Improving antibiotic prescribing decisions on suspected urinary tract infections in frail older adults: A tailored approach in four European countries

Frail older adults frequently receive antibiotics for a suspected urinary tract infection. In frail older adults, recognition and diagnosis of urinary tract infections is often difficult, leading to inappropriate antibiotic use. To provide guidance to health care professionals, a decision-tool was previously developed by an international expert team to guide antibiotic prescribing decisions. However, improving antibiotic prescribing for urinary tract infections in frail older adults is challenging. Many factors influence the decision to prescribe antibiotics or not. Moreover, the care setting for older adults is heterogeneous within and between countries. To improve antibiotic prescribing behaviour, it is thus important to understand the local setting and factors of influence. We performed a qualitative study and a subsequent cluster randomized controlled trial in general practices and older adult care organisations in Poland, the Netherlands, Norway, and Sweden. The qualitative study provides insight in the process leading to an antibiotic prescription for a suspected urinary tract infection, and shows many factors that influence antibiotic prescribing decisions. These findings helped in the design and implementation of an antibiotic stewardship intervention in the subsequent cluster randomized controlled trial. Health care professionals in intervention clusters received a multifaceted antibiotic stewardship intervention, with the decision tool for appropriate antibiotic prescribing for urinary tract infections at its core, supported by a toolbox with educational materials. Implementation took place using a participatory-action-research approach with sessions for education and evaluation. Health care professionals in control clusters provided care as usual. We found that the multifaceted antibiotic stewardship intervention is effective in reducing antibiotic prescribing for suspected urinary tract infections in frail older adults without evidence for increased adverse outcomes. Additionally, we performed a process evaluation, in which we evaluated the different components of the antibiotic stewardship intervention and its implementation. Last, we described the disease course after a suspected urinary tract infection and the risk of subsequent adverse outcomes. In summary, this thesis helps to provide a better understanding of antibiotic prescribing decisions for suspected urinary tract infections in frail older adults and provides guidance on how to improve them.