title: Implementation of an antimicrobial stewardship program targeting residents with urinary tract infections in three community long-term care facilities: a quasi-experimental study using time-series analysis.
abstract: BACKGROUND
  Asymptomatic bacteriuria in the elderly commonly results in antibiotic administration and, in turn, contributes to antimicrobial resistance, adverse drug events, and increased costs. This is a major problem in the long-term care facility (LTCF) setting, where residents frequently transition to and from the acute-care setting, often transporting drug-resistant organisms across the continuum of care. The goal of this study was to assess the feasibility and efficacy of antimicrobial stewardship programs (ASPs) targeting urinary tract infections (UTIs) at community LTCFs.
  
  
  METHODS
  This was a quasi-experimental study targeting antibiotic prescriptions for UTI using time-series analysis with 6-month retrospective pre-intervention and 6-month intervention period at three community LTCFs. The ASP team (infectious diseases (ID) pharmacist and ID physician) performed weekly prospective audit and feedback of consecutive prescriptions for UTI. Loeb clinical consensus criteria were used to assess appropriateness of antibiotics; recommendations were communicated to the primary treating provider by the ID pharmacist. Resident outcomes were recorded at subsequent visits. Generalized estimating equations using segmented regression were used to evaluate the impact of the ASP intervention on rates of antibiotic prescribing and antibiotic resistance.
  
  
  RESULTS
  One-hundred and four antibiotic prescriptions for UTI were evaluated during the intervention, and recommendations were made for change in therapy in 40 (38 %), out of which 10 (25 %) were implemented. Only eight (8 %) residents started on antibiotics for UTI met clinical criteria for antibiotic initiation. An immediate 26 % decrease in antibiotic prescriptions for UTI during the ASP was identified with a 6 % reduction continuing through the intervention period (95 % Confidence Interval ([CI)] for the difference: -8 to -3 %). Similarly, a 25 % immediate decrease in all antibiotic prescriptions was noted after introduction of the ASP with a 5 % reduction continuing throughout the intervention period (95 % CI: -8 to -2 %). No significant effect was noted on resistant organisms or Clostridium difficile.
  
  
  CONCLUSIONS
  Weekly prospective audit and feedback ASP in three community LTCFs over 6 months resulted in antibiotic utilization decreases but many lost opportunities for intervention.
authors.affiliation: Department of Internal Medicine, Division of Infectious Diseases, University of California, San Francisco, 513 Parnassus Avenue, room S-380, Box 0645, San Francisco, CA 94143 USA.
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Doernberg
authors.affiliation: UCSF Medical Center, 505 Parnassus Avenue, San Francisco, CA 94143 USA.
authors.forename: Victoria
authors.initials: V
authors.lastname: Dudas
authors.affiliation: Trivedi Consultants, 1563 Solano Avenue, #443, Berkeley, CA 94707 USA.
authors.forename: Kavita K
authors.initials: KK
authors.lastname: Trivedi
keywords: Antimicrobial resistance; Antimicrobial stewardship; Long-term care; Urinary tract infection