UTI Communication Toolkit Clinician Letter Page 2 of 2

UTI Communication Toolkit Clinician Letter—page 2 of 2

UTI Communication Toolkit

Clinician Letter

PRINTED ON NURSING HOME OR MEDICAL DIRECTOR’S STATIONERY

[MONTH] 20XX

Prescribing Clinician Name

Recipient Address

City, State Zip

Re:Change in protocol regarding urinalyses to improve care and antibiotic stewardship

Dear XXXXX,

Based on clinical practice guidelines developed by nursing home, infectious diseases, and geriatric experts, our facility has decided to modify its protocol around urinalysis to optimize antibiotic use for urinary tract infections (UTIs). We will use a Suspected Urinary Tract Infection (UTI) Situation, Background, Assessment, and Recommendation Form (UTI SBAR) to facilitate gathering critical information by nurses to communicate to prescribing clinicians. The UTI SBAR form is intended to enhance communication and provide guidance regarding managing potential urinary tract infections and indications for ordering urinalyses and cultures. The UTI SBAR formis based on the SBAR form of communication, or Situation, Background, Assessment, and Recommendation. The SBAR communication style has been shown to promote better communication by addressing the specific types of information that clinicians are likely to need for decision making.

As you know, UTIs are the most commonly treated infection among nursing home residents,but proper diagnosis and treatment pose significant and distinctive challenges. While residents with specific UTIsymptoms, such as dysuria, usually need treatment,urinalyses and cultures may be obtained for a variety of reasons and their results may lead to a prescription for an antibiotic.

However, research provides no evidence that treating asymptomatic bacteriuria in older adults is of benefit.Antimicrobial treatments do not affect the prevalence of bacteriuria, the frequency of symptomatic urinary infections, morbidity, or mortality.[1]-7Asymptomatic bacteriuria applies to a positive result from any routinely collected culture, such as one obtained after a course of antibiotics used to treat an infection.

Moreover, research has shown that such treatments are potentially harmful. Nursing homes serve as one of our most fertile breeding grounds for antibiotic-resistant strains of bacteria—a very high rate of antibiotic use gives rise to Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), fluoroquinolone-resistant strains of a variety of bacteria, and multi-drug resistant organisms (MDROs).8-14 In addition, residents with asymptomatic bacteriuria who were treated with an antibiotic have been found to be 8.5 times more likely to develop Clostridium difficileinfection (CDI)within the three months following their course of antibiotics.15

Embedded in the UTI SBAR formis our new protocol for initiating antibiotics for urinary tract infections.In addition to providing standardized information to help with decision-making, aclinician will be provided with recommendations from the nursing home’s protocol for initiating antibiotics. This recommendation will be based on current best practices and clinical guidelines. Nonetheless, prescribing decisionsultimately rest with the prescribing clinician. As with any guideline, unusual circumstances requiring exceptional treatment will occur.

In preparation for implementing the UTI SBAR form when communicating with you and your staff,please find enclosed a copy of the UTI SBAR form.

Your cooperation with our new protocolis greatly appreciated. We deeply appreciate your assistance in making this a success. If you have any questions, please feel free to contact me at your convenience at (###) ###-#### or .

Sincerely,

Signature

Printed name

Medical Director

Nursing home

Address

● May 2014AHRQ Pub. No. 14-0010-3-EF

[1]Abrutyn E, Mossey J, Berlin JA, et al. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med. 1994;120(10):827-33. PMID: 7818631.

2Boscia JA, Kobasa WD, Knight RA, et al. Therapy vs no therapy for bacteriuria in elderly ambulatory nonhospitalized women. JAMA. 1987;257(8):1067-71. PMID: 3806896.

3Nicolle L E. Asymptomatic Bacteriuria – Important or Not? N Engl J Med. 2000;343(14):1037-9. PMID: 11018172.

4Nicolle L E, Bjornson J, Harding GK, et al.Bacteriuria in elderly institutionalized men. N Engl J Med. 1983; 309(23):1420-5.PMID: 6633618.

5Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987;83(1):27-33.PMID: 3300325.

6Nordenstam GR, Bradberg CA, Odén AS, et al. Bacteriuria and mortality in an elderly population. N Engl J Med. 1986;314(18):1152-6. PMID: 3960089.

7Ouslander JG, Schapira M, Schnelle JF, et al. Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents? Ann Intern Med. 1995;122(10):749-54. PMID: 7717597.

8Denis O, Jans B, Deplano A, et al. Epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) among residents of nursing homes in Belgium. J Antimicrob Chemother. 2009 Dec;64(6):1299-306. PMID: 19808236.

9Lautenbach E, Marsicano R, Tolomeo P, et al. Epidemiology of antimicrobial resistance among gram-negative organisms recovered from patients in a multistate network of long-term care facilities.Infect Control Hosp Epidemiol. 2009 Aug;30(8):790-3. PMID: 19566445.

10Matheï C, Niclaes L, Suetens C, et al. Infections in residents of nursing homes. Infect Dis Clin N Am. 2007;21:761–72

11Sandoval C, Walter SD, McGeer A, et al. Nursing home residents and Enterobacteriaceae resistant to third-generation cephalosporins. Emerg Infect Dis. 2004 June;10(6):1050–5. PMCID: PMC3323163.

12Vromen M, van der Ven AJ, Knols A, et al. Antimicrobial resistance patterns in urinary isolates from nursing home residents. Fifteen years of data reviewed. J Antimicrob Chemother. 1999 Jul;44(1):113-6. PMID: 10459818.

13Wiener J, Quinn JP, Bradford PA, et al. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA. 1999 Feb 10;281(6):517-23. PMID: 10022107.

14Yoshikawa TT. VRE, MRSA, PRP, and DRGNB in LTCF: lessons to be learned from this alphabet. J Am Geriatr Soc. 1998 Feb;46(2):241-3. PMID: 9475457.

15Rotjanapan P, Dosa D, Thomas KS. Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes. Arch Intern Med. 2011 Mar 14;171(5):438-43. PMID: 21403040.