The goal of this proposal is to improve the care and safety of residents of skilled nursing facilities (SNFs) in rural areas of Utah by addressing the growing problem of antibiotic resistance and inappropriate antibiotic use in this setting. Antibiotics are heavily used in nursing homes, and the selection pressure exerted by this level of antibiotic use, particularly in a contained environment, is enormous. Not surprisingly, antibiotic resistance in SNFs, and the risk of infection with an antibiotic-resistant organism, is rising. This is of particular concern in a clinical setting where elderly residents already have an increased risk of infection.     The focus of this work will be antibiotic resistance among urinary isolates of gram-negative bacteria and the management of catheter-associated bacteriuria and urinary tract infections (UTI), particularly as they relate to the rural SNF setting. We hypothesize that the problems of antibiotic resistance and inappropriate antibiotic use exist to significant degrees in SNFs in rural communities, where little is known about management practices and surveillance is rarely, if at all, performed. These hypotheses will be investigated by two approaches. The first approach will employ a personal digital assistant (PDA)-based surveillance tool at SNFs throughout rural Utah to track antimicrobial resistance among gram-negative urinary isolates, particularly those from long-term catheterized patients. The second approach will use a similar PDA-based data collection tool to prospectively assess management of catheter-associated bacteriuria and UTI in long-term catheterized patients from rural Utah SNFs. These studies will pave the way for a third project, where we will design and implement an intervention using a PDA-based decision-support tool to improve the management of catheter-associated asymptomatic bacteriuria and symptomatic urinary tract infection for residents of rural SNFs, emphasizing the potential impact on patient care, patient safety, and overall costs.