Improving rational prescribing for UTI in frail elderly

Frail elderly people, especially those receiving home nursing care or living in nursing homes, are a vulnerable population group. They often have urinary tract infections (UTIs) and almost 60% of antibiotics used in this population are for UTIs. However, a significant part of these prescriptions may be unnecessary. Diagnosing UTI is challenging in frail elderly people, with a risk of antibiotic overuse. This applies in particular to antibiotic courses prescribed for UTIs with non-specific symptoms. Another cause of overuse of antibiotics in this population of frail elderly is recurrent UTIs, which can lead to monthly courses of antibiotics. Previous studies have shown that antibiotic resistance is a growing problem in nursing homes and that the risk of transfer of resistant organisms between healthcare institutions is increasing. There is therefore a need for better antibiotic management in nursing homes. The studies proposed here aim to reduce antibiotic overuse for UTI in this population through the use of a new algorithm, to support a "wait-and-see" approach in cases of suspected UTI in the frail elderly. As a first step, with the help of interviews with nursing home patients, relatives and healthcare personnel, we have developed a model that contributes to decision support for UTI in this population (Work package 1). We then developed and implemented an intervention (Work package 2). The core of this intervention will be the decision support algorithm. In addition, we will conduct a double-blind, randomized study on the safety and effect of prophylactic use of methenamine hippurate in elderly women with recurrent UTI (Work package 3). In work package 1, all 15 interviews have been conducted and translated, and analysis has started together with the other 3 countries. Articles have been published. In work package 2, 9 nursing homes in Oslo have been recruited with a total of 210 patients. The intervention was postponed due to corona and was carried out in autumn 2020, with a 7-month follow-up in winter/spring 2021 which has been completed. Articles have been published. In work package 3, 81 patients have been recruited, in the Netherlands 98 patients, in Sweden 100 patients and in Poland 10 patients. Patient follow-up has ended, data has been collected and analysis has started. Protocol article has been published. Completion and submission of the main article and one to two additional articles from work package 3 will take place by the summer of 2024.

Resultatene fra arbeidspakke 1 og 2 er brukt i RASK (Riktigere Antibiotikabruk i Sykehjem/Kommunale helseinstitusjoner), som er et antibiotikastyringsprogram for norske sykehjem. RASK ble gjennomført som avsluttede fylkesvise prosjekter i perioden 2016-2022, men fra 2023 er RASK videreutviklet til et nasjonalt, permanent program. Med materiell og resultater fra ImpresU-prosjektet er det grunn til å tro at RASK vil medføre riktigere antibiotikabruk og mindre resistensutvikling på norske sykehjem. Også i andre land blir resultatene fra arbeidspakke 1 og 2 brukt i antibiotikastyringsprogrammer i primærhelsetjenesten. Resultatene fra arbeidspakke 3 blir først klare i løpet av 2024. Det er grunn til å tro at disse resultatene vil medføre en endret og forbedret håndtering av residiverende urinveisinfeksjoner hos skrøpelige eldre.

Frail elderly, particularly those receiving home care or living in a care home, constitute a vulnerable and under researched population. They are frequently diagnosed with urinary tract infection (UTI) and almost 60% of the antibiotics (AB) used in this population are for UTI. However, a substantial part of these prescriptions might not be necessary. Diagnosing UTI is challenging in frail elderly, due to atypical illness presentation, the lack of reliable diagnostics and the high prevalence of (asymptomatic) bacteriuria. Combined with the influence of contextual factors, these factors increase the risk of AB overuse. This applies especially to AB courses that are prescribed for UTI with non-specific S&S. Another driver of AB overuse in this population of frail elderly is recurrent UTI, which may lead to monthly courses of AB. Previous studies have shown that antimicrobial resistance is a growing problem in long term care and that the risk of transmission of resistant organisms between health care settings is increasing. Therefore, antibiotic stewardship interventions (ASI) are much needed in the continuum of home care and institutional care settings for frail elderly. For this purpose, the studies proposed here aim to reduce AB overuse for UTI in this population through implementation of a new algorithm - developed by an international Delphi panel - to support clinical decision making on signs and symptoms that justify a ?watchful waiting? approach in cases of suspected UTI in frail elderly. As a first step, we will develop a conceptual model of factors that contribute to the prescribing decision in this population. Next, using a modifi action research approach, we will develop and implement a tailored ASI. Core of this intervention will be the implementation of the decision support algorithm. In addition, we will conduct a double blinded RCT on the safety and effectivity of prophylactic use of metenamine hippurate in older women With recurrent UTI.