreased among VA CLCs, as did use of fluoroquinolones. Antibiotic stewardship efforts across VA CLCs should be applauded, and these efforts should continue

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting