{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,23]],"date-time":"2026-08-23T14:59:35Z","timestamp":1787497175457,"version":"build-2736575974"},"reference-count":50,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2020,6,25]],"date-time":"2020-06-25T00:00:00Z","timestamp":1593043200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100008397","name":"Velux Fonden","doi-asserted-by":"publisher","award":["N.A."],"award-info":[{"award-number":["N.A."]}],"id":[{"id":"10.13039\/100008397","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Kvalitets- og Efteruddannelsesudvalget in the Capital Region of Denmark (KEU)","award":["N.A."],"award-info":[{"award-number":["N.A."]}]},{"DOI":"10.13039\/501100007037","name":"Danish Ministry of Health","doi-asserted-by":"publisher","award":["N.A."],"award-info":[{"award-number":["N.A."]}],"id":[{"id":"10.13039\/501100007037","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Antibiotics"],"abstract":"<jats:p>Background: Inappropriate antibiotic treatments for urinary tract infections (UTIs) in nursing homes cause the development of resistant bacteria. Nonspecific symptoms and asymptomatic bacteriuria are drivers of overtreatment. Nursing home staff provide general practice with information about ailing residents; therefore, their knowledge and communication skills influence prescribing. This paper describes the development of a tailored, complex intervention for a cluster-randomised trial that targets the knowledge of UTI and communication skills in nursing home staff to reduce antibiotic prescriptions. Methods: A dialogue tool was drafted, drawing on participatory observations in nursing homes, interviews with stakeholders, and a survey in general practice. The tool was tailored through a five-phase process that included stakeholders. Finally, the tool and a case-based educational session were tested in a pilot study. Results: The main barriers were that complex patients were evaluated by healthcare staff with limited knowledge about disease and clinical reasoning; findings reported to general practice were insignificant and included vague descriptions; there was evidence of previous opinion bias; nonspecific symptoms were interpreted as UTI; intuitive reasoning led to the inappropriate suspicion of UTI. Conclusion: Sustainable change in antibiotic-prescribing behaviour in nursing homes requires a change in nursing home staff\u2019s beliefs about and management of UTIs.<\/jats:p>","DOI":"10.3390\/antibiotics9060360","type":"journal-article","created":{"date-parts":[[2020,6,25]],"date-time":"2020-06-25T10:36:54Z","timestamp":1593081414000},"page":"360","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4805-4684","authenticated-orcid":false,"given":"Sif H.","family":"Arnold","sequence":"first","affiliation":[{"name":"The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, \u00d8ster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark"},{"name":"Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6036-7988","authenticated-orcid":false,"given":"Julie A.","family":"Olesen","sequence":"additional","affiliation":[{"name":"The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, \u00d8ster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5061-9766","authenticated-orcid":false,"given":"Jette N.","family":"Jensen","sequence":"additional","affiliation":[{"name":"Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0969-0063","authenticated-orcid":false,"given":"Lars","family":"Bjerrum","sequence":"additional","affiliation":[{"name":"The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, \u00d8ster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3819-3429","authenticated-orcid":false,"given":"Anne","family":"Holm","sequence":"additional","affiliation":[{"name":"The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, \u00d8ster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marius B.","family":"Kousgaard","sequence":"additional","affiliation":[{"name":"The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, \u00d8ster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Ricchizzi, E., Latour, K., K\u00e4rki, T., Buttazzi, R., Jans, B., Moro, M.L., Nakitanda, O.A., Plachouras, D., Monnet, D.L., and Suetens, C. (2018). Antimicrobial use in european long-term care facilities: Results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017. Eurosurveillance, 23.","DOI":"10.2807\/1560-7917.ES.2018.23.46.1800394"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.jamda.2014.10.003","article-title":"Antibiotic prescribing in dutch nursing homes: How appropriate is it?","volume":"16","author":"Veenhuizen","year":"2015","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2856","DOI":"10.1093\/jac\/dkr395","article-title":"Antibiotic use in long-term care facilities","volume":"66","author":"Daneman","year":"2011","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.1001\/jamainternmed.2015.2770","article-title":"Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents","volume":"175","author":"Daneman","year":"2015","journal-title":"JAMA Intern. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"c2096","DOI":"10.1136\/bmj.c2096","article-title":"Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis","volume":"340","author":"Costelloe","year":"2010","journal-title":"BMJ"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Gajd\u00e1cs, M. (2019). The concept of an ideal antibiotic: Implications for drug design. Molecules, 24.","DOI":"10.3390\/molecules24050892"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/j.jamda.2013.11.009","article-title":"Clinical Uncertainties in the Approach to Long Term Care Residents With Possible Urinary Tract Infection","volume":"15","author":"Nace","year":"2014","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1111\/jgs.12070","article-title":"Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections","volume":"61","author":"Loeb","year":"2013","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"E75","DOI":"10.1093\/cid\/ciz021","article-title":"Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America","volume":"68","author":"Nicolle","year":"2019","journal-title":"Clin. Infect. Dis."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Mayne, S., Bowden, A., Sundvall, P.D., and Gunnarsson, R. (2019). The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing\u2014A systematic literature review. BMC Geriatr., 19.","DOI":"10.1186\/s12877-019-1049-7"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1093\/ofid\/ofy101","article-title":"Leveraging antimicrobial stewardship in the emergency department to improve the quality of urinary tract infection management and outcomes","volume":"5","author":"Jorgensen","year":"2018","journal-title":"Open Forum Infect. Dis."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Zalmanovici Trestioreanu, A., Lador, A., Sauerbrun-Cutler, M.-T., and Leibovici, L. (2015). Antibiotics for asymptomatic bacteriuria. Cochrane database Syst. Rev.","DOI":"10.1002\/14651858.CD009534.pub2"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12877-019-1181-4","article-title":"Asymptomatic bacteriuria in older adults: The most fragile women are prone to long-term colonization","volume":"19","author":"Biggel","year":"2019","journal-title":"BMC Geriatr."},{"key":"ref_14","first-page":"1","article-title":"Investigation of suspected urinary tract infection in older people","volume":"4070","author":"Ninan","year":"2014","journal-title":"BMJ"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1016\/j.jamda.2019.12.004","article-title":"Nursing Home Clinicians\u2019 Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment","volume":"21","author":"Kistler","year":"2020","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_16","unstructured":"Sundheds- og \u00e6ldreministeriet (2016). National Unders\u00f8gelse af Forholdene p\u00e5 Plejecentre [National Investigation into the Conditions at Nursing Homes]."},{"key":"ref_17","unstructured":"Central Enhed for Infektionshygiejne (2018). Overv\u00e5gning af sundhedssektorerhvervede infektioner og antibiotikaaudit p\u00e5 plejehjem HALT 3. [Survailance of Health Sector Acquired Infections and Antibiotics Audit at Nursing Homes HALT 3.]."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1781","DOI":"10.1093\/jac\/dks085","article-title":"Antimicrobial prescribing in residential homes","volume":"67","author":"McClean","year":"2012","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_19","first-page":"98","article-title":"Antibiotic prescribing practice in residential aged care facilities - Health care providers\u2019 perspectives","volume":"201","author":"Lim","year":"2014","journal-title":"Med. J. Aust."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1007\/s40266-015-0292-7","article-title":"Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement","volume":"32","author":"Crnich","year":"2015","journal-title":"Drugs Aging"},{"key":"ref_21","first-page":"1","article-title":"Factors influencing antibiotic prescribing in long-term care facilities: A qualitative in-depth study","volume":"14","author":"Doncker","year":"2014","journal-title":"BMC Geriatr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1016\/j.jamda.2017.06.019","article-title":"Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review","volume":"19","author":"Feldstein","year":"2018","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Saha, S.K., Kong, D.C.M., Thursky, K., and Mazza, D. (2020). A Nationwide Survey of Australian General Practitioners on Antimicrobial Stewardship: Awareness, Uptake, Collaboration with Pharmacists and Improvement Strategies. Antibiotics, 9.","DOI":"10.3390\/antibiotics9060310"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Raban, M.Z., Gasparini, C., Li, L., Baysari, M.T., and Westbrook, J.I. (2020). Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: A systematic review and meta-analysis. BMJ Open, 10.","DOI":"10.1136\/bmjopen-2018-028494"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Baker, R., Gillies, C., Ej, S., Cheater, F., Flottorp, S., Robertson, N., Wensing, M., Fiander, M., Mp, E., and J, V.L. (2015). Tailored interventions to address determinants of practice. Cochrane Database Syst. Rev.","DOI":"10.1002\/14651858.CD005470.pub3"},{"key":"ref_26","first-page":"979","article-title":"Developing and evaluating complex interventions: The new Medical research council guidance","volume":"337","author":"Craig","year":"2008","journal-title":"BMJ"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1090","DOI":"10.12968\/bjon.2005.14.20.20053","article-title":"Pilot study to show the loss of important data in nursing handover","volume":"14","author":"Pothier","year":"2005","journal-title":"Br. J. Nurs."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1308\/003588407X168352","article-title":"An experimental comparison of handover methods","volume":"89","author":"Bhabra","year":"2007","journal-title":"Ann. R. Coll. Surg. Engl."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"669","DOI":"10.1136\/bmj.38602.586343.55","article-title":"Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: Cluster randomised controlled trial","volume":"331","author":"Loeb","year":"2005","journal-title":"BMJ"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Mcmaughan, D.K., Nwaiwu, O., Zhao, H., Frentzel, E., Mehr, D., Imanpour, S., Garfinkel, S., and Phillips, C.D. (2016). Impact of a decision-making aid for suspected urinary tract infections on antibiotic overuse in nursing homes. BMC Geriatr., 16.","DOI":"10.1186\/s12877-016-0255-9"},{"key":"ref_31","first-page":"1798","article-title":"Kommunikation p\u00e5 hospitalet ved hj\u00e6lp af en standardiseret metode. [Communication in a hospital by means of a standardised method]","volume":"174","author":"Ydemann","year":"2012","journal-title":"Ugeskr. Laeger"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e17710","DOI":"10.2196\/17710","article-title":"Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial","volume":"9","author":"Arnold","year":"2020","journal-title":"JMIR Res. Protoc."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1016\/j.jamda.2018.05.001","article-title":"The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure","volume":"19","author":"Vreeken","year":"2018","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.archger.2008.01.012","article-title":"Detection of urinary tract infection (UTI) in long-term care setting: Is the multireagent strip an adequate diagnostic tool?","volume":"48","author":"Arinzon","year":"2009","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/1471-2318-14-88","article-title":"Interleukin-6 concentrations in the urine and dipstick analyses were related to bacteriuria but not symptoms in the elderly: A cross sectional study of 421 nursing home residents","volume":"14","author":"Sundvall","year":"2014","journal-title":"BMC Geriatr."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"4","DOI":"10.3928\/0098-9134-20040601-04","article-title":"Urinary tract infections. Does the smell really tell?","volume":"30","author":"Midthun","year":"2004","journal-title":"J. Gerontol. Nurs."},{"key":"ref_37","unstructured":"Heneghan, C., and Spencer, E. (2020, May 13). Catalogue of Bias. Available online: https:\/\/catalogofbias.org\/biases\/previous-opinion-bias\/."},{"key":"ref_38","unstructured":"Public Health England (2019). Diagnosis of Urinary Tract Infections: Quick Reference Tool for Primary Care for Consultation and Local Adaptation Diagnosis of Urinary Tract Infections: Quick Reference Tool for Primary Care."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1111","DOI":"10.1046\/j.1532-5415.2003.51360.x","article-title":"Predictive value of nonspecific symptoms for acute illness in nursing home residents","volume":"51","author":"Boockvar","year":"2003","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_40","unstructured":"Bjerrum, L., Maagaard, R., Jensen, M.B., Kristensen, J.K., Jarb\u00f8l, D.E., Ertmann, R.K., Rosendal, M., Christensen, K.S., and Lange, P. (2014). Almen Medicin [Family Medicine], Munksgaard. [1st ed.]."},{"key":"ref_41","first-page":"1248","article-title":"Maps of bounded rationality: A perspective on intuitive judgment and choice","volume":"106","author":"Kahneman","year":"2002","journal-title":"Sveriges Riksbank Prize Econ. Sci. Mem. Alfred Nobel"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3402\/meo.v16i0.5890","article-title":"An analysis of clinical reasoning through a recent and comprehensive approach: The dual-process theory","volume":"16","author":"Pelaccia","year":"2011","journal-title":"Med. Educ. Online"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Festinger, L. (1957). A theory of Cognitive Dissonance, Standford University Press.","DOI":"10.1515\/9781503620766"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1097\/00006223-199703000-00018","article-title":"Preparing advanced practice nurses for clinical decision making in specialty practice","volume":"22","author":"Lipman","year":"1997","journal-title":"Nurse Educ."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"646","DOI":"10.3928\/01484834-20141023-05","article-title":"Teaching dual-process diagnostic reasoning to doctor of nursing practice students: Problem-based learning and the illness script","volume":"53","author":"Durham","year":"2014","journal-title":"J. Nurs. Educ."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1544","DOI":"10.1016\/j.ajic.2016.04.238","article-title":"Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention","volume":"44","author":"Grigoryan","year":"2016","journal-title":"Am. J. Infect. Control"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1007\/s11096-005-1191-5","article-title":"Managing urinary tract infections in nursing homes: A qualitative assessment","volume":"27","author":"Schweizer","year":"2005","journal-title":"Pharm. World Sci."},{"key":"ref_48","unstructured":"Ministry of Health (2017). Healthcare in Denmark."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pone.0150205","article-title":"Defining feasibility and pilot studies in preparation for randomised controlled trials: Development of a conceptual framework","volume":"11","author":"Eldridge","year":"2016","journal-title":"PLoS ONE"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1109\/47.867942","article-title":"Thinking aloud: Reconciling theory and practice","volume":"43","author":"Boren","year":"2000","journal-title":"IEEE Trans. Prof. Commun."}],"container-title":["Antibiotics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2079-6382\/9\/6\/360\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:42:56Z","timestamp":1760175776000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2079-6382\/9\/6\/360"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,25]]},"references-count":50,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2020,6]]}},"alternative-id":["antibiotics9060360"],"URL":"https:\/\/doi.org\/10.3390\/antibiotics9060360","relation":{},"ISSN":["2079-6382"],"issn-type":[{"value":"2079-6382","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,6,25]]}}}