Unnecessary Antibiotic Use Without Laboratory Confirmation
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) and a suprapubic catheter was started on Ertapenem, a broad-spectrum antibiotic, for a suspected UTI without adequate clinical indications or supporting laboratory evidence. The physician ordered a urinalysis with reflex culture, but the urine sample was not collected, and no urinalysis or urine culture results were documented. Despite the absence of fever, normal white blood cell count, and lack of other clinical signs of infection, the antibiotic regimen was continued. Interviews with facility staff, including the Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse, confirmed that the antibiotic should not have been continued without laboratory confirmation of infection. Staff acknowledged that there was a failure to follow up on obtaining the necessary urine sample and to discontinue the antibiotic in the absence of supporting evidence. This resulted in the resident receiving unnecessary antibiotics, contrary to facility policy and best practices for antimicrobial stewardship.