The urine culturing cascade: variation in nursing home urine culturing and association with antibiotic use and c. difficile infection
Brown KA, Daneman N, Schwartz KL, Langford B, McGeer A, Quirk J, Diong C, Garber G. Clin Infect Dis. 2019; Jun 14 [Epub ahead of print]. DOI: 10.1093/cid/ciz482.
Background — Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Inappropriate antibiotic prescribing for a presumed urinary tract infection is often initiated by inappropriate urine culturing. We examined nursing home urine culturing practices and their association with antibiotic use.
Methods — We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering over 90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (e.g. nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment, and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates.
Results — 131,218 residents in 591 nursing homes were included. 7.9% of resident assessments had a urine culture in the prior 14 days, and this proportion was highly variable across the 591 nursing homes (10th percentile=3.4%, 90th percentile=14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio per doubling of urine culturing [RR]=1.21, 95% confidence interval [CI]: 1.18-1.23), urinary antibiotic use (RR=1.33, 95% CI: 1.28-1.38), and C. difficile infection (incidence rate ratio=1.18, 95% CI: 1.07-1.31).
Conclusions — Nursing homes have highly divergent urine culturing rates, and this variability is associated with higher antibiotic use and rates of C. difficile infection.