Reducing unnecessary urine culturing and antibiotic overprescribing in long-term care: a before-and-after analysis

BACKGROUND: Antibiotic use in long-term care homes is highly variable. High rates of antibiotic use are associated with antibiotic resistance and Clostridium difficile infection. We asked 2 questions regarding a program designed to improve diagnosis and management of urinary tract infections in long-term care: whether the program decreased urine culturing and antibiotic prescribing rates and whether specific strategies of the program were more or less likely to be adopted. METHODS: The study included 10 long-term care homes in Ontario, Canada, between December 2015 and May 2017. We assessed the implementation of the program's 9 strategies via semistructured interviews with key informants. Using a before-and-after study design, and on the basis of monthly facility-level records, we measured changes in the rates of urine specimens sent for culture and susceptibility testing, prescriptions for antibiotics commonly used to treat urinary tract infections and total antibiotic prescriptions, using Poisson regression. RESULTS: Participating homes implemented an average of 6.1 of the 9 strategies. Urine culturing decreased from 3.20 to 2.09 per 1000 resident-days from the baseline to the intervention phase (adjusted incidence rate ratio [IRR_adjusted] = 0.72, 95% confidence interval [CI] 0.63-0.82), urinary antibiotic prescriptions fell from 1.52 to 0.83 per 1000 resident-days (IRR_adjusted = 0.60, 95% CI 0.47-0.74) and total antibiotic prescriptions fell from 3.85 to 2.60 per 1000 resident-days (IRR_adjusted = 0.74, 95% CI 0.65-0.83). After adjusting for secular trends, these reductions were not statistically significant. INTERPRETATION: We demonstrated a reduction in urine culturing and antibiotic use following implementation of the Urinary Tract Infection Program. This initial analysis supports a broader implementation of this program, although ongoing evaluation is required to monitor secular trends in urine culturing and antibiotic use.