The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents.

Objectives Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections ( UTIs) in nursing home ( NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship. Methods Chart review of 260 randomly-selected cases from 247 NH residents treated with an antibiotic for a presumed UTI in 31 NHs in North Carolina. We examined the prescribing pathway from presenting illness, to the prescribing event, illness work-up and subsequent clinical events including emergency department use, hospitalization, and death. Analyses described the decision-making processes and outcomes and compared decisions made with Loeb criteria for initiation of antibiotics. Results Of 260 cases, 60% had documented signs/symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). NH providers (81%) were the most common prescribers and ciprofloxacin (32%) was the most commonly prescribed antibiotic. Fourteen percent of presumed UTI cases included a white blood cell count, 71% included a urinalysis, and 72% had a urine culture. Seventy-five percent of cultures grew at least one organism with ≥100,000 colony-forming units/milliliter and 12% grew multi-drug resistant organisms; 28% of antibiotics were prescribed for more than 7 days, and 7% of cases had a subsequent death, emergency department visit, or hospitalization within 7 days. Discussion Non-specific signs/symptoms appeared to influence prescribing more often than urinary tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide the decision-making process to reduce antibiotic overuse and antibiotic resistance. [ABSTRACT FROM AUTHOR]