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Background: Older adults (aged ≥65) are at high risk of harm from overdiagnosis and overtreatment of urinary tract infections (UTIs) with antibiotics. Involving patients/caregivers in their antibiotic treatment decisions has potential to improve prescribing. To engage effectively, patients/caregivers must have sufficient knowledge about UTIs, asymptomatic bacteriuria (ASB: bacteria in the urine without signs of UTI), and antibiotics and opportunities to share their concerns and treatment preferences with healthcare staff. Patient education is one of the core elements of antibiotic stewardship recommended by the Centers for Disease Control and Prevention but, there are few resources for patients/caregivers about UTIs and antibiotics, leaving a knowledge gap as to what effective patient/caregiver antibiotic education for UTIs looks like. We sought to better understand the perspectives of patients/caregivers at high-risk of antibiotic overuse for UTIs and create an educational leaflet on UTIs, antibiotics, and ASB. Method: Between 11/2022 and 03/2023, we conducted virtual semi-structured interviews with patients ≥65yrs who had experienced UTI and caregivers about their needs, experiences, and preferences for educational support. Interviews lasted ~1 hour. Audio recordings were transcribed verbatim. NVivo software managed the data, which we analyzed using thematic analysis. Results: We conducted 9 interviews (5 patients, 4 caregivers). Interviewees expressed desire to be involved in their treatment decisions and learn more about antibiotics and alternative strategies (themes shown in Figure 1). Reported reasons for limited involvement in decisions included lacking the knowledge and confidence to ask questions, emotional factors (e.g., embarrassment/stress), deference to healthcare staff, and time constraints. Healthcare staff behaviors were described both as barriers (e.g., assertive treatment decisions) and facilitators (e.g., effective communication) of patient/caregiver engagement. Interviewees were eager for printed and digital educational support that could provide tailored content to help improve their knowledge and prepare for future conversations with healthcare staff. From this feedback we developed an educational leaflet (Figure 2). Conclusions: Involving patients/caregivers in antibiotic treatment decisions represents an opportunity to intervene before patients experience antibiotic overuse. Our findings offer important insights on patient/caregiver’ educational needs and preferences as well as perceived barriers to engaging in antibiotic treatment decisions for UTI. We used these insights to inform the development of educational materials about UTIs, ASB, and antibiotics for patients/caregivers and plan to test their use through multiple mediums with tailoring for unique patient needs, experiences, and backgrounds.

Background: Inappropriate diagnosis and treatment of urinary tract infections (UTI) contributes to antibiotic overuse. The Inappropriate Diagnosis of UTI (ID-UTI) measure—which quantifies the percentage of treated bacteriuria that is asymptomatic (ASB) using a standard definition of UTI—has been validated in acute care hospitals, but not in critical access hospitals (CAHs) where resources differ. Methods: From October 2022-July 2023, ten CAHs participated in a program to reduce ASB treatment, including education, coaching, and hospital feedback using the ID-UTI measure. Our primary aim was to assess performance characteristics of the ID-UTI standard definition and measure in CAHs (Figure 1). Non-physician abstractors from each CAH submitted clinical data (e.g., signs/symptoms) via REDCap for consecutive adult patients who were admitted or discharged from the emergency department and received antibiotics for bacteriuria. The case abstraction goal for each CAH was 5-6 cases/month. To assess feasibility, we evaluated the ability of each CAH to achieve goal case abstractions. To assess validity and reliability of the ID-UTI standard definition, two physicians reviewed 10% of submitted cases using deidentified patient notes and assessed agreement with the standard ID-UTI definition and consensus clinical opinion. Based on submitted data, we provided bi-monthly feedback reports to CAHs including the hospital-level ID-UTI measure to benchmark progress and for peer comparison. We measured monthly change in the ID-UTI measure using a mixed-effects logistic regression model (Figure 1, Figure 2). Results: Among 10 CAHs, 4 (40%) submitted >59 cases over 10 months (goal) while 3 (30%) submitted >35 cases (secondary goal). Physician reviewers assessed 9.5% (58/608) of cases. Utilizing the ID-UTI standard definition, there was high agreement (93%) in ASB vs UTI designation between each physician reviewer and the CAH’s REDCap assessment (Figure 3). Compared to clinical opinion, the ID-UTI standard definition identified 48% (16/33) of ASB cases and 100% (25/25) of UTI cases (Figure 4). Over the program, the percentage of cases treated for UTI that were ASB decreased from 28.4% (range 0-63%) to 18.6% (range, 0-33%; p=0.055) (Figure 5). Conclusions: Case abstraction with use of the ID-UTI measure was feasible and reliable to implement with modifications for CAHs. Data collection by untrained staff was as reliable as physician adjudication. Though the ID-UTI standard definition undercounted ASB cases (low sensitivity), cases reported as ASB were always ASB when adjudicated (high specificity). The program, including performance feedback using the ID-UTI measure, was associated with a trend toward lower treatment of ASB.

Background: Antibiotic overuse and the resulting patient outcomes span all hospitals. However, although antibiotic stewardship can improve antibiotic use, effective stewardship programs require expertise and an infrastructure that are not present in all hospitals. Rural hospitals have less access to resources, infectious disease expertise, and participation in academic research. Thus, we compared antibiotic overuse at discharge between rural and nonrural hospitals for patients diagnosed with community-associated pneumonia (CAP) or urinary tract infection (UTI)—the 2 most common hospital infections. Methods: To determine whether antibiotic overuse at discharge was higher among rural versus nonrural hospitals, we analyzed data from a 41-hospital prospective cohort of patients treated for CAP or UTI between July 1, 2017, and July 30, 2019, in Michigan. Antibiotic overuse was defined as treatment that was unnecessary (ie, patient did not have an infection), excessive (ie, duration >4 days for CAP), or included suboptimal fluoroquinolone use (ie, safer alternative available). Overuse was determined based on patient risk factors, symptoms, allergies, diagnostic results, and time to stability. Hospital rurality was defined using the Rural–Urban Continuum Codes (RUCC) score. We defined rural as a score ≥4 and very rural as a score of 7–9. We used t tests to compare the mean percentage of patients with antibiotic overuse at discharge between nonrural and rural (and very rural) hospitals. Results: Across 41 hospitals, we included 23,449 patients with CAP or UTI. There were 5 rural (and 3 very rural) hospitals with 2,039 (and 1,082) patients. Antibiotic overuse at discharge was present in 43.1% of patient cases in nonrural hospitals, 52.5% in rural hospitals (P = .04 vs nonrural) and 58.1% in very rural hospitals (P = .007 vs nonrural). Compared to nonrural hospitals, the mean percentage of cases with antibiotic overuse at discharge in rural hospitals was 9.4% higher (15.1% higher in very rural hospitals). Results were similar in a subgroup analysis of only patients with UTI (47.0% in rural vs 37.5% in nonrural, mean difference, 9.5%; P = .03) but were not statistically significant in patients with CAP (53.8% vs 48.0%, respectively; mean difference, 5.8%; P = 0.23). Conclusions: In this retrospective study, rural hospitals—especially very rural hospitals, had higher rates of antibiotic overuse at discharge than nonrural hospitals. Our findings suggest that antibiotic stewardship interventions tailored toward the unique differences in infrastructure, resources, and needs of rural hospitals are essential to community health.