Healthcare Infection Prevention - SHEA coverage: Hydration program cuts UTIs, antibiotic use

SHEA coverage

Hydration program cuts UTIs, antibiotic use

Compelling pilot study warrants clinical trial

Many long-term care patients receiving antibiotics for suspected urinary tract infections (UTIs) simply may be suffering from dehydration, researchers are finding. If a recent pilot study is borne out by randomized clinical trials, an inexpensive intervention may be at hand that could lower infections and inappropriate antibiotic use. "Antimicrobial use in long-term care accounts for 40% of all prescribed medications and is frequently inappropriate," said Shelly McNeil, MD, an epidemiologist in the division of infectious diseases at Dalhousie University in Halifax, Nova Scotia. "The treatment of [UTIs] represents the most common indication for antibiotics in this setting," she said recently in Salt Lake City at the annual meeting of the Society for Healthcare Epidemiology of America.

Since diagnosis of UTIs in nursing home residents is often difficult, antibiotics may be administered for suspected infections based on "dark, foul-smelling, or cloudy" urine, McNeil noted. However, such symptoms also could indicate a noninfectious etiology: dehydration. Residents of long-term care facilities may be dehydrated because of age-related impairments and difficulty retaining water, she said.

"Dehydration is one of the leading cause of delirium, aggravation, and confusion, three of the main [symptoms] known to trigger the ordering of a urine culture." McNeil and colleagues conducted a pilot study to assess the impact of an oral hydration program on overall infection rates, UTI rates, and antibiotic use in a 34-bed unit of a long-term care facility in Nova Scotia. To establish baseline data, the overall infection rates, UTI rates, and antibiotic usage were tracked before and after the program began.

"Infection surveillance was performed by a trained infection control practitioner for 10 months before and 10 months after the introduction of the oral hydration program," McNeil explained. "All residents of the unit were targeted for hydration unless chart review revealed a pre-existing order for fluid restrictions or their primary physician requested that they be excluded."

The oral hydration program consisted of a comprehensive educational campaign designed to optimize fluid intake among residents on the unit. The facility dietician or the ICP conducted a series of educational inservices at the time of the induction of the program and periodically over the next 10 months to reinforce the program.

"The primary behavioral intervention consisted of verbal prompts to drink and careful attention to continuous, easy access to fluid to ensure the residents received the minimum of 1,500 ml per day," McNeil said. She added that all staff were encouraged to offer noncaffeinated beverages and medications were taken with a full glass of water.

The overall infection rate decreased from 11.1 to 4.1 per 1,000 resident days following introduction of the program.¹ "Although much of this reduction could be accounted for by reduction in UTI rates, a statistically significant reduction in respiratory and skin infections was also seen," she said. McNeil hypothesized that the liquid intake bolstered immunity and skin quality. The rate of UTIs decreased from 5.5 to 2.4 per 1,000 resident days. Overall, antibiotic use decreased from 14.7 courses per 1,000 resident days to 5.9 courses.

"Some reduction in the antibiotic use may be explained by the number of urine cultures sent," she said. Overall, the researchers noted a 67% reduction in the number of urine cultures sent for testing following the introduction of the program. "The program was enthusiastically embraced by most health care workers and other staff on this study unit," she said. "The results of this pilot study support conducting a randomized controlled clinical trial to assess this potentially inexpensive and dramatic intervention in long-term care facilities"

Reference

1. McNeil S, Ryan J. Impact of a multidisciplinary oral hydration program on infection rates and antimicrobial use among residents of a long-term care facility. Abstract 257. Presented at the Society for Health Care Epidemiology of America. Salt Lake City; April 6-9, 2002.