Impact of an Altered Mental Status (AMS)/Suspected Urinary Tract Infection (UTI) Protocol on Urine Culture Collection and Antibiotic Consumption in a Long-Term Care Facility

Abstract

Background. There are several causes of AMS in the elderly; however, AMS often leads to unnecessary antibiotic treatment for suspected UTI. Increased antibiotic consumption in long-term care facilities leads to health risks for all residents. This study evaluates the effectiveness of a protocolized approach for addressing AMS and UTI treatment in a long-term care facility. The primary objective of the protocol is to decrease total antibiotic consumption and unnecessary urine cultures. Methods. A comprehensive protocol for assessment and management of altered mental status was created using Situation Background Assessment Recommendation (SBAR) format (figure). The protocol stressed appropriate culturing scenarios and technique as well as standard orders for enhanced observation and vital sign monitoring in select patients. Providers and nursing staff were educated by the infectious disease (ID) pharmacist and ID physician on the protocol, facility antibiogram, and appropriate UTI therapy. Prospective data were collected for all patients where the protocol was initiated from January 1 - March 31, 2016 and compared to retrospective data from the same time period in 2015. Urine cultures, antibiotic consumption, and resident hospitalizations during the study periods were evaluated for all residents. Patients eligible for the protocol who were not enrolled were identified through retrospective chart review. Results. During the study period, 16/30 eligible patients were enrolled in the AMS/ UTI protocol. Decreases in total antibiotic DOT/1000 patient days (142.9 versus 72.4, p < 0.0001) and UTI DOT/1000 patient day (21.1 versus 14.3, p = 0.0003) for the facility were seen. The average number of monthly urine cultures decreased from 22.3 to 8.3 (p < 0.001). The proportion of urine cultures with “no growth” increased (0.254 versus 0.36, NS); however, there was a numerical decrease in these cultures. No adverse events or hospitalizations occurred in the patients who followed the protocol. Conclusion. An AMS/suspected UTI protocol, in conjunction with nurse and provider education, may significantly reduce antibiotic prescribing for UTI in long-term care facilities. (Figure Presented) .