A VA study has documented a drop in the use of antibiotics to treat urinary tract infections at VA community living centers. (Photo: ©iStock/StockPlanets)

Study finds decline in antibiotic use for older Veterans with urinary infections—a positive result from stewardship efforts

August 1, 2019

By Mike Richman
VA Research Communications

A new study finds a significant drop in antibiotic use at VA community living centers treating older Veterans with urinary tract infections—a positive sign in efforts to limit the health problems that can result from the improper use of antibiotics.

The findings appeared online in the journal Infection Control & Hospital Epidemiology in July 2019.

The researchers found that much of the decline in antibiotics stemmed from a reduced use of fluoroquinolones during the five-year study period. The fluoroquinolone class of antibiotics is  often used to treat illnesses, such as respiratory and urinary tract infections (UTIs), and includes agents like ciprofloxacin (commercial name Cipro) and levofloxacin (commercial name Levaquin).

“Antibiotic stewardship efforts across VA community living centers should be applauded and should continue to be an ongoing effort,” the researchers write. “Antibiotic stewardship can be used to reduce inappropriate use of antibiotics and ultimately improve the care of residents with UTIs.” Antibiotic stewardship also refers to efforts to promote the right antibiotic, dose, and duration of use.

Dr. Haley Appaneal, a clinician scientist at the Providence VA Medical Center in Rhode Island, led the study. With expertise in infectious diseases, antibiotic stewardship, and pharmacy practice, she’s interested in improving the quality of Veteran care at community living centers through a reduction in inappropriate antibiotic use. Such facilities, which are similar to nursing homes, provide services to Veterans who need a medically skilled environment to assist with short- and long-term stays.

Antibiotics could potentially do more harm than good

The findings in the study are important, Appaneal says, because antibiotics are among the most commonly used drugs at all VA and non-VA long-term care facilities, they are often used for urinary tract infections, and they are often used the wrong way.

“All antibiotic use, both appropriate and inappropriate, can lead to problems,” says Appaneal, who is also an adjunct assistant professor at the University of Rhode Island. “However, when antibiotics are used inappropriately, they may cause more harm than good. Problems that antibiotics can lead to include adverse drug effects, allergic reactions, serious diarrhea due to a bacteria known as Clostridium difficile or C. diff, hospitalizations, and an increased risk of infections because of bacteria that resist the effects of antibiotics and are harder to treat.”

Antibiotics are the most effective agents for treating urinary tract infections, which are caused by bacteria in parts of the urinary tract, including the urethra, bladder and kidneys. When someone also has symptoms of an infection, such as pain or burning when urinating or the need to urinate more often, antibiotics are needed to kill the bacteria and treat the infection. The problem is that antibiotics are often not used correctly for UTIs, Appaneal says.

The two main ways antibiotics can be used the wrong way, she explains, are when they aren’t needed and when they are needed but not used correctly. One of the major problems with UTIs is that antibiotics are frequently used unnecessarily, for example, when patients have no symptoms of a UTI but have bacteria in their urine. It’s very common for older people to have bacteria in their urine without UTI symptoms, and in most cases treating these patients with antibiotics doesn’t help them live better or longer, she notes.

“Older residents often have bacteria in their urine without any signs or symptoms of infection, a condition that’s different from a urinary tract infection and is called asymptomatic bacteriuria,” Appaneal says. “Antibiotics generally are not needed when residents don’t have signs or symptoms of an infection. That’s when antibiotics can cause more harm than good.”

Fluroquinolones, in particular, have been the target of many safety alerts from the U.S. Food and Drug Administration (FDA). The FDA has warned of the risk of ruptured aortic aneurysms, tendon rupture, and potentially permanent side effects involving nerves, muscles, tendons, and joints. “Older, debilitated patients, such as those in VA community living centers, may be at risk for these side effects,” says Dr. Allison Kelly, an infectious disease specialist at the Cincinnati VA Medical Center. “Although these adverse outcomes are rare, they highlight the need to avoid antibiotics in situations where they are unlikely to provide benefit.”

The right drug, dose, and duration

Appaneal’s work focuses more on the other aspect of inappropriate antibiotic use.

“After the decision to use antibiotics is made, we just want to make sure they’re being used the right way,” she says. “This involves appropriately choosing the drug to use, the dose being prescribed to the patient, and the duration the medication is being taken. It’s not just common for antibiotics to be used when they’re not needed, but also for the wrong antibiotic drug or wrong dose to be used or for an overly long duration. That’s what my work is getting at. This study represents the first step in understanding what antibiotics are being used to treat UTIs. We’ll determine later whether the right antibiotic drug, dose, and durations are being used.”

Appaneal and her team didn’t assess what factors led to the decline in antibiotic use at community living centers. But she attributes the drop to an increase in antibiotic stewardship efforts targeting UTIs, including an improvement in the diagnosis and treatment of urinary tract infections. She cites this as a common antibiotic stewardship goal at long-term-care facilities.

She says she was influenced to pursue her study because not many papers have described which antibiotics are most often used to treat UTIs in long-term care facilities or tracked changes in the antibiotics being used over time.

“While this study does not define or describe any type of inappropriate antibiotic use, it does describe what antibiotic agents are most commonly being used to treat urinary tract infections,” Appaneal says. “Results can be used to identify problem or target areas in what antibiotic drug choice is being used for UTIs. Those areas include the potential overuse of antibiotic drugs that may not be recommended as the first choice in national UTI treatment guidance or that carry an increased risk of adverse drug events, such as the fluoroquinolone class of antibiotics.”

Antibiotics that are recommended for patients with UTIs before fluoroquinolones include sulfamethoxazole-trimethoprim (commercial names Bactrim, Septra) and fosfomycin (commercial names Monurol, Monuril).

Antibiotic use dropped 10% per year

Using the electronic health record, the research team identified all episodes of UTIs among residents at 110 VA community living centers from 2013 to 2017. There were nearly 30,000 episodes involving some 15,000 Veterans. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. The Veterans’ average age was 76, and nearly all of them were men.

Urine cultures are used to detect bacteria in the urine. The research team defined UTI episodes as culture-positive or culture-negative. Culture-positive samples included a growth of no more than two pathogens, while culture-negative episodes meant no pathogens were found in the sample. Almost half of the episodes were culture-positive, and a quarter were culture-negative. The remaining UTI episodes were classified as neither positive nor negative—in some cases because pathogens were isolated, but only in very small quantities.

“The urine culture helps to detect bacteria in the urine,” Appaneal says. “But symptoms of infection, such as a burning feeling when urinating, are needed to diagnose a UTI. Antibiotics aren’t needed if the patient does not have symptoms of an infection, especially if the urine culture is also negative.”

The most common forms of bacteria in the culture-positive episodes were Escherichia coli, which is also called E. coli; Proteus mirabilis; and Klebsiella.  All three are known to live in the digestive tract and can cause various types of infections, including UTIs. Among the culture-positive UTI episodes, ciprofloxacin, sulfamethoxazole-trimethoprim, and ceftriaxone (commercial name Rocephin) were the most commonly used antibiotics.

The total rate of antibiotic use per 1,000 bed days of care declined 10% per year among UTI episodes. Fluoroquinolone use dropped by 15% per year. The researchers observed similar reductions in rates of antibiotic and fluoroquinolone use among culture-positive and culture-negative UTI episodes.

“Given the goals set forth by the U.S. National Action Plan for Combatting Antibiotic-Resistant Bacteria to reduce inappropriate antibiotic use by 50% in outpatient settings and 20% in inpatient settings, the success of VA community living centers in reducing prescribing by 10% per year [for UTIs] demonstrates VA’s ability to implement programs to attain those goals,” Kelly says.

Antibiotic stewardship on the rise in VA

Appaneal says she wasn’t surprised that antibiotic use declined over the five-year study period.

“Antibiotic stewardship efforts in VA have been increasingly adopted,” she says. “As well, a focus of antibiotic stewardship in long-term care facilities has been on efforts to improve the diagnosis of UTIs and to only use antibiotics when they’re needed for patients with symptoms of infection. But one surprising finding was that a bacterial cause of UTIs wasn’t identified for about 25% of UTI episodes in this study. This may be an easy target for future antibiotic stewardship activities to stop antibiotic treatment when the patient also has no signs or symptoms of a urinary tract infection.”

VA’s National Antimicrobial Stewardship Initiative assists with the implementation of antibiotic stewardship programs at VA facilities. A VA study found that inpatient antibiotic use overall in VA medical centers, not only  for UTIs, declined 12% after the implementation of national antibiotic stewardship initiatives. Other research has focused on the treatment of urinary tract infections at VA hospitals. But data are lacking on how UTIs are handled in community living centers, Appaneal says, noting that treatment strategies in hospitals may not apply to long-term care facilities.

“There are many barriers to successful antibiotic stewardship in long-term care settings,” she says. “Diagnosing and treating infections, particularly UTIs, are difficult with older residents, who often have non-specific or non-typical signs of infection, such as altered mental status. Long-term care facilities also have limited resources. While hospitals may often have access to people with antibiotic expertise, such as pharmacists trained in infectious diseases or antibiotic stewardship, such expertise is often lacking in long-term care facilities.”

Educating pharmacists

With that in mind, Appaneal hopes to develop and pilot test an education program for pharmacists at VA community living centers that will improve the treatment of patients with UTIs and reduce the inappropriate use of antibiotics. Efforts that can improve the use of antibiotics and the care of people with UTIs, she says, include the creation of guidelines that help clinicians determine when antibiotic treatment is needed and that help them select the right drug, at the right dose, and for the right duration of therapy. Another example is having a process in place where a pharmacist reviews all antibiotic regimens to make sure they’re appropriate and provides feedback to providers. That strategy is recommended in the Infectious Disease Society of America’s guidelines on implementing anti-microbial stewardship programs.

She first plans to interview pharmacists at two community living centers to assess their approach to treating UTIs and how they are faring at their facilities. She’ll then use data from her 2019 study and observations from the interviews to try to develop a program that can help pharmacists at VA community living centers treat patients with UTIs.

“I hope my work will help us understand what aspects of antibiotic use for UTIs are most likely to be inappropriate—whether it’s the drug that’s chosen, the drug used, or the duration—at VA community living centers,” she says. “By targeting those problem areas, I can help improve the treatment of UTIs in those facilities and lead to better care for our Veterans.”

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