Failure to Review and Document Rationale for Duplicate Antibiotic Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis and later received a second antibiotic, cefuroxime, without documented review or rationale for the concurrent use of both antibiotics. The resident was initially admitted with acute kidney failure, dysuria, and urinary retention, and was placed on Bactrim for ongoing UTI prevention. After reporting symptoms suggestive of a UTI, the resident was evaluated in the emergency department, where no infection was found. Subsequently, the resident's primary care provider prescribed cefuroxime following a urine dipstick that showed trace leukocytes, resulting in the resident receiving both antibiotics simultaneously. Facility staff, including nursing and infection control personnel, recognized the duplicate antibiotic therapy and attempted to contact the resident's primary care provider for clarification regarding the necessity of both medications. Despite these attempts, there was no response from the provider, and no documentation was made to justify the dual antibiotic regimen. The facility's antibiotic stewardship policy required validation of antibiotic use for correct indication, dose, route, and duration, but this was not followed in this case, as there was no documented rationale for the continued use of both antibiotics.