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Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people?: A qualitative study of physicians' and nurses' perceptions

Susan Walker^*, Allison McGeer, Andrew E. Simor, Maxine Armstrong-Evans and Mark Loeb^¶

From *the Department of Anthropology, McMaster University, Hamilton, Ont.; the Departments of Microbiology at Mount Sinai Hospital and Sunnybrook & Women's College Health Sciences Centre, University of Toronto, Toronto, Ont.; the Hamilton Health Sciences Corporation, Hamilton, Ont.; and ¶the Hamilton Regional Laboratory Medicine Program and the Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ont.

Background: Antibiotic therapy for asymptomatic bacteriuria in institutionalized elderly people has not been shown to be of benefit and may in fact be harmful; however, antibiotics are still frequently used to treat asymptomatic bacteriuria in this population. The aim of this study was to explore the perceptions, attitudes and opinions of physicians and nurses involved in the process of prescribing antibiotics for asymptomatic bacteriuria in institutionalized elderly people.

Methods: Focus groups were conducted among physicians and nurses who provide care to residents of long-term care facilities in Hamilton, Ont. A total of 22 physicians and 16 nurses participated. The focus group discussions were tape-recorded, and the transcripts of each session were analysed for issues and themes emerging from the text. Content analysis using an open analytic approach was used to explore and understand the experience of the focus group participants. The data from the text were then coded according to the relevant and emergent themes and issues.

Results: We observed that the ordering of urine cultures and the prescribing of antibiotics for residents with asymptomatic bacteriuria were influenced by a wide range of nonspecific symptoms or signs in residents. The physicians felt that the presence of these signs justified a decision to order antibiotics. Nurses played a central role in both the ordering of urine cultures and the decision to prescribe antibiotics through their awareness of changes in residents' status and communication of this to physicians. Education about asymptomatic bacteriuria was viewed as an important priority for both physicians and nurses.

Interpretation: The presence of nonurinary symptoms and signs is an important factor in the prescription of antibiotics for asymptomatic bacteriuria in institutionalized elderly people. However, no evidence exists to support this reason for antibiotic treatment. Health care providers at long-term care facilities need more education about antibiotic use and asymptomatic bacteriuri

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