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Clin Infect Dis. 2019 Jun 14. pii: ciz482. doi: 10.1093/cid/ciz482. [Epub ahead of print]

The Urine Culturing Cascade: Variation in Nursing Home Urine Culturing and Association with Antibiotic Use and C. difficile infection.

Author information

1
Public Health Ontario, Toronto, Canada.
2
The Institute for Clinical Evaluative Sciences, Toronto, Canada.
3
Dalla Lana School of Public Health, University of Toronto, Canada.
4
Sunnybrook Research Institute, Division of Infectious Diseases, Toronto, Canada.
5
The Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada.
6
St. Joseph's Health Centre, Toronto, Canada.
7
Mount Sinai Hospital, Toronto, Canada.
8
Ottawa Research Institute, Ottawa, Canada.

Abstract

BACKGROUND:

Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Inappropriate antibiotic prescribing for a presumed urinary tract infection is often initiated by inappropriate urine culturing. We examined nursing home urine culturing practices and their association with antibiotic use.

METHODS:

We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering over 90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (e.g. nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment, and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates.

RESULTS:

131,218 residents in 591 nursing homes were included. 7.9% of resident assessments had a urine culture in the prior 14 days, and this proportion was highly variable across the 591 nursing homes (10th percentile=3.4%, 90th percentile=14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio per doubling of urine culturing [RR]=1.21, 95% confidence interval [CI]: 1.18-1.23), urinary antibiotic use (RR=1.33, 95%CI: 1.28-1.38), and C. difficile infection (incidence rate ratio=1.18, 95%CI: 1.07-1.31).

CONCLUSIONS:

Nursing homes have highly divergent urine culturing rates, and this variability is associated with higher antibiotic use and rates of C. difficile infection.

KEYWORDS:

Clostridium difficile infection (CDI); antibiotic stewardship; long term care; urine culture; variation in care

PMID:
31197362
DOI:
10.1093/cid/ciz482

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