NL Antibiotic Use in 2014 Data Source: National (CARSS)

Antibiotic Usage:

  • In 2014, NL prescribed more antibiotics than any other province; one-third higher than the second highest use rate.

NL Antibiotic Use in 2016 Data Source: National (CARSS)

Antibiotic Usage:

  • In 2016, NL prescribed 955 prescriptions per 1,000 inhabitants; 19% more than the second highest prescription rate.
  • That is almost one prescription for every resident in NL.

Antibiotic Resistance is Increasing in the Community

Choosing Wisely Canada Guidelines: 6 Ways to Use Antibiotics Wisely

  1. Don’t use antibiotics for upper respiratory infections that are likely viral in origin, such as influenza-like illness, or self-limiting, such as sinus infections of less than seven days of duration.
  2. Don’t collect urine specimens for culture from adults who lack symptoms localizing to the urinary tract or fever unless they are pregnant or undergoing genitourinary instrumentation where mucosal bleeding is expected.
  3. Don’t prescribe antibiotics for asymptomatic bacteriuria (ASB) in non-pregnant patients.
  4. Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis.
  5. Don’t use antibiotics in adults and children with uncomplicated sore throats.
  6. Don’t use antibiotics in adults and children with uncomplicated acute otitis media.

What You Can Do! Consider Writing a Delayed Prescription

Write a post-dated prescription with clear instructions for the pharmacist not to fill until the specified date.

  • Provide the patient with the prescription and specific instructions of when to fill.
  • Leave the prescription at the receptionist’s desk to be picked up if symptoms persist.
  • Ask the patient to re-contact to office if symptoms persist for a specific time frame.
  • Tailor the specific time delay to the clinical context.

Alternatively, ask your patient to return to the clinic, it may be more effective than providing patient with a prescription. The evidence from randomized clinical trials supporting delayed prescribing is primarily for respiratory tract infections and urinary tract infections.

Tools to Help your Practice

Percentage (%) of most frequently prescribed oral antibiotics in the province by all Nurse Practitioners (NPs).

Prescription records for oral antibiotics in patients 65+ years with NLPDP coverage for 2015-2016 Fiscal Year (n = 5969).

Choosing Wisely Canada Guidelines: Nursing

  1. Don’t insert an indwelling urinary catheter or leave it in place without daily assessment.
    • The use of indwelling urinary catheters among hospital patients is common. Yet it can also lead to preventable harms such as urinary tract infection, sepsis and delirium. Guidelines support routine assessment of appropriate urinary catheter indications —including acute urinary obstruction, critical illness and end-of-life care—and minimizing their duration of use. Strategies consistent with CAUTI (catheter-associated urinary tract infection) guidelines regarding inappropriate urinary catheter use have been shown to reduce health care-associated infections.
  2. Don’t advise routine self-monitoring of blood glucose between appointments for clients with type 2 diabetes who are not taking insulin or other medications that could increase risk for hypoglycemia.
    • Many studies show that, once target control is achieved, routine self-monitoring of blood glucose (SMBG) does little to control blood sugar for most adults with type 2 diabetes who don’t use insulin or other medications that could increase risk for hypoglycemia. It should be noted that SMBG may be indicated during acute illness, medication change or pregnancy; when a history or risk of hypoglycemia exists (e.g., if using a sulfonylurea), and when individuals need monitoring to maintain targets — considerations that should be part of assessment and client education.
  3. Don’t add extra layers of bedding (sheets, pads) beneath patients on therapeutic surfaces.
    • Additional layers of bedding can limit the pressure-dispersing capacities of therapeutic surfaces (such as therapeutic mattresses or cushions). As a result, extra sheets and pads can contribute to skin breakdown and impede the healing of existing pressure wounds.
  4. Don’t use oxygen therapy to treat non-hypoxic dyspnea.
    • Oxygen is frequently used to relieve shortness of breath. However, supplemental oxygen does not benefit patients who are short of breath but not hypoxic. Supplemental flow of air is as effective as oxygen for non-hypoxic dyspnea.
  5. Don’t routinely use incontinence containment products (including briefs or pads) for older adults.
    • Adult incontinence containment products are frequently used for continent patients (especially women) with low mobility. Yet the literature associates their use with multiple adverse outcomes including diminished self-esteem and perceived quality of life, and higher incidence rates of dermatitis, pressure wounds and urinary tract infections. Among older adults, nurses should conduct a thorough assessment to determine the risk of such outcomes before initiating or continuing the use of incontinence containment products. The development of a continence care plan should be a shared decision-making process that includes the known wishes of clients regarding care needs and the perspectives of carers and the health care team.
  6. Don’t recommend tube feeding for clients with advanced dementia without ensuring a shared decision-making process that includes the known wishes of clients regarding future care needs and the perspectives of carers and the health care team.
    • Tube feeding for older adults with advanced dementia offers no benefit over careful feeding assistance related to the outcomes of aspiration pneumonia and the extension of life. While food is the preferred form of obtaining nutrition, oral supplements may be beneficial if this intervention meets the person’s known goals of care. Tube feeding may contribute to client discomfort and result in agitation, the use of physical and/or chemical restraint and worsening pressure wounds.
  7. Don’t recommend antipsychotic medicines as the first choice to treat symptoms of dementia.
    • People with dementia frequently exhibit responsive behaviors, which are often misinterpreted as aggression, resistance to care and challenging or disruptive behaviours. In such instances antipsychotic medicines are regularly prescribed. The benefit of these drugs is limited, however, and they can also cause serious harm including premature death. Their use should be limited to cases where non-pharmacologic measures have failed and where patients pose an imminent threat to themselves or others. Identifying and addressing the causes of behaviour change can render drug treatment unnecessary. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescriber.
  8. Don’t recommend antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
    • Signs and symptoms suggestive of urinary tract infection (UTI) are increased frequency, urgency, pain or burning on urination, supra-pubic pain, flank pain and fever. Dark, cloudy and/or foul-smelling urine may not be suggestive of UTI but rather of inadequate fluid intake. Cohort studies have found no adverse outcomes associated with asymptomatic bacteriuria for older adults. Not only does antimicrobial treatment for such bacteriuria in older adults show no benefits, it increases adverse antimicrobial effects. Consensus criteria have been developed for the specific clinical symptoms that (when associated with bacteriuria) define UTI. Exceptions to these criteria include recommended screening for and treatment of asymptomatic bacteriuria before urologic procedures where mucosal bleeding is anticipated. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescribers.
  9. Don’t routinely recommend antidepressants as a first-line treatment for mild depressive symptoms in adults.
    • Antidepressant response rates are higher for moderate or severe adult depression. For mild depressive symptoms a complete assessment, ongoing support and monitoring, psychosocial interventions and lifestyle modifications should be the first lines of treatment. This approach can avoid the side-effects of medication and establish etiological factors important to future assessment and management. Antidepressants are appropriate in cases of persistent mild depression where a past history of more severe depression exists or where other interventions have failed. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescriber.

For additional information and sources, please visit Choosing Wisely Canada/Nursing.

Choosing Wisely Canada Guidelines: Nursing: Infection & Prevention Control

  1. Don’t do a urine dip or send urine specimens for culture unless urinary tract symptoms are present.
    • Don’t do a urine dip or send urine specimens for culture when patients/clients/residents (including the elderly or persons with diabetes) do not have urinary tract symptoms or when following up to confirm effective treatment. Testing should only be done when there are urinary tract infection (UTI) symptoms such as urinary discomfort, frequency, urgency, supra-pubic pain, flank pain or fever. Dark, cloudy and/or foul-smelling urine may not be suggestive of UTI but rather of inadequate fluid intake. Delirium by itself is not considered a symptom of cystitis in non-catheterized patients. Testing often shows bacteria in the urine, with as many as 50% of those tested showing bacteria without localizing symptoms to the genitourinary tract. Over-testing and treating asymptomatic bacteriuria with antibiotics lead to an increased risk of diarrhea and infection with Clostridium difficile. Overuse of antibiotics contributes to increasing antimicrobial resistance. The only exceptions to such overuse are screening in early pregnancy, for which there are clear guidelines, and screening for asymptomatic bacteriuria before urologic procedures in which mucosal bleeding is anticipated.
  2. Don’t recommend antibiotics for infections that are likely viral in origin, such as an influenza-like illness.
    • Since the vast majority of upper respiratory infections are viral, antibiotics are rarely indicated and may lead to adverse effects. Overuse or misuse of antibiotics can lead to increased antibiotic resistance in the individual and the larger society. Antiviral drugs are authorized for influenza treatment and prophylaxis in Canada. Their use will depend on a number of factors such as patient risk, relevant history and the duration and severity of symptoms. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescribers.
  3. Don’t overuse gloves.
    • Gloves should only be worn: (1) when a point-of-care risk assessment indicates a risk of contact with broken skin, blood or body fluids, mucous membranes or contaminated surfaces (as per routine practices); (2) for situations where additional (contact) precautions are indicated; or (3) for contact with chemicals (e.g., during environmental cleaning, preparing chemotherapy, etc.). When a task requires gloves, they should be put on immediately beforehand and removed immediately after, at which point hands should be cleaned. Gloves are not necessary for social touch (e.g., shaking hands) or when contact is limited to intact skin (e.g., taking blood pressure, dressing a client) or clean surfaces. Don’t wear multiple layers of gloves and don’t substitute gloves for hand hygiene. Hand hygiene is the single most important way to prevent transmission of infection, and alcohol-based hand rub (ABHR) is the preferred method. If gloves must be worn, after cleaning hands, allow them to dry before putting on gloves to reduce the risk of chronic irritant contact dermatitis (ICD) and colonization of hands. If hands are not visibly soiled, this risk could be reduced by avoiding handwashing and using ABHR instead.*
  4. Don’t send unnecessary or improperly collected specimens for testing.
    • Don’t routinely send specimens for testing or screening (e.g., for methicillin-resistant Staphylococcus aureus [MRSA]) unless clinical evidence of infection is present (e.g., for incisions or eyes). If the highest quality specimen that can be obtained is through a swab of infected skin, tissue or wound, cleanse the area with sterile saline beforehand to reduce surface contaminants. Do not take a specimen of the discharge unless it is specifically ordered. Improperly collected or poor-quality specimens (including swabs) can reduce patient safety by prompting antimicrobial therapy (in cases of colonization) and increase laboratory and pharmacy expenses. To promote sensible antimicrobial use and optimize the treatment of infected patients, while reducing unnecessary microbiology lab workup, attention should be paid to appropriate specimen collection.
  5. Don’t collect stool that is not diarrhea for Clostridium difficile infection testing or test of cure.
    • Don’t routinely collect or process specimens for Clostridium difficile testing when stool is not diarrhea (i.e., does not take the shape of the specimen container), the patient has had a prior nucleic acid amplification test result within the past seven days (e.g., polymerase chain reaction) or as a test of cure. A positive test in the absence of diarrhea likely represents C. difficile colonization. Repeated C. difficile testing within seven days of a negative test generally adds little diagnostic value. A test of cure in patients with recent C. difficile infection is also not recommended, as colonization may continue indefinitely. Contact precautions are required until symptoms (i.e., diarrhea) resolve.
  6. Don’t prolong the use of invasive devices.
    • Invasive devices (such as central venous catheters and endotracheal tubes) should not be used without specific indication (determined by appropriate clinical assessment) and should not be left in place without daily re-assessment. If required, invasive devices should not be used longer than necessary, as they breach skin and body integrity and are portals of entry for infection.
  7. Don’t shave hair for medical procedures. Use clippers if hair removal is required.
    • Shaving hair (e.g., preoperatively, for insertion of vascular access devices and electrode application) can result in microscopic cuts and abrasions to the underlying skin surface. According to World Health Organization guidelines, hair should not be removed unless it interferes with a surgical procedure. The use of razors (shaving) prior to surgery increases incidents of wound infection when compared to clipping, depilatory use or the non-removal of hair. If hair must be removed, clipper use is sufficient for any body part (razor use is not appropriate for any operative site). Clippers should be used as close to the time of surgery as possible. To facilitate better contact for electrodes or vascular access device dressings, disposable (or cleaned and disinfected reusable-head) surgical clippers should be used.

For additional information and sources, please visit Choosing Wisely Canada/Nursing.