1. Antibiotic stewardship interventions safely reduced antibiotic prescribing for frail older adults with suspected urinary tract infections.
Evidence Rating Level: 1 (Excellent)
Inappropriate antibiotic use is an important contributor to antibiotic resistance. Older adults are often inappropriately prescribed antibiotics for non-specific symptoms of suspected urinary tract infections. Current guidelines recommend being restrictive with antibiotic prescribing when specific urinary tract symptoms are absent, however implementation of these guidelines in practice is challenging. This study evaluated whether a multifaceted antibiotic stewardship intervention was effective in reducing antibiotic prescribing for suspected urinary tract infections in various older adult care settings across four European countries. This randomized controlled trial involved 1041 frail adults, defined as those 70 year or older, with physical or mental disabilities, or both, dependency in activities of daily living, no use of prophylactic antibiotics, not receiving hospice care and not estimated to have a very limited life expectancy. Over 38 clusters consisting of one or more general practices and older adult care organizations were included in the study. Clusters were assigned as intervention or usual care stratified by country and cluster size. The providers in the intervention cluster received the multifaceted antibiotic stewardship intervention, and those in the control cluster were told they were participating in research on urinary tract infections. The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year, with secondary outcomes including the incidence of complications. Those in the intervention group had a lower rate of receiving antibiotic prescription for suspected urinary tract infections compared to the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). Between both groups, no differences were seen in the incidence of complications. Limitations to this study include the lack of blinding due to the nature of the study. Additionally, data on antibiotic prescriptions for other indications was not collected. The study was also over a seven-month follow-up period, making it difficult to evaluate the sustainability of the results. Finally, the study was conducted over the COVID-19 pandemic, when antibiotic use was lower in general. Overall, this study indicates that the implementation of an antibiotic stewardship intervention reduced antibiotic prescribing for suspected urinary tract infections in frail older adults, with no impact on the rate of complications. Future studies examining the sustainability of the results, as well as studies focusing on other indications for antibiotics are needed to help with future guidelines for antibiotic stewardship.
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