Failure to Implement Effective Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program when a resident returned from the hospital with a new order for Keflex to treat a urinary tract infection (UTI). The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and chronic kidney disease, was sent to the emergency room for chest pain and returned with a UTI diagnosis and an order for Keflex. Hospital records showed that a urine culture identified Enterobacter Cloacae as the causative organism, which was not sensitive to Keflex. Despite this, the resident received the full seven-day course of Keflex as ordered. The acting Infection Preventionist (IP) at the facility was responsible for reviewing antibiotic use for residents returning from the hospital. The IP identified that the organism causing the UTI was not sensitive to the prescribed antibiotic and completed an antibiotic time-out, reaching out to the resident's physician. However, the Antibiotic Time Out report incorrectly documented the organism as E. coli, for which Keflex would have been appropriate, rather than Enterobacter Cloacae. The physician was informed of the incorrect organism and did not respond until the antibiotic course was nearly complete, instructing to finish the course despite its ineffectiveness against the identified organism. Facility policy required the IP to monitor antibiotic use, review laboratory results, and ensure antibiotics were appropriate for the identified infection. The policy also stated that the Medical Director was responsible for setting standards for antibiotic prescribing and overseeing adherence. In this case, there was no evidence that the antibiotic was changed to one effective against the organism identified in the culture, and the resident received an ineffective antibiotic regimen, contrary to the facility's antibiotic stewardship policy.