Improving Antibiotic Stewardship in Wisconsin Nursing Homes

A clinical trial led by Christopher Crnich, MD, PhD, associate professor, Infectious Disease (pictured above, on right), and James Ford, PhD, assistant professor, Social and Administrative Sciences Division, University of Wisconsin–Madison School of Pharmacy (pictured above, on left), will compare strategies for implementing a toolkit aimed at improving urinary tract infection (UTI) management in Wisconsin nursing homes. 

Suspicion of a UTI is the most common indication for antibiotic prescribing in nursing homes across the U.S., and the condition most often associated with inappropriate antibiotic use in those facilities.

That’s led to a rise in antibiotic resistance, which in turn threatens to create a scenario in which existing antimicrobial therapies fail to treat common, previously treatable infections. 

Investigators leading the UW–Madison trial, which was described in a protocol paper recently published in JAMA Network Open, have recruited 30 nursing homes from across Wisconsin to participate. 

Each nursing home will implement the Wisconsin UTI Improvement Toolkit, a suite of resources and best practices designed to help clinicians and staff in long-term care facilities standardize how they assess residents with a suspected UTI and promote appropriate antibiotic stewardship.

Participating nursing homes will also be randomized to one of two arms: usual implementation or enhanced implementation. 

Those in the usual implementation arm will participate in a toolkit kickoff meeting, have ongoing access to online training and be able to track and visualize facility urine culture and UTI treatment rates.

Those in the enhanced implementation arm will also be assigned a clinical coach, be able to participate in collaborative peer learning, and receive peer comparison feedback. Investigators hypothesize that those additional supports will result in improved toolkit adoption and reduced urine culture testing and antibiotic use. 

“External facilitation is a proven and cost-effective strategy for assisting healthcare organizations implement change,” explained Dr. Ford. “A prior study by this team using external facilitation was associated with reductions in antibiotic days of therapy and appears to have improved antibiotic de-escalation.” (Related story.)

“Nursing homes play a critical role in the concentration, amplification and dissemination of antibiotic resistance,” added Dr. Crnich. “Identifying effective interventions to improve antibiotic prescribing as well as strategies for enhancing the adoption of these interventions is a critical need.” 

Drs. Crnich and Ford agree that the study will not only generate important knowledge about the benefits of external facilitation, and ways to improve the recognition and management of urinary tract infections in nursing homes, but it will also identify ways to make external facilitation even more effective when used as an implementation strategy in this environment—thereby benefitting future quality improvement efforts. 

The Wisconsin UTI Improvement Toolkit is available free to charge to any nursing home, regardless of whether or not it is participating in the trial. 

It was designed around a previously published decision algorithm for managing suspected UTI, developed by the Wisconsin Healthcare-Associated Infections in Long-Term Care Coalition, and supported by a Collaborative Health Sciences Program grant from the Wisconsin Partnership Program at the UW School of Medicine and Public Health.