Background 50% of antibiotic courses in long-term care facilities (LTCFs) are unnecessary, leading to increased risk of harm such as Clostridiodes difficile infection and antibiotic-resistant organisms. Antimicrobial Stewardship (AS) interventions plays an important role in optimizing antibiotic use. Most studies to improve antibiotic prescribing in LTCFs showed modest and unsustained results. We aimed to identify facilitators, barriers and strategies in implementing a urinary tract infection (UTI)-focused AS intervention at a LTCF with the secondary objective of exploring the pharmacist’s potential role(s) in this intervention. Methods A qualitative approach using conventional content analysis was used. Through purposeful sampling, we recruited different healthcare providers and administrators at Kensington Gardens. Interviewees attended focus groups or one-on-one interviews. Data were collected using a semi-structured interview guide. Data were analyzed inductively using a codebook modified in an iterative analytic process. Barrier and facilitator themes were identified from the transcripts and mapped using the COM-B (capability, opportunity, motivation and behaviour) model (Michie et al). Similarly, themes were identified from the transcripts regarding the pharmacist’s roles in this intervention. Results Sixteen participants were interviewed. Most barriers and facilitators mapped to the opportunities domain of the COM-B model. The main barrier themes were lack of access, lack of knowledge, ineffective communication, lack of resources and external factors while the main facilitator themes were education, effective collaboration, good communication, sufficient resources and access. For the pharmacist’s role, the barrier themes were ineffective collaboration and communication. Furthermore, the pharmacist can play a role in education and antibiotic selection. Conclusions A UTI-focused antimicrobial stewardship intervention in LTCF should consider strategies to improve access, knowledge, communication and collaboration in its design, having sufficient resources and addressing external factors in order to optimize the intervention’s success. Pharmacists can play a role in education and antibiotic selection. / Thesis / Master of Science (MSc) / Half of antibiotics prescribed in long-term care are not needed, leading to increased harm. It is unclear which strategies should be used to improve antibiotic prescribing. This project aims to identify facilitators, barriers and strategies in identifying and managing urinary tract infection in a long-term care facility as well as exploring the role of the pharmacist in this setting. We conducted focus groups and interviews to gather information and analyzed the transcripts to determine barrier and facilitator themes relating to urinary tract infection management and the role of the pharmacist. The main barrier themes were lack of access, lack of knowledge, ineffective communication, lack of resources and external factors while the main facilitator themes were education, effective collaboration, good communication, sufficient resources and access. For the pharmacist’s role, the barrier themes were ineffective collaboration and communication. In addition, the pharmacist can play a role in education and antibiotic selection.

The efficacy of short term (3 day) oral amoxicillin therapy was compared to conventional (14 day) oral therapy in an experimental model of bacterial lower urinary tract infection (UTI) in the cat. Chemical cystitis was induced using an infusion solution of salicylic acid, 70% ethanol, and normal saline via transabdominal cystocentesis. Cats were challenged with a Staphylococcus intermedius inoculum twenty-four hours later introduced via urethral catheterization. Serial quantitative aerobic bacterial urine cultures obtained via cystocentesis were used to evaluate groups of cats. Eighteen adult cats (9 males and 9 females) were divided into 3 groups of 6 cats (3 males and 3 females): Group I = conventional amoxicillin therapy (14 day), Group II = control group (no treatment), and Group III = short term therapy (3 day). Results indicated the conventional therapy successfully eradicated infection, however, the short term therapy did not eradicate infection when compared to controls. During the study period the diuretic furosemide was used in some cats to facilitate cystocentesis procedures. Those cats were observed to exhibit less stranguria, which is a common sign of lower UTI. The second study evolved from observations made in the first study and evaluated the effect of furosemide on conventional antibiotic therapy in an experimental model of bacterial lower UTI in the cat. A similar experimental design was utilized with Group I = control group (no treatment), Group II = oral furosemide (14 day), and Group III = oral furosemide and oral amoxicillin (14 day). Statistical analysis failed to demonstrate the efficacy of the furosemide and amoxicillin combination, but showed furosemide alone was not an appropriate therapy when compared to controls. It was again observed that those cats receiving furosemide showed fewer secondary signs of lower UTI such as stranguria which suggests a possible role for furosemide as adjunct therapy in the treatment of lower UTI in the cat. / Master of Science

Bakgrund: Urinvägsinfektioner är en av de vanligaste vårdrelaterade infektionerna inom svensk sjukvård. Varje år drabbas 65 000 personer av en vårdrelaterad infektion, av dessa är 14 % urinvägsrelaterad. Detta medför onödigt lidande för patienten, men ger också upphov till förlängda vårdtider och ökade kostnader för hälso- och sjukvården. Syfte: Syftet var att beskriva hur sjuksköterskan kan arbeta preventivt för att minska förekomsten av vårdrelaterade urinvägsinfektioner. Metod: Studiens design var en litteraturöversikt innehållande 15 vetenskapliga artiklar, varav 13 stycken var kvantitativa och två stycken var kvalitativa. Datainsamlingen har skett via sökningar i databaserna PubMed och Cinahl, valda artiklar granskades med granskningsmallar och sammanställdes sedan i resultatet. Resultat: Resultatet visade att ett förebyggande arbete kring rutiner vid kateterisering innebar minskade risker för att drabbas av urinvägsinfektioner. Utbildning och ökad medvetenhet kring hygien visade sig ha en positiv effekt både hos patienter och bland personal. Det påvisades även ett positivt samband med ett ökat vätskeintag samt kosttillskott i form av tranbärskapslar. Slutsats: För att minska vårdrelaterade urinvägsinfektioner krävs det att sjuksköterskan har en följsamhet i det förebyggande arbetet. Utbildning bland personal och patienter, större medvetenhet kring basala hygienrutiner och korrekt rutiner vid kateterisering har en stor betydelse i det preventiva arbetet. / Background: Urinary tract infection is one of the most common nosocomial infections in Swedish health care. Each year, 65 000 people suffer from a nosocomial infection, of which 14 % are urinary tract related. This problem causes unnecessary suffering for the patient, prolonged waiting times and increased costs for health care. Aim: The aim of this study was to describe how nurses could prevent nosocomial urinary tract infections. Methods: This was a literature review based on 15 articles. Of these, 13 studies had a quantitative approach and two studies had a qualitative approach. The data collection has been done by searching in the databases PubMed and Cinahl. Chosen articles were reviewed by using reviewing templates, analyzed and were compiled in the result. Results: The result showed that proactive work regarding routines when catheterize amounted to less risks for patients suffering from urinary tract infections. Education and increased awareness around hygiene turned out to have a positive effect on patients in decreasing urinary tract infections and on staff behavior. There was also a positive correlation between an increased fluid intake and cranberry capsules as a supplement. Conclusion: To reduce nosocomial urinary tract infections it is required that the nurse is involved in the proactive work. Education for staff and patients, greater awareness around basic hygiene routines and correct routines when catheterizing has a big impact on the proactive work.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Lower urinary tract disorders are significant prognostic indicators of institutionalisation and lower quality of life in the elderly and their incidence increases with age. Urodynamics, the gold standard in diagnosis, replicates symptoms to assess functionality through controlled filling and voiding of the bladder but its interpretation is subjective and may be inconclusive; often requiring further testing or leading to inappropriate treatment. Normal filling and voiding biomechanics of the bladder relate directly to the structural composition of the bladder wall. Alterations to tissue composition in aging and pathology have significant impacts on biomechanics but are yet to be fully described. The aim of this thesis was to gain insight into the individual microstructural components of the bladder wall and how they relate to the gross mechanical response. Additionally, representation of these observations in a mathematical model that can be used to improve our understanding of urodynamic data. This aim was achieved through a combination of in situ mechanical testing and the development of a microstructural constitutive model, which was then included within an overall micturition framework to simulate filling and voiding functions, and evaluated with clinical data. Coupled systems of multiphoton microscopy and uniaxial, biaxial and inflation testing were used to correlate extra cellular matrix interactions with the mechanical response of young and aged murine bladder. Wall-layer specific collagen fibre orientation, dispersion and recruitment were quantified and implemented into a novel microstructural constitutive model. The bladder was modelled as a nonlinear elastic, constrainedmixture planar membrane with contribution from smooth muscle and collagen fibres in the detrusor. Collagen recruitment in the detrusor was observed to occur at a finite stretch; correlated with a steep increase in stiffness of the tissue, while collagen of the lamina propria plays a capacitance role. Collagen recruitment was modelled using a triangular probability density function; quantified from sequential microscopy images and fitted to mechanical data. Increased collagen area fraction and changes in dominant fibre orientation were attributed to reduced compliance in aged bladder. This behaviour was captured by the model. The microstructural model was modified to an isotropic thin-walled spherical membrane for the filling phase of a micturition model framework, consisting of a bladder outlet relation and urethral resistance relation. A contractile smooth muscle element was included in the active response. In the first steps towards clinical application the model was applied to male and female 'normal' patient urodynamic data to observe quality of model fit and estimate baseline parameter values. The model simulated key filling and voiding features seen in normal male and female clinical data. Mechanobiological modelling combined with clinically relevant micturition modelling has the potential to quantify bladder dysfunction. Moreover, improved understanding of how the microstructure influences macroscopic mechanics will yield improved understanding of how changes to the bladder impair its functionality. We predict that modelling will become a clinically relevant tool in urodynamics; leading to new options for diagnosis and management of patients with bladder dysfunction.

In the United States, many hospitalized patients with indwelling urinary catheters acquire catheter-associated urinary tract infections (CAUTI) during their hospital stay. CAUTI negatively affects peoples' health and quality of life and causes a financial burden to individuals and the nation. The purpose of this quantitative cross-sectional study was to explore the relationship between gender, age, and hospital types and CAUTI incidence in New York and North Carolina over a 3-year period. The theoretical framework of choice was the Donabedian model. Simple logistic regression and hierarchical multivariable logistic regression analysis were performed on archival data that was requested from Healthcare Cost and Utilization Project (HCUP) agency. According to the findings, males (n = 61,040) were at a higher risk of developing CAUTI compared to female (n = 66,792) (p < .001) in New York and North Carolina between 2012 and 2014. The odds of getting CAUTI were much higher among age > = 45 compared to the < 17 years. These findings fit in with previous literature identifying age and gender as having a significant relationship with CAUTI occurrence. The outcomes in this study may guide the formulation of policies that are age-appropriate, gender-specific, and facility-tailored to reduce the incidence of CAUTI.

Diss. (sammanfattning) Linköping : Univ., 2004. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 5 uppsatser.

More than 13,000 deaths and $340 million in health care costs are the result of catheter-associated urinary tract infections (CAUTIs) annually in the United States. CAUTIs can also result in acute patient discomfort and potentially preventable exposure to antibiotics. The hospital for which this quality improvement project was developed was above the National Healthcare Safety Network CAUTI bench mark. Framed within the Iowa model of evidence-based practice, a multidisciplinary team of 8 hospital stakeholders guided the project (n=8). The purpose of the project was to develop an indwelling urinary catheter maintenance checklist using evidence-based practice guidelines related to preexisting inappropriate risk factors for catheterization and appropriate indications for catheterization, as well as evidence-based maintenance practices for care of the indwelling catheter. Each piece of evidence to be included in the checklist was evaluated by 4 content experts using a 10 item 5 point Likert scale ranging from 'strongly disagree' to 'strongly agree'. Descriptive analysis showed an average of 4.8/5 for all items with 'agree' being voiced in two of the items rather than 'strongly agree'. The checklist was completed and presented to hospital senior leadership who recommended that the checklist be incorporated into the hospital CAUTI prevention plan. All project team members (n=8) completed an 8 item 5 point Likert scale summative evaluation of the purpose, goal, objectives, and my leadership which averaged as 5 or 'strongly agree' supporting the development of the project. Implications for social change include improved patient outcomes, mindful stewardship of healthcare dollars, and increased patient and family satisfaction.