Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark.
Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark.
Lancet Infect Dis. 2021 Nov;21(11):1549-1556. doi: 10.1016/S1473-3099(21)00001-3. Epub 2021 Jul 22.
When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI.
This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062.
Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33).
The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality.
Danish Ministry of Health and the Velux Foundation.
当怀疑患有尿路感染（UTI）时，养老院的工作人员会代表居民与医生联系并提供临床信息；因此，对 UTI 的理解不足或缺乏临床沟通技巧可能会导致过度使用抗生素治疗。我们研究了一项针对养老院工作人员的专门干预措施，该措施旨在提高他们对 UTI 的认识和沟通技能，是否会影响 UTI 的抗生素处方。
这是一项在丹麦 22 家参与的养老院进行的开放性、平行组、集群随机对照试验。符合条件的患者为年龄在 65 岁及以上的养老院居民，其常住地址为养老院，居住在指定给痴呆症或躯体健康护理需求患者的居住空间。我们纳入了未参与其他 UTI 项目的养老院，以及工作人员随时在院的养老院。研究人员使用计算机生成的随机数和按市进行分层，将养老院（1:1）随机分配至接受互动教育课程和使用对话工具组，或继续接受标准护理组。统计分析是盲法的。工作人员参加了为期 8 周、共 75 分钟的课程，学习如何区分 UTI 和无症状菌尿、评估非特异性症状以及使用对话工具。主要结局是每位有风险的居民每天急性 UTI 的抗生素处方数，定义为居民在试验期间在养老院的天数。该试验在 ClinicalTrials.gov 上注册，编号为 NCT03715062。
在 2017 年 6 月 1 日至 2018 年 6 月 1 日期间，共有 68 家邀请的养老院中有 22 家参与了研究。在随机分配的 22 家养老院（1625 名居民）中，有 11 家接受了干预（770 名[92.2%]分配的居民），11 家为对照组（790 名[89.2%]分配的居民）。干预组的标准护士人数为 572 人，对照组为 535 人。所有养老院均完成了试验。干预组有 65 名居民未纳入数据收集，对照组有 85 名居民未纳入数据收集。1470 名居民（干预组 765 名；对照组 705 名）被纳入主要结局分析。干预组每 84035 天有风险的居民中，有 134 人接受了 UTI 抗生素治疗，对照组每 77817 天有风险的居民中，有 228 人接受了 UTI 抗生素治疗。未调整模型中，接受 UTI 抗生素治疗的比率（RR）为 0.51（95%CI 0.37-0.71），调整模型中为 0.42（0.31-0.57）。在 140 份疑似 UTI 的日记中，没有报告死亡病例。421 名（1475 名居民的 28.5%）居民住院。干预组的全因住院风险增加（调整模型 RR 1.28，95%CI 0.95-1.74），而干预组的全因死亡率较低（0.91，0.62-1.33）。
该干预措施有效地减少了 UTI 的抗生素处方和不适当的治疗，而不会对全因住院和死亡率产生实质性影响。
丹麦卫生部和 Velux 基金会。
Zotero 插件