title: The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.|Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Christine E
authors.initials: CE
authors.lastname: Kistler
authors.affiliation: School of Social Work, Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina.|Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Zimmerman
authors.affiliation: School of Nursing, Duke University, Durham, North Carolina.
authors.forename: Kezia
authors.initials: K
authors.lastname: Scales
authors.affiliation: Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Ward
authors.affiliation: Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: David
authors.initials: D
authors.lastname: Weber
authors.affiliation: Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: David
authors.initials: D
authors.lastname: Reed
authors.affiliation: Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Mallory
authors.initials: M
authors.lastname: McClester
authors.affiliation: Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.|Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Philip D
authors.initials: PD
authors.lastname: Sloane
mesh_terms: D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002939:Ciprofloxacin / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D008297:Male; D009657:North Carolina; D009735:Nursing Homes / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016482:Urinalysis / Q000379:methods; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality
chemical_list: D000900:Anti-Bacterial Agents; D002939:Ciprofloxacin
keywords: antibiotic stewardship; decision-making; older adults