Key summary points
To describe use-patterns of UTI antibiotics two years prior to and following care home admission in Denmark.
AbstractSection FindingsUse of antibiotics for urinary tract infections double about six months prior to care home admission. Following care home admission, the use of antibiotics for urinary tract infection remains at a persistent high level.
AbstractSection MessageUse of antibiotics for urinary tract infections shows an overall decrease throughout the years 2016 to 2021, despite variation between residents, care homes, and geographical regions.
Abstract
Purpose
Older people have the highest use of antibiotics for acute and chronic urinary tract infection (UTI), despite diagnostic uncertainty and the growing problem of antibiotic resistance. We aim to describe use-patterns of UTI antibiotics two years prior to and following care home admission in Denmark.
Methods
This was a register-based nationwide drug-utilization study. In a cohort comprising all Danish residents admitted into a care home from 2015 to 2021, we described the use of UTI antibiotics, and examined differences between regions and individual care homes in rates of UTI antibiotic use. Further, we described trends in UTI-related contacts with hospitals in the two years prior to and following care home admission.
Results
The cohort comprised 101,297 residents (61% female; median age 84 years). UTI antibiotic use doubled from 7 to 14 treatments/100 residents/month two months prior to care home admission and remained at 10 treatments/100 residents/month the following two years. Prescription of pivmecillinam (55%) was most common. Primary care practitioners prescribed the majority (92%) of UTI antibiotics. UTI-related hospital contacts peaked at two months prior to care home admission, with 6 admissions/100 residents/month, subsequently dropping to 2 admission/100 residents/month. We found considerable variation in UTI antibiotic use, with 10% of care homes responsible for 20% of treatments in 2021.
Conclusion
Use of UTI antibiotics increased prior to and remained at a stable high level following care home admission in Denmark. Despite variation in use across regions and individual care homes, an overall decrease was seen throughout the years 2016–2021.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Antibiotic resistance is considered one of the biggest threats to global health by the World Health Organization (WHO) [1], among other things driven by a high use of antibiotics among older people [2,3,4]. Residents in care homes are vulnerable to infections [5,6,7,8] due to several factors, including immunosenescence [9], multimorbidity [6], use of catheters and feeding tubes [10,11,12], close living proximity [11, 12], and repeated and continuous contact with nursing staff and medical equipment [11, 12]. A European study on use of antimicrobial medications in long-term care facilities [13] showed that the most common type of antimicrobials prescribed were for urinary tract infections (UTIs) (46%), including both acute treatment episodes and long-term prophylaxis [13]. High use of UTI antibiotics in care homes may be driven by several factors, in particular a high prevalence of asymptomatic bacteriuria among such residents (up to 50%) compared to older people living in the community (4%), despite no reported benefit from antibiotic treatment for asymptomatic bacteriuria [14, 15]. Another contributing factor is the clinical uncertainty around common occurrences such as confusion, falls, and agitation being attributed to UTIs [16, 17]. The time after transitioning from independent living to living in care home is of particular interest, as this may precipitate behavioral changes such as increased confusion, irritability, and agitation often associated with care home admission [18, 19], in turn, possibly exposing the newly admitted residents to antibiotic treatments for presumed UTIs. The aim of this study is therefore to provide knowledge to help inform clinical guidelines and regulations by describing and characterizing patterns of antibiotic use for UTIs and UTI-related hospital contacts up to and after care home admission in a nation-wide cohort of Danish care home residents.
Methods
This was a register-based national drug utilization study among a cohort of all people admitted into care homes across Denmark from 2015 to 2021. The cohort was linked with individual-level registry data on prescriptions filled in community pharmacies in Denmark.
Design and data sources
The national cohort was assembled, encrypted, and provided by the Danish Health Data Authority using data from various Danish health registries and linked via the personal identification number assigned to all Danish residents since 1968 [20]. Individual-level data on filled prescriptions were collected from the Danish National Prescription Register [21], containing data on all prescriptions filled in community pharmacies in Denmark since 1995. This includes variables such as the type of drug, amount, and Anatomic Therapeutic Chemical (ATC) classification [22]. Data on hospital contacts and admissions were collected from the Danish National Patient Registry [23]. The Patient Registry includes variables such as admission and discharge diagnoses, coded using ICD-10 since 1994, hospital departments, and admission/discharge dates and times. Prescriber information from the Prescription Registry was linked with the Registry of Health Care Providers [24] to identify type of prescriber (primary health care sector versus secondary health care sector). Currently no national guideline exists on the selection of antibiotics for UTIs. However, regional guidelines primarily suggest pivmecillinam (J01CA08) as first-line treatment for UTIs [25,26,27,28,29,30]. The chosen antibiotics are in Danish clinical context used almost exclusively for UTIs [31,32,33,34], and was based on discussion with clinicians and on Danish Health Care Guidelines [25,26,27,28,29,30]. We examined the following oral antibiotics that are commonly used for UTI in Denmark: pivmecillinam (J01CA08), nitrofurantoin (J01XE01), trimethoprim (J01EA01), sulfonamide drugs (sulfamethizole (J01EB02) and sulfamethoxazole/trimethoprim (J01EE01)), and ciprofloxacin (J01MA02). UTI-related hospital contacts within the cohort was examined using the following diagnoses according to the Patient Registry [23]: cystitis (ICD-10: N30.X and N39.0), pyelonephritis (ICD-10: N10.X, N11.X and N12.X), observation due to suspected UTI (ICD-10: Z038A and Z038B), and urosepsis (ICD-10: A419B).
Research questions
We structured the analyses across five individual research questions. All analyses were carried out both overall and stratified by sex. A treatment episode was defined by the filling of a prescription for a UTI antibiotic. Multiple fills within 15 days were considered to belong to the same treatment episode. As the data material included individuals moving into care homes from 2015 onwards, analyses of total use were restricted to 2016 onwards to ensure comparability in the cohorts over time. All analyses utilized the Danish National Prescription Register [21], while the fourth and fifth analysis, respectively, also utilized the Danish National Patient Registry [23], and the Registry of Health Care Providers [24].
First, to describe the overall rate of use of UTI antibiotics among care home residents, we calculated the total number of treatment episodes per month per 100 residents in the two years leading up to and following care home admission and specified by type of antibiotic.
Second, to describe differences in use of UTI antibiotics across the five Danish regions and 98 individual municipalities, as well as changes in the period 2016–2021, we calculated the annual average number of treatment episodes per person-year per location.
Third, to describe the skewness of use of UTI antibiotics among individual care homes, we generated an inverse Lorenz curve for the year 2021, restricting to care homes with more than 10 person-years follow-up among its residents. In short, a Lorenz curve [35] depicts the proportion of all drug use, here UTI antibiotics, used by a proportion of the population, here individual care homes. If the use of UTI antibiotics were equally distributed between care homes the Lorenz curve would thus be a straight line.
Fourth, to describe the trends of UTI-related hospital contacts within the cohort, we calculated number of contacts related to UTIs in the two years leading up to and following care home admission. Hospital contacts were restricted to primary diagnoses associated with emergency room admissions and inpatient admissions (thus excluding ambulatory contacts).
Lastly, we determined what type of doctors (primary health care sector; general practitioner and other specialists, secondary health care sector; hospital physician, unknown) are responsible for prescribing UTI antibiotics in the two years leading up to and following care home admission.
Ethics and approvals
This study did not require approval from an ethics review board, according to Danish law on studies based solely on register data [36]. In terms of data protection, the study was registered at the repository of University of Southern Denmark (11.277).
Results
The cohort comprised 101,297 residents, of which 61% were female and the median age was 84 years (Table 1). Most (78%) had at least one hospital contact (any cause) during the last six months prior to being admitted into a care home. One fifth of residents (n = 19,615) had passed away or were censored six months following care home admission. This increased to 36% (n = 36,024) and 60% (n = 60,539) one year and two years following care home admission, respectively.
In the year leading up to care home admission, a total of 45,522 individuals (45%) were prescribed at least one UTI antibiotic. Similarly, in the year following care home admission, there were 44,964 individuals (44%) filling UTI antibiotics. Among those using UTI antibiotics prior to care home admission, 22% also filled a prescription in the six months after care home admission. We identified a total of 200,877 and 222,844 prescriptions of UTI antibiotics in the two years prior to and following care home admission, respectively. Use of pivmecillinam (55%) was most common, followed by trimethoprim (18%), sulfonamides (10%), nitrofurantoin (9.1%), and ciprofloxacin (8.2%) (Supplementary Fig. 1, Supplementary Table 1). We found that 15% of all UTI antibiotic prescriptions were followed by another UTI antibiotic prescription within 15 days, most often a new prescription for the same antibiotic (51–60%), except for sulfonamides that were followed equally by either a new sulfonamide or pivmeciliam prescription (Supplementary Table 2). The 90-day mortality following care home admission was 14% and 11%, for residents receiving a UTI antibiotic within six months prior to admission and those without such a prescription, respectively. Similarly, the one-year mortality was 35% and 29%.
Use of UTI antibiotics increased from around six months prior to care home admission from 7 treatment episodes per 100 residents per month to 14 treatment episodes per 100 residents per month at two months prior to care home admission (Fig. 1).
Following care home admission, this changed to 10 treatment episodes per 100 resident per months and stayed consistent for the following 2 years. The rate of UTI treatments was higher among women with a peak of 16 treatment episode per 100 residents per month two months prior to admission compared to that of men (11 treatment episodes per 100 residents per month two months prior to admission) (Supplementary Fig. 2). The distribution in use of UTI antibiotics were similar between men and women (Supplementary Fig. 3). The overall average number of treatment episodes per person-year in the five regions of Denmark decreased during the years from 2016 to 2021, ranging from 2.95 treatment episodes/person-year in 2016 to 1.75 treatment episodes/person-year in 2021 (Fig. 2). A similar trend of overall decrease in number of treatment episodes per person-year, was seen among the 98 different municipalities in Denmark (Supplementary Fig. 4).
When looking at the level of the individual care home, we found considerable variation, with ten percent of care homes responsible for one fifth of all UTI treatments in 2021, and 50% were responsible for 68% of treatment episodes (Fig. 3). This skewness in use was consistent during the study period (Supplementary Fig. 5).
Hospital contacts related to UTIs peaked at two months prior to care home admission with six contacts per 100 residents per month (Fig. 4). However, contrary to the use of UTI antibiotics, where women used more medicine than men, men had more hospital UTI-related contacts following care home admission (Supplementary Fig. 6). The most prominent reasons for hospital contact were cystitis (N30.X, N39.0) and urosepsis (A419B), both among women and men (Supplementary Fig. 7). However, men were more often admitted due to urosepsis than women, whom were most often admitted due to cystitis. This trend persisted both during the year prior to and the year following care home admission. Among both sexes there was an increase in contacts due to urosepsis after moving into care homes from 7 to 11% and 18–25%, for women and men, respectively.
Lastly, we examined which types of physicians who most often prescribed UTI antibiotics. We found that the majority (81–97%) of all UTI antibiotics for care home residents was prescribed by practitioners in the primary healthcare sector (e.g., general practitioners or other specialists) (Supplementary Table 3). We also examined prescription patterns following care home admission and found that the percentage of UTI antibiotic prescriptions issued by general practitioners and other specialists increased with 3.6% during the two subsequent years (Supplementary Table 3). This increase was almost entirely made up for by a decrease of 3.7% by hospital physicians. Hospital physicians’ prescribing of UTI antibiotics decreased among all UTI antibiotic groups (− 1.0% to − 4.9%), while general practitioners’ prescribing increased for all UTI antibiotics (0.7–5.2%), with the highest increase seen with ciprofloxacin (5.2%) in the two years following care home admission.
Discussion
We found that the use of UTI antibiotics increased in the six months prior to care home admission. In the two years following care home admission the use of UTI antibiotics decreased slightly but remained high compared to the time before care home admission. Hospital contacts related to UTIs also peaked around care home admission. Further, we found that, overall, women were more often treated with UTI antibiotics compared to men. However, men were more often admitted to hospital with a UTI-related diagnosis, which were often of a more serious/life threatening character, compared to women. Finally, we found an overall decrease in use patterns throughout 2016–2021, at both regional, institutional, and resident level, despite also showing variation at all levels.
A main strength of this study is the complete national cohort of all Danes admitted to nursing home in 2015 and onwards, with unambiguous linkage across Danish health registries. The study also has several limitations. First, we do not know the specific indication for why a certain antibiotic is prescribed, nor did we have access to biochemical or microbiological data. However, of the included antibiotics only ciprofloxacin is to some extent used for other non-UTI indications [37]. The final selection of UTI antibiotics included in this study was based on Danish Health Care Guidelines [25,26,27,28,29,30] and discussion with clinicians. As such, while overestimation of UTI antibiotic use is possible, only 8.2% of UTI antibiotic prescriptions were ciprofloxacin. Second, ICD-10 UTI-related diagnoses may not represent actual community-acquired UTI. A Danish validation study found that the positive predictive value for UTIs was 54% [38], thus supporting that misclassification of such contacts will have impacted our findings by leading to an overestimation of the number of hospital contacts related to UTIs. Thirdly, if patients are admitted due to UTIs in Danish emergency rooms, short course UTI antibiotics (e.g. around 3 days) can be provided directly in the emergency room without prescription. This use of UTI antibiotics is therefore not present in the data from the prescription registry, which only records prescriptions from community-pharmacies, possibly leading to an underestimation of the actual use.
A study examining use of UTI antibiotics among residents of long-term care facilities in over 20 different European countries similarly found that Denmark is among the countries with the highest proportion of use of UTI antibiotics among residents [13], comparable to Finland, Ireland, the Netherlands, and Wales. The wide variation in use of UTI antibiotics across regions, municipalities, care homes, and individual residents, may to some extend be due to the lack of a national guideline [25,26,27,28,29]. Interestingly, the fluctuations in use patterns seems to follow an overall national trend, although no single region consistently using more antibiotics than others. The potential explanations for this variation are unknown and could be related to factors such as changing local guideline or changes to clinical practice brought about by new local prescribers. Identifying drivers of low use of UTI antibiotics remain an area for further study. The increase in use of UTI antibiotics 6 months prior to care home admission may to some extent be related to presumed UTI diagnoses due to symptoms such as confusion and asymptomatic bacteriuria [16, 17]. These symptoms are commonly associated with the time period around care home admission, as a result of changes in health status [39]. Whether similar findings can explain the sustained high-level use of antibiotics following care home admission is unknown. These findings of high antibiotic use around time of care home admission and considerable variation at care home level is also reported in several studies examining the general use of antibiotics among care home residents [40,41,42].
Clinical implication
A recent study testing a multifaceted antibiotic stewardship intervention on UTI prescriptions in frail older adults in Poland, the Netherlands, Norway, and Sweden found that their intervention reduced the number of prescriptions of UTI antibiotics safely [43]. These finding match a similar Danish cluster randomized trial [44]. Both intervention studies found that educating care home staff on UTIs and how to communicate with other healthcare professionals substantially lowered the use of UTI antibiotics and the risk of inappropriate prescribing [44,45,46,47]. This supports the importance of national guidelines on treatment regimen, and suggests that perhaps national efforts to increase the knowledge on UTIs and communication skills among care home staff may be effective in reducing the risk of inappropriate prescribing and use of UTI antibiotics [43]. Implementing national efforts may prove to be difficult, it may therefore be more efficient to initiate changes regionally. However, future studies on barriers for implementing such interventions is needed.
Conclusion
We found that the use of urinary tract infection antibiotics is high among care home residents. The use increases prior to care home admission and remains at a stable high level during the two-year follow-up after care home admission. Further, we found variation in the use patterns at both regional, institutional, and residential level, despite also seeing an overall decrease in use throughout 2016 to 2021.
Data availability
Individual level data cannot be shared by the authors owing to Danish data protection regulations. Deidentified data can be made available for authorised researchers after application to Forskerservice at the Danish Health Data Authority.
References
“Antibiotic resistance. World Health Organization. Accessed May, 2022. https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance.” Accessed: Apr. 27, 2021. [Online]. Available: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance
Zazzara MB et al (2022) Medication Use and Costs Among Older Adults Aged 90 Years and Older in Italy. Front Pharmacol 13:818875. https://doi.org/10.3389/fphar.2022.818875
Gouin KA, Fleming-Dutra KE, Tsay S, Bizune D, Hicks LA, Kabbani S (2022) Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data — United States, 2019. Morb Mortal Wkly Rep 71(6):202–205. https://doi.org/10.15585/mmwr.mm7106a3
Ardoino I et al (2019) Antibiotic use and associated factors in a large sample of hospitalised older people. J Glob Antimicrob Resist 19:167–172. https://doi.org/10.1016/j.jgar.2019.04.013
Cotter M (2012) Healthcare-associated infection in Irish long-term care facilities: results from the First National Prevalence Study. J Hosp Infect: 5
Eilers R, Veldman-Ariesen MJ, Haenen A, van Benthem BH (2012) Prevalence and determinants associated with healthcare-associated infections in long-term care facilities (HALT) in the Netherlands, May to June 2010. In: Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull 17(34)
Moro ML et al (2013) Infections and antimicrobial resistance in long term care facilities: a national prevalence study. Ann Ig Med Prev E Comunita 25(2):109–118. https://doi.org/10.7416/ai.2013.1912
European Centre for Disease Prevention and Control.. In: Point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities: April–May 2013. LU: Publications Office, 2014. Accessed: Apr. 27, 2021. [Online]. Available: https://data.europa.eu/doi/10.2900/24172
Aw D, Silva AB, Palmer DB (2007) Immunosenescence: emerging challenges for an ageing population. Immunology 120(4):435–446. https://doi.org/10.1111/j.1365-2567.2007.02555.x
Nicolle LE, Strausbaugh LJ, Garibaldi RA (1996) Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev 9(1):1–17
Richards CL (2007) Infection control in long-term care facilities. J Am Med Dir Assoc 8(3 Supplement): S18–S25. https://doi.org/10.1016/j.jamda.2006.12.002.
Garibaldi RA (1999) Residential care and the elderly: the burden of infection. J Hosp Infect 43:S9–S18. https://doi.org/10.1016/S0195-6701(99)90061-0
Ricchizzi E, et al. (2018) Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016–2017. In: Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull 23(46). https://doi.org/10.2807/1560-7917.ES.2018.23.46.1800394
Leihof RF, Nielsen KL, Frimodt-Møller N (2021) Asymptomatic bacteriuria (ABU) in elderly: prevalence, virulence, phylogeny, antibiotic resistance and complement C3 in urine. Microorganisms. https://doi.org/10.3390/microorganisms9020390
Nicolle LE (2006) Asymptomatic bacteriuria: review and discussion of the IDSA guidelines. Int J Antimicrob Agents 28:42–48. https://doi.org/10.1016/j.ijantimicag.2006.05.010
Mayne S, Bowden A, Sundvall P-D, Gunnarsson R (2019) The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing—a systematic literature review. BMC Geriatr 19(1):32. https://doi.org/10.1186/s12877-019-1049-7
Nace DA, Drinka PJ, Crnich CJ (2014) Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. J Am Med Dir Assoc 15(2):133–139. https://doi.org/10.1016/j.jamda.2013.11.009
Helvik A-S, Selbæk G, Šaltytė Benth J, Røen I, Bergh S (2018) The course of neuropsychiatric symptoms in nursing home residents from admission to 30-month follow-up. PLOS One 13(10):e0206147. https://doi.org/10.1371/journal.pone.0206147
Morriss RK, Rovner BW, German PS (2004) Clinical and psychosocial variables associated with different types of behaviour problem in new nursing home admissions. Int. J. Geriatr. Psychiatry 10(7):547–555
Schmidt M, Pedersen L, Sørensen HT (2014) The Danish civil registration system as a tool in epidemiology. Eur J Epidemiol 29(8):541–549. https://doi.org/10.1007/s10654-014-9930-3
Pottegård A, Schmidt SAJ, Wallach-Kildemoes H, Sørensen HT, Hallas J, Schmidt M (2017) Data resource profile: the danish national prescription registry. Int J Epidemiol 46(3):798–798f. https://doi.org/10.1093/ije/dyw213
Anatomical Therapeutic Chemical (ATC) Classification. World Health Organization. Accessed May, 2022. https://www.who.int/tools/atc-ddd-toolkit/atc-classification. Accessed: May 25, 2022. [Online]. Available: https://www.who.int/tools/atc-ddd-toolkit/atc-classification
Schmidt M, Schmidt SAJ, Sandegaard JL, Ehrenstein V, Pedersen L, Sørensen HT (2015) The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol 7:449–490. https://doi.org/10.2147/CLEP.S91125
[The Registry of Health Care Providers] (In Danish: Yderregistret). The Danish Health Data Authority. Available from: sundhedsdatastyrelsen.dk/da/registre-og-services/om-de-nationale sundhedsregistre/personoplysninger-og-sundhedsfaglig beskaeftigelse/yderregisteret. Last accessed May, 2022.
[Infections - The North Denmark Region] (In Danish: Infektioner - Region Nordjylland ). Available from: https://www.sundhed.dk/sundhedsfaglig/information-til-praksis/nordjylland/almen-praksis/laegemidler/basislisten-nordjylland/o-infektioner/. Last accessed May, 2022.
[Infections - The Capital Region of Denmark] (In Danish: Infektioner - Region Hovedstaden). Available from: https://www.sundhed.dk/sundhedsfaglig/information-til-praksis/hovedstaden/almen-praksis/laegemidler/basislisten-hovedstaden/infektioner/. Last accessed May, 2022.
[Infections - Region Zealand] (In Danish: Infektioner - Region Sjælland). Available from: https://www.sundhed.dk/sundhedsfaglig/information-til-praksis/sjaelland/almen-praksis/laegemidler/basislisten-sjaelland/infektioner/. Last accessed May, 2022.
[Infections - the Region of Southern Denmark] (In Danish: Infektioner - Region Syddanmark). Available from: https://www.sundhed.dk/sundhedsfaglig/information-til-praksis/syddanmark/almen-praksis/laegemidler/basislisten-indikationer-syddanmark/infektioner/. Last accessed May, 2022.
[Infections - Central Denmark Region] (In Danish: Infektioner - Region Midtjylland). Available from: https://www.sundhed.dk/sundhedsfaglig/information-til-praksis/hovedstaden/almen-praksis/laegemidler/basislisten-hovedstaden/infektioner/. Last accessed May, 2022.
[Urinary tract infections in general practice - DSAM guidelines] (In Danish: Urinvejsinfektioner i almen praksis - DSAM Vejledninger). Available from: https://vejledninger.dsam.dk/fakta/uvi/?mode=visKapitel&cid=1367. Last accessed March 2023. Accessed: Mar. 03, 2023. [Online]. Available: https://vejledninger.dsam.dk/fakta/uvi/?mode=visKapitel&cid=1367
Holm A, Cordoba G, Aabenhus R (2019) Prescription of antibiotics for urinary tract infection in general practice in Denmark. Scand J Prim Health Care 37(1):83–89. https://doi.org/10.1080/02813432.2019.1569425
[Lower urinary tract infection among men - Medical Handbook at sundhed.dk] (In Danish: Nedre urinvejsinfektion hos mænd - Lægehåndbogen på sundhed.dk). Accessed: Mar. 22, 2023. [Online]. Available: https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/nyrer-og-urinveje/tilstande-og-sygdomme/infektioner/nedre-urinvejsinfektion-hos-maend/
[Cystitis among non-pregnant women - Medical Handbook from sundhed.dk] (In Danish: Cystitis hos ikke-gravide kvinder - Lægehåndbogen på sundhed.dk). Accessed: Mar. 22, 2023. [Online]. Available: https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/nyrer-og-urinveje/tilstande-og-sygdomme/infektioner/cystitis-hos-ikke-gravide-kvinder/
[Urinary tract infection, catheter - Medical Handbook from sundhed.dk] (In Danish: Urinvejsinfektion, kateter - Lægehåndbogen på sundhed.dk). Accessed: Mar. 22, 2023. [Online]. Available: https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/nyrer-og-urinveje/tilstande-og-sygdomme/infektioner/urinvejsinfektion-kateter/
Hallas J, Støvring H (2006) Templates for analysis of individual-level prescription data. Basic Clin Pharmacol Toxicol 98(3):260–265. https://doi.org/10.1111/j.1742-7843.2006.pto_257.x
Thygesen LC, Daasnes C, Thaulow I, Brønnum-Hansen H (2011) Introduction to Danish (nationwide) registers on health and social issues: structure, access, legislation, and archiving. Scand J Public Health 39(7 Suppl):12–16. https://doi.org/10.1177/1403494811399956
Aabenhus R, Hansen MP, Siersma V, Bjerrum L (2017) Clinical indications for antibiotic use in Danish general practice: results from a nationwide electronic prescription database. Scand J Prim Health Care 35(2):162–169. https://doi.org/10.1080/02813432.2017.1333321
Henriksen DP, Nielsen SL, Laursen CB, Hallas J, Pedersen C, Lassen AT (2014) How Well do discharge diagnoses identify hospitalised patients with community-acquired infections? A validation study. PLoS One 9(3):e92891. https://doi.org/10.1371/journal.pone.0092891
Holmes HM et al (2013) Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging 30(9):655–666. https://doi.org/10.1007/s40266-013-0095-7
Smith CM et al (2020) Antibiotic prescribing in UK care homes 2016–2017: retrospective cohort study of linked data. BMC Health Serv Res 20(1):555. https://doi.org/10.1186/s12913-020-05422-z
Patterson L et al (2019) Evidence of a care home effect on antibiotic prescribing for those that transition into a care home: a national data linkage study. Epidemiol Infect 147:e115. https://doi.org/10.1017/S0950268818003382
Raban MZ, Lind KE, Day RO, Gray L, Georgiou A, Westbrook JI (2020) Trends, determinants and differences in antibiotic use in 68 residential aged care homes in Australia, 2014–2017: a longitudinal analysis of electronic health record data. BMC Health Serv Res 20(1):883. https://doi.org/10.1186/s12913-020-05723-3
Hartman EAR et al (2023) Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries. BMJ 380:e072319. https://doi.org/10.1136/bmj-2022-072319
Arnold SH et al (2021) Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial. Lancet Infect Dis 21(11):1549–1556. https://doi.org/10.1016/S1473-3099(21)00001-3
van Buul LW et al (2015) Antibiotic prescribing in dutch nursing homes: how appropriate is it? J Am Med Dir Assoc 16(3):229–237. https://doi.org/10.1016/j.jamda.2014.10.003
[Evalutation rapport - Antibiotics and the elderly] (In Danish: Evalueringsrapport - Antibiotika og ældre). [Online]. Available: https://www.herlevhospital.dk/afdelinger-og-klinikker/Afdeling-for-Klinisk-Mikrobiologi/Forskning/PublishingImages/Sider/Projekter/Evalueringsrapport%20%C3%A6ldre%20final%20Mindre%20AB%20forbrug%20og%20f%C3%A6rre%20UVI%20blandt%20borgere%20p%C3%A5%20plejecentre.pdf
Kistler CE et al (2022) Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline. J Am Geriatr Soc 70(4):1070–1081. https://doi.org/10.1111/jgs.17638
Acknowledgements
Morten Olesen (University of Southern Denmark), Lars Christian Lund (University of Southern Denmark), Jacob Harbo Andersen (University of Southern Denmark), and Martin Thomsen Ernst (University of Southern Denmark) are acknowledged for their help validating and improving the analytical code used in the study.
Funding
Open access funding provided by University of Southern Denmark. University of Southern Denmark and the Danish Independent Research Council (2034-00305B).
Author information
Authors and Affiliations
Contributions
The initial study idea was proposed by Anton Pottegård, and the study was designed by Anton Pottegård and Emma Bjørk. The data analysis and the initial draft was written by Emma Bjørk. All authors participated in writing and revising the article as well as read and approved the final version of the manuscript. All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Sponsor’s Role: This article was supported by a grant from University of Southern Denmark and the Danish Independent Research Council (2034-00305B). The University of Southern Denmark and the Danish Independent Research Council had no role in designing and conducting this study or the decision to submit the manuscript for publication.
Corresponding author
Ethics declarations
Conflicts of interest
Anton Pottegård reports participation in research projects funded by Alcon, Almirall, Astellas, Astra-Zeneca, Boehringer-Ingelheim, Novo Nordisk, Servier, and LEO Pharma, all regulator-mandated phase IV-studies, all with funds paid to the institution where he was employed (no personal fees) and with no relation to the work reported in this paper. Remaining authors report no conflict of interest.
Ethical approval
This study was conducted in accordance with the Declaration of Helsinki. This study did not require approval from an ethics review board, according to Danish law on studies based solely on register data. In terms of data protection, the study was registered at the repository of University of Southern Denmark (11.277).
Informed consent
For this type of study, relying solely on registries not using biological material, no informed consent is required.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Bjørk, E., Aabenhus, R., Larsen, S.P. et al. Use of antibiotics for urinary tract infections up to and after care home admission in Denmark: a nationwide study. Eur Geriatr Med 15, 797–805 (2024). https://doi.org/10.1007/s41999-024-00976-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s41999-024-00976-1