Implementation of a Provider-Based Antimicrobial Stewardship Strategy at a Long Term Acute Care Hospital (LTACH) and Inpatient Physical Medicine and Rehabilitation (PMR) Facility
Antimicrobials are often overutilized in long term care facilities, particularly for urinary tract infections (UTI) and asymptomatic bacteriuria (ASB). However, limited data exists to guide antimicrobial stewardship in these settings. This study sought to determine if implementation of empiric UTI evaluation and treatment guidelines, along with education and targeted prescriber feedback would reduce the number of urine cultures ordered, prevent inappropriate treatment of ASB, and improve appropriate antimicrobial selection.
We conducted a single-center prospective cohort study with historic controls at a 96-bed LTACH and PMR facility in Philadelphia from 9/2013 to 4/2014. Treatment guidelines were developed using unit-specific antibiograms. Guidelines were then implemented through educational sessions and distributed as pocket cards on 1/15/2014. Clinical characteristics (LTACH and PMR) and antimicrobial regimens (PMR) for UTI were compared for a 4-month pre- (PRE) and 3-month post-intervention (POST) group. All patients who had a urine culture ordered and received empiric UTI antimicrobials were included.
Patients were similar in the two groups except for a higher frequency of LTACH patients with indwelling urinary catheters in the POST group (38.9% vs. 15.3%; p=0.004). Fewer urine cultures were ordered in POST compared to PRE group (mean cultures per month: 62 vs. 92; p=0.037). For the PMR unit, a total of 32 antimicrobial regimens (20 UTI, 12 ASB) were evaluated in the PRE group and 21 regimens (15 UTI, 6 ASB) in the POST group. Inappropriate treatment of ASB did not differ significantly between POST and PRE groups (6/21 [28.6%] vs. 12/32 [37.5%]; p=0.56). The intervention improved both empiric antimicrobial choice for UTI episodes (POST vs. PRE: 13/15 [86.7%] vs. 1/20 [5.0%]; p<0.001) as well as appropriate dose/frequency (POST vs. PRE: 15/15 [100%] vs. 7/20 [35%]; p<0.001).
A bundled stewardship intervention was effective at reducing the number of urine cultures and improving appropriate drug selection for UTI at an LTACH and PMR facility. The intervention was well received and easy to implement using limited resources, demonstrating that stewardship strategies can be successfully incorporated into long term care and other post-acute care settings.
S. Binkley, None
D. Timko, None
S. Morgan, None
D. Pegues, None
K. Hamilton, None