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Chan OS, Wu P, Cowling B, Lee E, Yeung M, St-Hilaire S, Tun H, Wernli D, Lam W. Prescribing antibiotics prudently-A survey of policy implementation drivers among physicians and veterinarians. One Health 2024; 18:100752. [PMID: 38832078 PMCID: PMC11145358 DOI: 10.1016/j.onehlt.2024.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024] Open
Abstract
Background As the antimicrobial resistance (AMR) problem accelerates, humans and animals are suffering from the consequences of infections with diminishing antimicrobial treatment options. Within the One Medicine and One Health mandate, which denotes a collaborative, multisectoral, and transdisciplinary approach to improve medicine and health across human and animal sectors, we investigate how human and veterinary medical practitioners apply their medical and policy knowledge in prescribing antimicrobials. Different regions and locations establish different intermediary policies and programs to support clinicians in that pursuit. In Hong Kong, there are locally adapted programs at governance and clinical levels in the human medical field. However, there is no locally adapted veterinary antibiotic prescription guideline or stewardship program, and veterinarians adopt overseas or international professions' antimicrobial use guidelines. Such a policy environment creates a natural experiment to compare local policy implementation conditions and clinicians' knowledge, perception, and practice. Method We construct the investigative survey tool by adaptation of Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, and Motivation-Behavior (COM-B) models. We identify, compare and contrast factors that influence clinicians' antimicrobial prescription behavior. The factors are considered both intrinsically, such as personal attributes, and extrinsically, such as societal and professional norms. Findings The absence of locally adopted antimicrobial guidelines influences AMR stewardship program implementation in local Hong Kong veterinary community. As medical allies, physicians and veterinarians share similar demographic influence, organization considerations and perception of public awareness. Both cohorts prescribe more prudently with more years-in-practice, time available to communicate with patients or caretakers, and public awareness and support.
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Affiliation(s)
- Olivia S.K. Chan
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Peng Wu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ben Cowling
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Elaine Lee
- Agriculture, Fisheries and Conservation Department, 5/F, Cheung Sha Wan Government Offices, 303 Cheung Sha Wan Road, Kowloon, Hong Kong SAR, China
| | - Michelle Yeung
- Agriculture, Fisheries and Conservation Department, 5/F, Cheung Sha Wan Government Offices, 303 Cheung Sha Wan Road, Kowloon, Hong Kong SAR, China
| | - Sophie St-Hilaire
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong SAR, People's Republic of China
| | - Hein Tun
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Sciences II, Quai Ernest-Ansermet 30, CH-1211 Genève, Switzerland
| | - Wendy Lam
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
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Kowalchuk A, Ostovar-Kermani TG, Schaper K, Grigoryan L, Hirth JM, Mejia MC, Spooner KK, Zoorob RJ. Factors associated with intention to implement SBI and SUD treatment: a survey of primary care clinicians in Texas enrolled in an online course. BMC PRIMARY CARE 2024; 25:192. [PMID: 38807054 PMCID: PMC11134618 DOI: 10.1186/s12875-024-02427-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/10/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Substance use disorder (SUD) presents a range of public health challenges and consequences. Despite the prevention potential of screening and brief intervention (SBI) in the primary care setting, implementation is low. The purpose of this study was to assess associations of primary care clinicians' knowledge of SBI and SUD treatment, subjective norms, and perceived behavioral control with intention to incorporate SBI and SUD treatment into regular clinical practice. METHODS This online survey was administered to primary care clinicians who practice in Texas between March 1, 2021, and February 5, 2023. Survey questions were mapped to factors in the Theory of Planned Behavior and included measures of knowledge, subjective norms, and perceived behavioral controls related to SBI and SUD treatment. Intention to engage in SBI and SUD treatment was assessed as the outcome. RESULTS Of 645 participants included in this study, 59.5% were physicians. Knowledge was low, with less than half correctly reporting what was considered a standard drink (39.6%) and only 20% knew the correct number of alcoholic beverages considered risky drinking in 21-year-old non-pregnant women. Subjective norms, such as having colleagues within their practice support addressing SUDs, and perceived behavioral control such as having SUD screening routinized within clinic workflows, were positively associated with intention to implement SBI and SUD treatment in primary care settings. CONCLUSIONS Modifying knowledge gaps, subjective norms, and perceived behavioral control requires a multipronged interventional approach that blends accessible clinician training with systemic workplace enhancements and a collective shift in professional norms.
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Affiliation(s)
- Alicia Kowalchuk
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA.
| | - Tiffany G Ostovar-Kermani
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA
| | - Kylie Schaper
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA
| | - Jacqueline M Hirth
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA
| | - Maria Carmenza Mejia
- Department of Population Health and Social Medicine, Schmidt College of Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, USA
| | - Kiara K Spooner
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA
| | - Roger J Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, suite 600, Houston, TX, 77098, USA
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Smith EEA, Nachimuthu N, Flynn J, Balasubramanyam A, Negrete JA, Trautner BW, Al Mohajer M. Assessing clinicians' and trainees' knowledge and practice of the IDSA guidelines for asymptomatic bacteriuria in older adults. Infect Control Hosp Epidemiol 2024; 45:664-666. [PMID: 38251669 DOI: 10.1017/ice.2023.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.
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Affiliation(s)
| | | | - John Flynn
- Baylor College of Medicine, Houston, Texas
- CommonSpirit Health Texas Division, Houston, Texas
| | | | | | - Barbara W Trautner
- Michael E. DeBakey Veterans Affairs' Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Bradley MS, Meckes N, Krishnamurti T. Decision-making and Treatment Preferences Surrounding Bacteriuria in Nonpregnant Women: A Qualitative Investigation. Int Urogynecol J 2024; 35:661-666. [PMID: 38324184 DOI: 10.1007/s00192-024-05725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/24/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Best practices suggest nontreatment for asymptomatic bacteriuria in a nonpregnant population, yet there is little literature on patient preference or understanding of asymptomatic bacteriuria treatment. We hypothesize that there might be core factors that affect antibiotic preferences and care-seeking decisions for urinary tract infection and asymptomatic bacteriuria in a postmenopausal population. METHODS We performed semi-structured interviews with postmenopausal individuals who had been previously treated for at least one patient-reported urinary tract infection. Interviews covered a discussion about their approach to seeking antibiotics for management and knowledge/preferences for asymptomatic bacteriuria management. Two authors independently coded the interviews and identified a set of symptom-related knowledge and experiences that relate to care-seeking and treatment preferences. We then graphically represented a mental model of antibiotic-seeking practices as an influence diagram, illustrating how knowledge and values affect preferences for care. RESULTS We performed 30 interviews of participants with a mean age of 69.4 (SD 6.4). Among participants, there were four core factors that influence antibiotic seeking for bacteriuria. Participants noted concern for sequelae from untreated bacteria as their primary motivation, but also noted past experiences, information sources, and testing results as themes that affected their mental model surrounding bacteriuria treatment. CONCLUSIONS The cognitive approach to care-seeking and treatment preference for bacteriuria is influenced by a few central factors. An improved ability to allay concerns either by provider discussions or educational materials are necessary to bridge the gap from the existence of evidence-based guidelines to patient and provider comfort with adherence to these guidelines.
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Affiliation(s)
- Megan S Bradley
- Department of Obstetrics, Gynecology and Reproductive Science, Division of Urogynecology, University of Pittsburgh Medical Center - Magee Womens Hospital, 300 Halket St, Rm 2324, Pittsburgh, PA, 15213, USA.
| | - Nicole Meckes
- Department of Obstetrics, Gynecology and Reproductive Science, Division of Urogynecology, University of Pittsburgh Medical Center - Magee Womens Hospital, 300 Halket St, Rm 2324, Pittsburgh, PA, 15213, USA
| | - Tamar Krishnamurti
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Chan OSK, Lam W, Zhao S, Tun H, Liu P, Wu P. Why prescribe antibiotics? A systematic review of knowledge, tension, and motivation among clinicians in low-, middle- and high-income countries. Soc Sci Med 2024; 345:116600. [PMID: 38394944 DOI: 10.1016/j.socscimed.2024.116600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/05/2024] [Accepted: 01/11/2024] [Indexed: 02/25/2024]
Abstract
Medical professionals such as physicians and veterinarians are responsible for appropriate antimicrobial prescription (AMP) and use. Although seemingly straightforward, the factors influencing antibiotic prescription, a category of antimicrobials, are complex. Many studies have been conducted in the past two decades on this subject. As a result, there is a plethora of empirical evidence regarding the factors influencing clinicians' AMP practices. AIM A systematic review of AMR studies on AMP was conducted, condensing findings according to a combination of the Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, Motivation-Behavior (COM-B) models. Review findings were then synthesized and analyzed for policy implementation according to the Consolidated Framework for Implementation Research (CFIR). DESIGN AND METHODOLOGY A systematic literature review was conducted according to PRISMA guidelines to identify peer-reviewed papers indexed in pre-determined medical science, social sciences, and humanities databases that apply the KAP model in their investigations. Antimicrobial prescription factors were compared and contrasted among low- and middle-income countries (LMICs) and high-income countries (HICs). FINDINGS The KAP model is a heuristic and structured framework for identifying and classifying respondents' knowledge. However, other than medical knowledge, factors that influence prescription decision-making can be expanded to include attitudes, perception, personal affinities, professional circumstances, relational pressure, and social norms.
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Affiliation(s)
- Olivia S K Chan
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Wendy Lam
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Shilin Zhao
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong Special Administrative Region, China.
| | - Hein Tun
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong Special Administrative Region, China.
| | - Ping Liu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Peng Wu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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Black EK, MacLean D, Bell M, Neville HL, Kits O, Ramsey TD, Sketris I, Johnston L. A qualitative study evaluating barriers and enablers to improving antimicrobial use for the management of bacteriuria in hospitalized adults. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e17. [PMID: 38415086 PMCID: PMC10897712 DOI: 10.1017/ash.2024.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 02/29/2024]
Abstract
Objective The objective of this study was to explore barriers and enablers to improving the management of bacteriuria in hospitalized adults. Design Qualitative study. Setting Nova Scotia, Canada. Participants Nurses, physicians, and pharmacists involved in the assessment, diagnosis, and treatment of bacteriuria in hospitalized patients. Methods Focus groups (FGs) were completed between May and July 2019. FG discussions were facilitated using an interview guide that consisted of open-ended questions coded to the theoretical domains framework (TDF) v2. Discussions were transcribed verbatim then independently coded to the TDFv2 by two members of the research team and compared. Thematic analysis was used to identify themes. Results Thirty-three healthcare providers from five hospitals participated (15 pharmacists, 11 nurses, and 7 physicians). The use of antibiotics for the treatment of asymptomatic bacteriuria (ASB) was the main issue identified. Subthemes that related to management of ASB included: "diagnostic uncertainty," difficulty "ignoring positive urine cultures," "organizational challenges," and "how people learn." Barriers and/or enablers to improving the management of bacteriuria were mapped to 12 theoretical domains within these subthemes. Barriers and enablers identified by participants that were most extensively discussed related to the domains of environmental context and resources, belief about capabilities, social/professional role and identity, and social influences. Conclusions Healthcare providers highlighted barriers and recognized enablers that may improve delivery of care to patients with bacteriuria. A wide range of barriers at the individual and organization level to address diagnostic challenges and improve workload should be considered to improve management of bacteriuria.
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Affiliation(s)
- Emily K. Black
- Dalhousie University, Halifax, NS, Canada
- IWK Health Centre, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
| | - Dianne MacLean
- IWK Health Centre, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
| | - Madison Bell
- Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
| | | | - Olga Kits
- Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
| | - Tasha D. Ramsey
- Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
| | | | - Lynn Johnston
- Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
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Advani SD, Claeys K. Behavioral Strategies in Diagnostic Stewardship. Infect Dis Clin North Am 2023; 37:729-747. [PMID: 37537001 DOI: 10.1016/j.idc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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8
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Claeys KC, Johnson MD. Leveraging diagnostic stewardship within antimicrobial stewardship programmes. Drugs Context 2023; 12:dic-2022-9-5. [PMID: 36843619 PMCID: PMC9949764 DOI: 10.7573/dic.2022-9-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Practice Science and Health Outcomes Research, Baltimore, MD, USA
| | - Melissa D Johnson
- Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA,Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center Durham, NC, USA
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Marantidis J, Sussman RD. Unmet Needs in Complicated Urinary Tract Infections: Challenges, Recommendations, and Emerging Treatment Pathways. Infect Drug Resist 2023; 16:1391-1405. [PMID: 36937144 PMCID: PMC10015946 DOI: 10.2147/idr.s382617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/24/2023] [Indexed: 03/16/2023] Open
Abstract
While urinary tract infections (UTIs) are one of the most common types of infections globally, the wide variety of presentations and of severity of disease can make it difficult to manage. The definition for uncomplicated UTIs (uUTIs) is generally regarded as UTIs in healthy, non-pregnant women whereas all other UTIs are considered complicated. There is, however, a lack of consensus definition of complicated UTIs (cUTIs), leading to global differences in management. In addition, the patients who develop complicated UTIs generally have other comorbidities that warrant more urgent intervention. One of the biggest challenges in treating cUTIs is the rise of antimicrobial resistance (AMR). While there have been recent drug approvals for new antibiotic to treat these resistant organisms, a multidisciplinary approach, including regulatory frameworks, provider education and public awareness campaigns, is crucial to limiting unnecessary treatments for asymptomatic bacteriuria (ASB) and uUTIs that can ultimately lead to more severe infections.
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Affiliation(s)
- Joanna Marantidis
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA
- Correspondence: Joanna Marantidis, 3800 Reservoir Road NW, Washington, DC, 20007, USA, Tel +1 202 444 9922, Fax +1 458 203 5006, Email
| | - Rachael D Sussman
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA
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10
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Singh S, Degeling C, Fernandez D, Montgomery A, Caputi P, Deane FP. How do aged-care staff feel about antimicrobial stewardship? A systematic review of staff attitudes in long-term residential aged-care. Antimicrob Resist Infect Control 2022; 11:92. [PMID: 35765093 PMCID: PMC9238058 DOI: 10.1186/s13756-022-01128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Antimicrobial resistance (AMR) is a problem in residential aged care facilities (RACF). There is a gap in our understanding of how psychosocial barriers such as risk perceptions shape staff attitudes towards antimicrobial stewardship (AMS). We sought to ascertain the attitudinal domains that have been identified to be of importance to AMS in RACF and comment on how they have been measured empirically. Our aim was to consolidate what is known regarding staff attitudes and perceptions in order to inform future stewardship.
Method
We searched PsycINFO, PsycARTICLES, CINAHL Plus, MEDLINE, PubMed, Web of Science, Cochrane, and Scopus databases for primary studies of healthcare workers attitudes to AMS in RACF (1990-February 2021).
Results
14 Studies were included in the review, within which 10 domains were identified: attitudes towards antimicrobial prescribing; guidelines; educational interventions; self-confidence regarding clinical assessment and prescribing; awareness of AMR as a problem and stewardship as a priority; self-efficacy; perception of role; perception of risk; team culture and resident/family members expectations. 46 measures were developed across the 14 studies to measure the 10 domains. The variability in the attitudinal domains and how these domains were measured was large. Only 13% included psychometric data regarding reliability and/or internal consistency.
Conclusions
Attitudes are generally defined as having three evaluative bases: cognitive, behavioural, and affective. Findings from the current review suggest that the measures commonly used to capture healthcare staff attitudes to AMS do not sufficiently capture affect; particularly with respect to staff’s risk perceptions, perceptions of their role, and family members’ expectations. Given that affective processes have been postulated to influence medical decision making, these findings highlight the importance of understanding how staff, especially nurses feel about implementing AMS strategies and other peoples’ (e.g. residents and their families) perceptions of stewardship. It is expected that a more nuanced understanding of RACF nurses affective experiences when applying AMS, and their perceptions of the risks entailed, will help in reducing barriers to overprescribing antibiotics.
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11
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van Horrik TMZXK, Laan BJ, Huizinga AB, Hoitinga G, Poortvliet WP, Geerlings SE. Why Are We Frequently Ordering Urinalyses in Patients without Symptoms of Urinary Tract Infections in the Emergency Department? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10757. [PMID: 36078472 PMCID: PMC9518362 DOI: 10.3390/ijerph191710757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/29/2022] [Accepted: 08/22/2022] [Indexed: 06/15/2023]
Abstract
(1) Background: In the emergency department (ED), ordering urine tests in patients without symptoms of a urinary tract infection can lead to inappropriate antimicrobial treatment. We aimed to identify factors contributing to the unnecessary ordering of urinalyses in the ED. (2) Methods: An online survey study among nurses and physicians working in the EDs of five hospitals in the Netherlands was conducted. (3) Results: The overall response rate was 26% (221/850; 85 nurses and 136 physicians). The vast majority of the respondents reported knowing when to order urine tests (197/221; 90%). Almost two-thirds of the respondents (145/221; 66%) agreed that they ordered urinalyses because it is rapid and non-invasive to patients. Most nurses (66/86; 78%) said they informed the doctor if they thought the urine test would not contribute to the patient's diagnosis, but only one-third of the physicians agreed with this statement (44/136; 32%). Most respondents (160/221; 72%) thought guidelines or protocols about urinalyses in the ED would be functional. (4) Conclusions: These results suggest urinalyses were frequently ordered in the ED to achieve a fast work process. Nurses and physicians could improve their communication about the indications for urine tests. Developing diagnostic guidelines for urine testing may be convenient.
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Affiliation(s)
- Tessa M. Z. X. K. van Horrik
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Room D3-226 Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bart J. Laan
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Room D3-226 Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Allard B. Huizinga
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Room D3-226 Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Gercora Hoitinga
- Department of Emergency Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Walter P. Poortvliet
- Department of Emergency Medicine, Meander MC, 3813 TZ Amersfoort, The Netherlands
| | - Suzanne E. Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Room D3-226 Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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12
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Guideline Adherence of Asymptomatic Bacteriuria Could Be Improved among General Practitioners in The Netherlands: A Survey Study. Antibiotics (Basel) 2022; 11:antibiotics11010075. [PMID: 35052953 PMCID: PMC8772807 DOI: 10.3390/antibiotics11010075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/30/2022] Open
Abstract
Asymptomatic bacteriuria (ASB) is a common finding in certain populations. This study assessed general practitioners’ (GPs’) knowledge about ASB and their current clinical practice regarding urine testing. Methods: An online survey was used for GPs in the Netherlands from October to December 2020. Results: In total, 99 surveys were included in the analyses. All GPs strongly agreed with the statements about their knowledge and self-confidence regarding urine diagnostics and treatment of ASB. The median knowledge score was 4 out of 6 (IQR 2 to 6). Most GPs (64 of 92; 70%) followed the guideline for the choice of urine diagnostics and reported appropriate indications for urine testing. However, 71/94 (75.5%) GPs would treat patients for ASB if they have diabetes mellitus. Further, 34 (37%) of 92 participants would inappropriately repeat a urine test after a patient was treated for a urinary tract infection (UTI). One-third of the GPs responded that ASB was insufficiently addressed within the guidelines for UTI. Conclusion: These results indicate that knowledge about ASB could be improved in primary care in the Netherlands, mainly in diabetic patients that have ASB, as well as for follow-up tests after treatment for UTI.
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Claeys KC, Trautner BW, Leekha S, Coffey KC, Crnich CJ, Diekema D, Fakih MG, Goetz MB, Gupta K, Jones MM, Leykum L, Liang SY, Pineles L, Pleiss A, Spivak ES, Suda KJ, Taylor J, Rhee C, Morgan DJ. Optimal Urine Culture Diagnostic Stewardship Practice- Results from an Expert Modified-Delphi Procedure. Clin Infect Dis 2021; 75:382-389. [PMID: 34849637 DOI: 10.1093/cid/ciab987] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped in three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed in a virtual meeting, and a then second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS 165 questions were reviewed with the panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional reflex urine cultures and urine white blood cell as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS These 18 guidance statements can optimize use of the imperfect urine culture for better patient outcomes.
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Affiliation(s)
- Kimberly C Claeys
- Infectious Diseases, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - K C Coffey
- Associate Hospital Epidemiologist, VA Maryland Healthcare System, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher J Crnich
- Chief of Medicine, Hospital Epidemiologist, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Dan Diekema
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - Mohamad G Fakih
- Chief Quality Officer, Quality Department, Clinical & Network Services, Ascension Healthcare, Grosse Pointe Woods and Wayne State University School of Medicine, Detroit, MI, USA
| | - Matthew Bidwell Goetz
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kalpana Gupta
- Associate Chief of Staff and Chief, Section of Infectious Diseases, VA Boston Healthcare System, of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Makoto M Jones
- Salt Lake City Veterans Affairs Healthcare System, Internal Medicine - Associate Professor, Division of Epidemiology, The University of Utah, Salt Lake City, UT, USA
| | - Luci Leykum
- Department of Internal Medicine, University of Texas at Austin Dell School of Medicine, Austin, TX, USA
| | - Stephen Y Liang
- Medicine, Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ashley Pleiss
- Lead Clinical Nurse, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily S Spivak
- Co-Director of the Antimicrobial Stewardship, University of Utah Health and the Salt Lake City Veterans Affairs Healthcare System, Salt Lake City, UT, USA
| | - Katie J Suda
- VA Pittsburgh Healthcare System, Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh and the, Pittsburgh, PA, USA
| | | | - Chanu Rhee
- Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Associate Hospital Epidemiologist, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel J Morgan
- Chief Hospital, VA Maryland Healthcare System, Epidemiologist Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
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14
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Abstract
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, but preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Duration of urinary catheterization is the most important modifiable risk factor for development of CAUTI. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of intervention bundles and collaboratives helps in the effective implementation of CAUTI prevention measures.
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Affiliation(s)
- Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, F4141 South University Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5226, USA.
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15
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Advani S, Vaughn VM. Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges. Curr Infect Dis Rep 2021; 23:16. [PMID: 34602864 PMCID: PMC8486281 DOI: 10.1007/s11908-021-00760-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting. RECENT FINDINGS Quality improvement initiatives aimed at reducing inappropriate treatment of asymptomatic bacteriuria often focus on optimizing urine test utilization (i.e., urine culture stewardship). Urine culture stewardship interventions in acute care hospitals span the spectrum of quality improvement initiatives, ranging from strong systems-based interventions like suppression of urine culture results to weaker interventions that focus on clinician education alone. While most urine culture stewardship interventions have met with some success, overall results are mixed, and implementation strategies to improve sustainability are not well understood. SUMMARY Successful diagnostic stewardship interventions are based on an assessment of underlying key drivers and focus on multifaceted and complementary approaches. Individual intervention components have varying impacts on effectiveness, provider autonomy, and sustainability. The best urine culture stewardship strategies ultimately include both technical and socio-adaptive components with long-term, iterative feedback required for sustainability.
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Affiliation(s)
- Sonali Advani
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Infection Control Outreach Network, Durham, NC, USA
| | - Valerie M. Vaughn
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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16
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Laan BJ, van Horrik TMZXK, Nanayakkara PWB, Geerlings SE. How many urinalysis and urine cultures are necessary? Eur J Intern Med 2021; 83:58-61. [PMID: 32830036 DOI: 10.1016/j.ejim.2020.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Urinalysis and urine culture are two of the most commonly ordered tests. A positive urine test in asymptomatic patients often leads to overtreatment. Antimicrobials for asymptomatic bacteriuria is one of the most common unnecessary treatments. We aimed to explore the current ordering patterns of urinalysis and cultures. METHODS This is a substudy of the multicentre RICAT-trial, a successful quality improvement project to reduce inappropriate use of intravenous and urinary catheters in seven hospitals in the Netherlands. Adult patients with a (central or peripheral) venous or urinary catheter admitted to internal medicine and non-surgical subspecialty wards were eligible for inclusion. Data were collected every other week during baseline (seven months) and intervention periods (seven months). The primary outcome was the proportion of urine cultures performed following a negative urinalysis, i.e. dipstick and/or microscopic analysis, within 24 h. RESULTS Between September 2016 and April 2018, we included 3748 patients, of which 3111 (83%) were admitted from the emergency department. Urinalysis and/or urine cultures were obtained in 2610 (70%) of 3748 patients. 626 (23.7%) of 2636 urine cultures and 1351 (55.8%) of 2419 microscopic analysis were unnecessary performed after a negative urinalysis. Cancelling urine testing orders after a negative dipstick would have saved almost € 19.500 during the study period in these seven hospitals. CONCLUSION Unnecessary urine testing is frequent in non-surgical patients in the Netherlands. We need to take action to reduce unnecessary urinalysis and cultures, and thereby probably reduce overtreatment of asymptomatic bacteriuria.
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Affiliation(s)
- Bart J Laan
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Tessa M Z X K van Horrik
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Amsterdam UMC, Vrije Universiteit Amsterdam, Internal Medicine, Acute Medicine, de Boelelaan 1117, Amsterdam, The Netherlands
| | - Suzanne E Geerlings
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
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17
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Milligan J, Goetz LL, Kennelly MJ. A Primary Care Provider's Guide to Management of Neurogenic Lower Urinary Tract Dysfunction and Urinary Tract Infection After Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2020; 26:108-115. [PMID: 32760189 DOI: 10.46292/sci2602-108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neurogenic lower urinary tract dysfunction (NLUTD), previously termed neurogenic bladder dysfunction, is a common secondary complication of spinal cord injury (SCI). It is associated with significant morbidity, reduced quality of life, increased health care costs, and mortality. Primary care providers (PCPs) play an important role in optimizing urohealth over the life span. This article will review NLUTD in SCI, its complication, surveillance, and management. PCPs should be aware of SCI-related NLUTD, its complications, management, and surveillance recommendations, and when to refer to a specialist.
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Affiliation(s)
- James Milligan
- The Centre for Family Medicine, Kitchener, Ontario, Canada.,McMaster University Department of Family Medicine, Hamilton, Ontario, Canada
| | - Lance L Goetz
- Department of Veterans Affairs, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Michael J Kennelly
- Carolinas Rehabilitation, Charlotte, North Carolina.,Atrium Health, Charlotte, North Carolina
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18
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Petty LA, Vaughn VM, Flanders SA, Patel T, Malani AN, Ratz D, Kaye KS, Pogue JM, Dumkow LE, Thyagarajan R, Hsaiky LM, Osterholzer D, Kronick SL, McLaughlin E, Gandhi TN. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa537. [PMID: 33324723 PMCID: PMC7724506 DOI: 10.1093/ofid/ofaa537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.
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Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Internal Medicine, Division of General Internal Medicine, University of Utah Medical School, Salt Lake City, Utah, USA
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Twisha Patel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa E Dumkow
- Department of Pharmacy, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | | | - Lama M Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan, USA
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan, USA
| | - Steven L Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
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19
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Goebel MC, Trautner BW, Wang Y, Van JN, Dillon LM, Patel PK, Drekonja DM, Graber CJ, Shukla BS, Lichtenberger P, Helfrich CD, Sales A, Grigoryan L. Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria. Am J Infect Control 2020; 48:1322-1328. [PMID: 32437753 DOI: 10.1016/j.ajic.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prior to implementing an antibiotic stewardship intervention for asymptomatic bacteriuria (ASB), we assessed institutional barriers to change using the Organizational Readiness to Change Assessment. METHODS Surveys were self-administered on paper in inpatient medicine and long-term care units at 4 Veterans Affairs facilities. Participants included providers, nurses, and pharmacists. The survey included 7 subscales: evidence (perceived strength of evidence) and six context subscales (favorability of organizational context). Responses were scored on a 5-point Likert-type scale. RESULTS One hundred four surveys were completed (response rate = 69.3%). Overall, the evidence subscale had the highest score; the resources subscale (mean 2.8) was significantly lower than other subscales (P < .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < .001 for both). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). The site with the lowest scores for resources (mean 2.4) also had lower scores for leadership and lower pharmacist effort devoted to stewardship. CONCLUSIONS Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and leadership support. These findings provide targets for tailoring the stewardship intervention to maximize success.
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20
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Ellena K, Wolf L, Dumkow LE, VanLangen KM. Treatment of asymptomatic pyuria in psychiatric patients discharged from the emergency department following antimicrobial stewardship implementation. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kamah Ellena
- Department of Pharmacy Mercy Health Saint Mary's Grand Rapids Michigan USA
| | - Lauren Wolf
- Department of Pharmacy Mercy Health Saint Mary's Grand Rapids Michigan USA
| | - Lisa E. Dumkow
- Department of Pharmacy Mercy Health Saint Mary's Grand Rapids Michigan USA
| | - Kali M. VanLangen
- Department of Pharmacy Mercy Health Saint Mary's Grand Rapids Michigan USA
- College of Pharmacy Ferris State University Grand Rapids Michigan USA
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21
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The association between urine neutrophil gelatinase-associated lipocalin and UTI in people with neurogenic lower urinary tract dysfunction. Spinal Cord 2020; 59:959-966. [DOI: 10.1038/s41393-020-00552-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 11/08/2022]
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22
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Conditional reflex to urine culture: Evaluation of a diagnostic stewardship intervention within the Veterans' Affairs and Centers for Disease Control and Prevention Practice-Based Research Network. Infect Control Hosp Epidemiol 2020; 42:176-181. [PMID: 32838829 DOI: 10.1017/ice.2020.400] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention. DESIGN We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression. SETTING The study included 6 acute-care hospitals within the Veterans' Health Administration across the United States. PARTICIPANTS Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included. METHODS At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days. RESULTS The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49). CONCLUSIONS Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.
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23
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Atkins L, Sallis A, Chadborn T, Shaw K, Schneider A, Hopkins S, Bunten A, Michie S, Lorencatto F. Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions. Implement Sci 2020; 15:44. [PMID: 32624002 PMCID: PMC7336619 DOI: 10.1186/s13012-020-01001-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 05/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Reducing the need for antibiotics is crucial in addressing the global threat of antimicrobial resistance. Catheter-associated urinary tract infection (CAUTI) is one of the most frequent device-related infections that may be amenable to prevention. Interventions implemented nationally in England target behaviours related to catheter insertion, maintenance and removal, but the extent to which they target barriers to and facilitators of these behaviours is unclear. This strategic behavioural analysis applied behavioural science frameworks to (i) identify barriers to and facilitators of behaviours that lead to CAUTI (CAUTI-related behaviours) in primary, community and secondary care and nursing homes; (ii) describe the content of nationally adopted interventions; and (iii) assess the extent to which intervention content is theoretically congruent with barriers and facilitators. Methods A mixed-methods, three-phased study: (1) systematic review of 25 studies to identify (i) behaviours relevant to CAUTI and (ii) barriers to and facilitators of CAUTI-related behaviours, classified using the COM-B model and Theoretical Domains Framework (TDF); (2) content analysis of nationally adopted CAUTI interventions in England identified through stakeholder consultation, classified using the Behaviour Change Wheel (BCW) and Behaviour Change Techniques Taxonomy (BCTTv1); and (3) findings from 1 and 2 were linked using matrices linking COM-B and TDF to BCW/BCTTv1 in order to signpost to intervention design and refinement. Results The most frequently reported barriers to and facilitators of CAUTI-related behaviours related to ‘environmental context and resources’; ‘knowledge’; ‘beliefs about consequences’; ‘social influences’; ‘memory, attention and decision processes’; and ‘social professional role and identity.’ Eleven interventions aiming to reduce CAUTI were identifed. Interventions were primarily guidelines and included on average 2.3 intervention functions (1–5) and six BCTs (2–11), most frequently ‘education’, ‘training’ and ‘enablement.’ The most frequently used BCT was ‘information about health consequences’ which was used in almost all interventions. Social professional role and identity and environmental context and resources were targeted least frequently with potentially relevant BCTs. Conclusions Interventions incorporated half the potentially relevant content to target identifed barriers to and facilitators of CAUTI-related behaviours. There were missed opportunities for intervention as most focus on shaping knowledge rather than addressing motivational, social and environmental influences. This study suggests that targeting motivational, social and environmental influences may lead to more effective intervention design and refinement.
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Affiliation(s)
- Lou Atkins
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK.
| | - Anna Sallis
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Tim Chadborn
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Karen Shaw
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Annegret Schneider
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK
| | - Susan Hopkins
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Amanda Bunten
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK
| | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK
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24
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Rowe TA, Brown T, Lee JY, Linder JA, Friedberg MW, Doctor JN, Meeker D, Ciolino JD, Persell SD. Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement. J Gen Intern Med 2020; 35:1797-1802. [PMID: 32128687 PMCID: PMC7280408 DOI: 10.1007/s11606-020-05748-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/14/2020] [Indexed: 11/29/2022]
Abstract
IMPORTANCE The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ji Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark W Friedberg
- RAND Corporation, Boston, MA, USA.,Blue Cross Blue Shield of Massachusetts, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Doctor
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jody D Ciolino
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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25
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Rowe TA, Brown T, Lee JY, Linder JA, Friedberg MW, Doctor JN, Meeker D, Ciolino JD, Persell SD. Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement. J Gen Intern Med 2020. [PMID: 32128687 DOI: 10.1007/s11606-020-05748-8/figures/3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
IMPORTANCE The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ji Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark W Friedberg
- RAND Corporation, Boston, MA, USA
- Blue Cross Blue Shield of Massachusetts, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Doctor
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jody D Ciolino
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Skelton F, May S, Grigoryan L, Poon I, Holmes SA, Martin L, Trautner BW. Spinal Cord Injury Provider Knowledge and Attitudes Toward Bacteriuria Management and Antibiotic Stewardship. PM R 2020; 12:1187-1194. [PMID: 32304350 DOI: 10.1002/pmrj.12384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/23/2020] [Accepted: 04/03/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Bacteriuria, either asymptomatic or urinary tract infection, is common in persons with spinal cord injury or disorder (SCI/D). In the Veterans Health Administration (VHA), conflicting clinical practice guidelines make appropriate bacteriuria management and antibiotic stewardship challenging. OBJECTIVE To explore SCI/D provider knowledge, attitudes, and teamwork around bacteriuria management during the VHA SCI/D annual examination. DESIGN Mixed methods. SETTING VHA SCI/D centers. PARTICIPANTS SCI/D staff providers and physical medicine and rehabilitation resident physicians. MAIN OUTCOME MEASUREMENTS Knowledge, safety, and teamwork scores on bacteriuria management using a validated questionnaire. Themes on barriers and facilitators to bacteriuria management during the SCI/D annual exam, and attitudes toward antibiotic stewardship in general. RESULTS We received 84 responses from 344 distributed surveys, with a response rate of 24%. Thirty percent of all participants endorsed incorrect triggers for obtaining a urine culture (change in urine color, cloudiness, or odor). The type of organism identified on culture drove unnecessary antibiotic use; 57% would treat asymptomatic bacteriuria if caused by extended spectrum beta-lactamase Escherichia coli. There were no significant differences between the median (interquartile range [IQR]) knowledge score of the staff providers (70.6 [58.8-82.4]) and the resident physicians (64.7 [58.8-82.4]), but the teamwork climate scores (P = .02) and safety climate scores (P < .01) were higher among staff providers than among resident physicians. Interview analysis identified how the limited recall of content among SCI/D providers of the guidelines for bacteriuria was a potential barrier to their use but attitudes toward guidelines and antibiotic stewardship initiatives were positive. CONCLUSION All participants objectively demonstrated actionable gaps in bacteriuria management and expressed uncertainty in their knowledge during qualitative interviews. Through addressing these gaps, we can develop effective antibiotic stewardship programs for the VHA SCI/D system of care.
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Affiliation(s)
- Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Sarah May
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ivy Poon
- Department of Pharmacy Practice, Texas Southern University, Houston, TX, USA
| | - Sally Ann Holmes
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Lindsey Martin
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Asymptomatic Bacteriuria: For How Long Will We Keep Swimming Against The Current? MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2020; 4:132-134. [PMID: 32280922 PMCID: PMC7140012 DOI: 10.1016/j.mayocpiqo.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Oswald F, Young E, Denison F, Allen RJ, Perry M. Staff and patient perceptions of a community urinary catheter service. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2020; 14:83-91. [PMID: 32793298 DOI: 10.1111/ijun.12230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction Urinary catheters are used extensively throughout healthcare for various reasons including management of urinary tract dysfunction. The purpose of this study was to simultaneously explore both catheter user experience and staff perception of catheter services within community urinary catheter care. Methods A questionnaire was conducted to investigate the views of community nursing staff. During the same time period, patients were interviewed about i) catheter-care standards and adherence to guidelines ii) patients' feelings towards their catheter and iii) potential improvements to catheter practices and design. Results Sixty-nine staff were surveyed. Although 97% of staff indicated they used local guidelines, in up to 62% of cases findings suggested practices in sending urine samples for culture did not comply with guidelines. Seventy-five percent of staff were satisfied with catheter care, but weaknesses were identified in handover processes, communication between staff and patients, and excessive documentation. Staff results were compared with the findings from interviews of 29 long-term urinary catheter users, demonstrating a higher level of satisfaction with catheter care amongst patients (86%). Patients and staff agreed that generally the impacts of their catheter on personal hygiene, sense of independence, sense of dignity and of patient happiness, were neutral (neither positive nor negative). However, regarding improvements to catheter practices and catheter design; 73% of staff but only 45% of patients suggested improvements in service, while 76% of patients but only 49% of staff suggested improvement in design. Conclusion The study reveals general satisfaction with community catheter care, but indicates areas of potential improvements regarding communication, documentation and catheter design. When compared to patient responses, staff overall had a less positive view of patients perception of their relationship with their catheter.
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Affiliation(s)
- Freya Oswald
- Tommy's Centre for Maternal and Fetal Health, University of Edinburgh MRC Centre for Reproductive Health, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ
| | - Ellen Young
- School of Physics and Astronomy, University of Edinburgh, Peter Guthrie Tait Road, Edinburgh EH9 3FD, UK
| | - Fiona Denison
- Tommy's Centre for Maternal and Fetal Health, University of Edinburgh MRC Centre for Reproductive Health, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ
| | - Rosalind J Allen
- School of Physics and Astronomy, University of Edinburgh, Peter Guthrie Tait Road, Edinburgh EH9 3FD, UK
| | - Meghan Perry
- Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Petty LA, Vaughn VM, Flanders SA, Malani AN, Conlon A, Kaye KS, Thyagarajan R, Osterholzer D, Nielsen D, Eschenauer GA, Bloemers S, McLaughlin E, Gandhi TN. Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients. JAMA Intern Med 2019; 179:1519-1527. [PMID: 31449295 PMCID: PMC6714039 DOI: 10.1001/jamainternmed.2019.2871] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined. OBJECTIVE To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis. EXPOSURES One or more antibiotic dose for treatment of ASB. MAIN OUTCOMES AND MEASURES Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post-acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing. RESULTS Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting. CONCLUSIONS AND RELEVANCE Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.
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Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Valerie M Vaughn
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Health System, Ann Arbor, Michigan
| | - Anna Conlon
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Rama Thyagarajan
- Internal Medicine, Division of Infectious Diseases, Beaumont Hospital, Dearborn, Michigan
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
| | - Daniel Nielsen
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | | | - Sarah Bloemers
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
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Meddings J, Manojlovich M, Fowler KE, Ameling JM, Greene L, Collier S, Bhatt J, Saint S. A Tiered Approach for Preventing Catheter-Associated Urinary Tract Infection. Ann Intern Med 2019; 171:S30-S37. [PMID: 31569226 DOI: 10.7326/m18-3471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jennifer Meddings
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., S.S.)
| | | | - Karen E Fowler
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (K.E.F.)
| | | | - Linda Greene
- University of Rochester Highland Hospital, Rochester, New York (L.G.)
| | - Sue Collier
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., J.B.)
| | - Jay Bhatt
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., J.B.)
| | - Sanjay Saint
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., S.S.)
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Affiliation(s)
- Kalpana Gupta
- Department of Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts
- Veterans Affairs Center for Healthcare Organization and Implementation Research, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Barbara W Trautner
- Center for Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas
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Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria. Infect Control Hosp Epidemiol 2019; 40:963-967. [PMID: 31339085 DOI: 10.1017/ice.2019.176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs). DESIGN Prospective surveys during January-June 2018. SETTING All acute and long-term care units of 4 Veterans' Affairs facilities. METHODS The survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ). RESULTS A total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings. CONCLUSIONS Our survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.
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Advani SD, Gao CA, Datta R, Sann L, Smith C, Leapman MS, Hittelman AB, Sabetta J, Dembry LM, Martinello RA, Juthani-Mehta M. Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines. Open Forum Infect Dis 2019; 6:5532507. [PMID: 31375836 PMCID: PMC6677670 DOI: 10.1093/ofid/ofz305] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters. Methods We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines. Results On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures. Conclusions Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.
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Affiliation(s)
- Sonali D Advani
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Catherine A Gao
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Rupak Datta
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence Sann
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Cindy Smith
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Adam B Hittelman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Louise-Marie Dembry
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Richard A Martinello
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Manisha Juthani-Mehta
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
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Horstman MJ, Spiegelman A, Naik AD, Trautner BW. National Patterns of Urine Testing During Inpatient Admission. Clin Infect Dis 2019; 65:1199-1205. [PMID: 29370366 DOI: 10.1093/cid/cix424] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/04/2017] [Indexed: 02/04/2023] Open
Abstract
Background Overuse of urine testing is a driver of inappropriate antimicrobial use. Limiting wasteful testing is important for patient safety. We examined the national prevalence and patterns of urine testing during adult inpatient admission in the United States. Methods We performed a retrospective cohort study using a national dataset of inpatient admissions from 263 hospitals in the United States from 2009 to 2014. We included all adult inpatient admissions, excluding those related to pregnancy, urology procedures, and with lengths of stay >30 days. A facility-level fixed-effects quasi-Poisson regression model was used to examine the incidence of urinalysis and urine culture testing for select diagnoses and patient factors. Results The cohort included 4473655 admissions. Charges for urinalysis were present for 2086697 (47%) admissions, with 584438 (13%) including >1 urinalysis. Charges for urine culture were present for 1197242 (27%) admissions, with 246211 (6%) having >1 culture. Urine culture testing varied by principal diagnosis. Heart failure and acute myocardial infarction had 29% and 35% fewer cultures sent on the first day of admission compared to all other admissions (P < .001). Female sex and receipt of antibiotics during the hospital admission consistently predicted increased culture testing, regardless of principal diagnosis or age. Conclusions Urine testing was common and frequently repeated during inpatient admission, suggesting large-scale overuse. The variation in testing by diagnosis suggests that clinical presentation modifies test use. The sex bias in urine testing is not clinically supported and must be addressed in interventions aimed at reducing excess urine testing.
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Affiliation(s)
- Molly J Horstman
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Advisory Board Company, Washington, District of Columbia.,Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas
| | | | - Aanand D Naik
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Advisory Board Company, Washington, District of Columbia.,Veterans Affairs Quality Scholars Coordinating Center, IQuESt, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Barbara W Trautner
- Veterans Affairs Quality Scholars Coordinating Center, IQuESt, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Section of Infectious Diseases, Department of Medicine, Houston, Texas.,Department of Surgery, Baylor College of Medicine, Houston, Texas
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Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infect Control Hosp Epidemiol 2019; 40:281-286. [PMID: 30786940 DOI: 10.1017/ice.2018.356] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices. DESIGN Retrospective before-and-after study. SETTING A 1,250-bed academic tertiary-care referral center. PATIENTS Hospitalized adults who had ≥1 urine culture performed during their stay. INTERVENTION The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends. RESULTS During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05). CONCLUSIONS Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
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Skelton F, Martin LA, Evans CT, Kramer J, Grigoryan L, Richardson P, Kunik ME, Poon IO, Holmes SA, Trautner BW. Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study. JMIR Res Protoc 2019; 8:e12272. [PMID: 30762584 PMCID: PMC6393777 DOI: 10.2196/12272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/20/2018] [Accepted: 12/09/2018] [Indexed: 12/24/2022] Open
Abstract
Background Bacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use. Objective Through a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices. Methods Aim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site. Results This protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019. Conclusions The negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition. International Registered Report Identifier (IRRID) DERR1-10.2196/12272
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Affiliation(s)
- Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,H Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Lindsey Ann Martin
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Charlesnika T Evans
- Center for Innovation for Complex Chronic HealthCare, Hines VA Hospital, Chicago, IL, United States.,Department of Preventive Medicine and Center for Health Care Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Peter Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States
| | - Mark E Kunik
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Ivy Oiyee Poon
- Department of Pharmacy Practice, Texas Southern University, Houston, TX, United States
| | - S Ann Holmes
- H Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,Infectious Disease Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Skelton-Dudley F, Doan J, Suda K, Holmes SA, Evans C, Trautner B. Spinal Cord Injury Creates Unique Challenges in Diagnosis and Management of Catheter-Associated Urinary Tract Infection. Top Spinal Cord Inj Rehabil 2019; 25:331-339. [PMID: 31844385 PMCID: PMC6907033 DOI: 10.1310/sci2504-331] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Catheter-associated urinary tract infection (CAUTI) is associated with increased morbidity and mortality and influences the quality of life of patients with spinal cord injury (SCI). Objectives: This clinical review aims to highlight the unique surveillance, prevention, diagnosis, and management challenges of CAUTI in the SCI population. Methods: Narrative review of the current literature on catheter use in persons with SCI was conducted to determine gaps in knowledge and opportunities for improvement. Results: Surveillance of CAUTI is challenging in the SCI population as the ability to detect symptoms used to diagnose CAUTI (ie, suprapubic pain, dysuria) is impaired. In terms of prevention of CAUTI, current strategies refocus on appropriate catheter insertion and care and early removal of catheters, which is not always feasible for persons with SCI. Prophylactic antibiotics, nutraceuticals, and coated catheters show limited efficacy in infection prevention. Diagnosing CAUTI after SCI is challenging, often resulting in an overdiagnosis of CAUTI when truly asymptomatic bacteriuria exists. In the management of CAUTI in patients with SCI, the use of multiple antibiotics over time in an individual increases the rate of multidrug-resistant organisms; therefore, the exploration of novel non-antibiotic treatments is of importance. The patient experience should be at the center of all these efforts. Conclusion: Better diagnostic tools or biomarkers are needed to define true CAUTI in people with SCI. SCI-specific evidence to inform catheter management and CAUTI treatment guidelines is needed, with the goal to minimize catheter-related harm, reduce antibiotic resistance, and improve satisfaction and overall quality of life for SCI patients.
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Affiliation(s)
- Felicia Skelton-Dudley
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - James Doan
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Katie Suda
- Center for Innovation for Complex Chronic HealthCare (CINCCH), Edward Hines Jr. VA Hospital, Chicago, Illinois
- University of Illinois at Chicago, Chicago, Illinois
| | - S. Ann Holmes
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Charlesnika Evans
- Center for Innovation for Complex Chronic HealthCare (CINCCH), Edward Hines Jr. VA Hospital, Chicago, Illinois
- Northwestern University, Department of Preventive Medicine and Center for Health Care Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Lee C, Phillips C, Vanstone JR. Educational intervention to reduce treatment of asymptomatic bacteriuria in long-term care. BMJ Open Qual 2018; 7:e000483. [PMID: 30588518 PMCID: PMC6280905 DOI: 10.1136/bmjoq-2018-000483] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/12/2018] [Accepted: 11/10/2018] [Indexed: 12/05/2022] Open
Abstract
Objective To determine if an educational intervention can decrease the inappropriate antibiotic treatment of long-term care (LTC) residents with asymptomatic bacteriuria (ASB). Design Prospective chart audit between May and July 2017. Setting Seven LTC facilities in Regina, Saskatchewan, Canada. Participants Chart audits were performed on all LTC residents over 18 years of age with a positive urine culture. Educational sessions and tools were available to all clinical staff at participating LTC facilities. Intervention Fifteen-minute educational sessions were provided to LTC facility staff outlining the harms of unnecessary antibiotic use, antibiotic resistance and the diagnostic criteria of a urinary tract infection (UTI). Educational sessions were complimented with posters and pocket cards that summarised UTI diagnostic criteria. Main outcome measure The primary outcome measure was the number of residents who received inappropriate antibiotic treatment for ASB. Secondary outcome measures included the appropriateness of urine culture tests, number of tests and cost associated with inappropriate treatments. Results In the preintervention period, 172 urine culture and sensitivity (UC&S) tests were performed, 62 (36.0%) were positive and 50/62 (80.6%) residents had ASB based on chart review. In the postintervention period, 151 UC&S tests were performed, 50 (33.1%) were positive and 35/50 (70.0%) residents had ASB. There was a statistically significant decrease in the number of residents treated with antibiotics for ASB, from 45/50 (90%) preintervention to 22/35 (62.9%) postintervention (χ2=9.087, p=0.003). Conclusions An educational intervention was associated with a statistically significant decrease in inappropriate antibiotic treatment of LTC residents with ASB.
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Affiliation(s)
- Christine Lee
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Casey Phillips
- Antimicrobial Stewardship Program, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Jason Robert Vanstone
- Antimicrobial Stewardship Program, Saskatchewan Health Authority, Regina, Saskatchewan, Canada.,Research and Performance Support, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
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Seniority of primary care physicians is associated with a decrease in PSA ordering habits in the years surrounding the United States Preventative Services Task Force recommendation against PSA screening. Urol Oncol 2018; 36:500.e21-500.e27. [DOI: 10.1016/j.urolonc.2018.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/25/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
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Abstract
Catheter-associated urinary tract infection remains one of the most prevalent, yet preventable, health care-associated infections. General prevention strategies include strict adherence to hand hygiene and antimicrobial stewardship. Duration of urinary catheterization is the most important modifiable risk factor. Targeted prevention strategies include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives should be considered. If catheterization is necessary, proper aseptic practices for insertion and maintenance and closed catheter collection systems are essential for prevention. The use of bladder bundles and collaboratives aids in the effective implementation of prevention measures.
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Affiliation(s)
- Emily K Shuman
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, F4007 University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5226, USA; Department of Infection Prevention and Epidemiology, Michigan Medicine, 300 North Ingalls Building 8B06, Ann Abror, MI 48109-5479, USA.
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, F4007 University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5226, USA; Antimicrobial Stewardship Program, Michigan Medicine, F4141 University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5226, USA
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Chou A, Trautner BW. Efficacy and Safety of short courses of antibiotic therapy for bacteremia caused by Enterobacteriaceae. Clin Infect Dis 2018; 67:482-483. [PMID: 29617741 DOI: 10.1093/cid/ciy117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrew Chou
- Infectious Disease Section, Michael E. DeBakey VA Medical Center, Texas.,Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Texas
| | - Barbara W Trautner
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Texas.,Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Texas.,Houston Veterans Affairs (VA) Health Services R&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Texas
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Shortened Courses of Antibiotics for Bacterial Infections: A Systematic Review of Randomized Controlled Trials. Pharmacotherapy 2018; 38:674-687. [DOI: 10.1002/phar.2118] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Santoso BI, Surya R, Yasmin FA, Irwinda R. The awareness of urinary tract infection management in pregnant women. A qualitative study. MAJALAH OBSTETRI & GINEKOLOGI 2018. [DOI: 10.20473/mog.v25i32017.92-96] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives: to identify knowledge, attitude, and practice of health providers including GPs and gynecologists to the implementation of the national guideline on the treatment of UTI among pregnant women.Materials and Methods: A cross-sectional study design was used. Subjects were women who attended the International Sym-posium of UTI. Questionnaires consisting ofregarding demo-graphic characteristics, knowledge, attitude, and practice were given to the subjects. The questionnaires had been tested for valid-ity and reliability by applying the Pearson correlation and Cronbach’s alpha test. Statistical analyses were performed using SPSS 23.0 for Windows.A two-tailed p value less than 0.05 was considered to be statistically significant.Results: A total of 140 subjects were recruited in this study. Of these, 104 subjects (74.3%) returned the questionnaire, and 99 subjects (70.7%) were eligible for this study. Nine (9.1%), 69 (69.7%), and 21(21.2%) subjects had good, fair, and poor know-ledge, respectively. Sixty-five (65.7%) and 64 subjects (64.6%) showed a positive attitude and had positive practice, respectively.Conclusion: Knowledge, attitude, and practice among respon-dents are good enough, despite only a few of them have read the updated guideline. Continuous medical education through online update or symposium may be one effective method to disseminate new update in guidelines.
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Abrantes-Figueiredo JI, Ross JW, Banach DB. Device Utilization Ratios in Infection Prevention: Process or Outcome Measure? Curr Infect Dis Rep 2018; 20:8. [DOI: 10.1007/s11908-018-0616-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Trautner BW, Prasad P, Grigoryan L, Hysong SJ, Kramer JR, Rajan S, Petersen NJ, Rosen T, Drekonja DM, Graber C, Patel P, Lichtenberger P, Gauthier TP, Wiseman S, Jones M, Sales A, Krein S, Naik AD. Protocol to disseminate a hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of asymptomatic bacteriuria. Implement Sci 2018; 13:16. [PMID: 29351769 PMCID: PMC5775527 DOI: 10.1186/s13012-018-0709-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We previously conducted a successful intervention, entitled "Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign," to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. METHODS This project uses an interrupted time series design with four control sites. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway and (2) case-based audit and feedback to train clinicians to use the algorithm. Our conceptual framework for the development and implementation of this intervention draws on May's General Theory of Implementation. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. The start-up for each facility consists of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes. DISCUSSION This project moves from a proof-of-concept effectiveness study to implementation involving significantly more sites, and uses the General Theory of Implementation to embed the intervention into normal processes of care with usual care providers. Aspects of implementation that will be explored include dissemination, internal and external facilitation, and organizational partnerships. "Less is More" is the natural next step from our prior successful Kicking CAUTI intervention, and has the potential to improve patient care while advancing the science of implementation.
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Affiliation(s)
- Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA. .,Baylor College of Medicine in Houston, Houston, TX, USA.
| | | | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX, 77098, USA
| | - Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Suja Rajan
- Department of Management, Policy and Community Heath, University of Texas (UT) - School of Public Health (SPH), E-319, 1200 Pressler Street, Houston, TX, 77030, USA
| | - Nancy J Petersen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Dimitri M Drekonja
- Infectious Diseases (111F), Minneapolis VA Medical Center, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Christopher Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, 11301 Wilshire Blvd, 111-F, Los Angeles, CA, 90073, USA
| | - Payal Patel
- Division of Infectious Diseases, III-i, University of Michigan, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | | | | | - Steve Wiseman
- Division of Infectious Diseases, III-i, University of Michigan, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Makoto Jones
- George E. Wahlen Veterans Affairs Medical Center, Mailstop 182, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
| | - Anne Sales
- Department of Learning Health Sciences, University of Michigan Medical School, 209 Victor Vaughan Building, 2054, 1111 E. Catherine St, Ann Arbor, MI, 48109-2054, USA
| | - Sarah Krein
- VA Ann Arbor Center for Clinical Management Research, North Campus Research Complex, Building 16-333W, 2800 Plymouth Rd, Ann Arbor, MI, 48109-2800, USA
| | - Aanand Dinkar Naik
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
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Redwood R, Knobloch MJ, Pellegrini DC, Ziegler MJ, Pulia M, Safdar N. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control 2018; 7:4. [PMID: 29340148 PMCID: PMC5759376 DOI: 10.1186/s13756-017-0278-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/14/2017] [Indexed: 11/24/2022] Open
Abstract
Background Inappropriate ordering and acquisition of urine cultures leads to unnecessary treatment of asymptomatic bacteriuria (ASB). Treatment of ASB contributes to antimicrobial resistance particularly among hospital-acquired organisms. Our objective was to investigate urine culture ordering and collection practices among nurses to identify key system-level and human factor barriers and facilitators that affect optimal ordering and collection practices. Methods We conducted two focus groups, one with ED nurses and the other with ICU nurses. Questions were developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We used iterative categorization (directed content analysis followed by summative content analysis) to code and analyze the data both deductively (using SEIPS domains) and inductively (emerging themes). Results Factors affecting optimal urine ordering and collection included barriers at the person, process, and task levels. For ED nurses, barriers included patient factors, physician communication, reflex culture protocols, the electronic health record, urinary symptoms, and ED throughput. For ICU nurses, barriers included physician notification of urinalysis results, personal protective equipment, collection technique, patient body habitus, and Foley catheter issues. Conclusions We identified multiple potential process barriers to nurse adherence with evidence-based recommendations for ordering and collecting urine cultures in the ICU and ED. A systems approach to identifying barriers and facilitators can be useful to design interventions for improving urine ordering and collection practices.
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Affiliation(s)
- Robert Redwood
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, Wisconsin 53705 USA
| | - Mary Jo Knobloch
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, Wisconsin 53705 USA.,William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, Wisconsin 53705 USA
| | - Daniela C Pellegrini
- Department of Infectious Disease, University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, Illinois 60637 USA
| | - Matthew J Ziegler
- Division of Infectious Disease, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania 19104 USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Madison, Wisconsin 53705 USA
| | - Nasia Safdar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, Wisconsin 53705 USA.,William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, Wisconsin 53705 USA
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Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions. Arch Phys Med Rehabil 2017; 99:219-225. [PMID: 29107038 DOI: 10.1016/j.apmr.2017.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/06/2017] [Accepted: 10/03/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To measure the prevalence of asymptomatic bacteriuria (ASB) in persons with spinal cord injury (SCI) at the time of their annual examination and to examine the effect on urine testing during the annual examination on subsequent antibiotic use. DESIGN Retrospective cohort study. SETTING A major SCI center. PARTICIPANTS Veterans (N=393) with SCI seen for an outpatient annual evaluation in 2012 or 2013. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Antibiotic use for bacteriuria within 7 days of the annual evaluation encounter. RESULTS There were 327 clinic visits that met inclusion criteria; of these 327 veterans, 249 had a urine culture performed. A total of 171 urine cultures (69%) were positive for bacteria, of which 22 (13%) represented urinary tract infection (UTI) cases and 149 (87%) were ASB cases. More than a third of the ASB cases (n=53 [36%]) were treated with antibiotics. None of the 78 visits with negative urine cultures received antibiotics to treat the UTI; thus, a positive urine culture alone was associated with antibiotic use (P<.01). Factors predicting antibiotic use were higher age, nitrite presence on urinalysis, and urease-producing organism on culture media. When comparing bladder management strategies, indwelling catheterization was found to be associated with higher levels of pyuria and hematuria than did spontaneous voiding or intermittent catheterization (P<.01). CONCLUSIONS Two-thirds of the urine cultures of persons with SCI presenting for their annual examination were positive. Most of the positive cultures represented ASB cases, and more than a third of these were treated with antibiotics. A better understanding of the mandate for urine testing at the annual examination and the outcomes of this practice is an important first step in developing antibiotic stewardship for UTI in persons with SCI.
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Abstract
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, yet preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Targeted strategies for prevention of CAUTI include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and closed catheter collection system is essential for preventing CAUTI. The use of "bladder bundles" and collaboratives aids in the effective implementation of CAUTI prevention measures.
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Affiliation(s)
- Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Sanjay Saint
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA; Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, 2800 Plymouth Road, Building 16, Room 430 West, Ann Arbor, MI 48109-2800, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Stagg A, Lutz H, Kirpalaney S, Matelski JJ, Kaufman A, Leis J, McCready J, Powis J. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2017; 27:140-147. [PMID: 28468911 PMCID: PMC5867434 DOI: 10.1136/bmjqs-2016-006250] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 03/28/2017] [Accepted: 04/08/2017] [Indexed: 11/16/2022]
Abstract
Background Despite evidence against the use of antimicrobials for asymptomatic bacteriuria (ASB), they are frequently prescribed leading to unnecessary adverse events. Prior studies have shown that reducing unnecessary urine cultures (UCs) results in decreased antimicrobial utilisation for ASB. Emergency departments (EDs) submit the largest volume of UCs, yet efforts to limit overordering in this patient setting have had limited success. Methods A new two-step model of care for urine collection, using a novel UC collection container, was implemented in the ED of a large community hospital. The collection system contains a preservative allowing UCs to be held at room temperature for up to 48 hours before processing. UCs were collected by front-line staff, but only processed in the microbiology lab if requested by ED physicians after clinical assessment. Results Following implementation there was a decrease in the percentage of weekly ED visits associated with a processed UC (5.97% vs 4.68%, p<0.001), a decrease in the percentage of monthly ED visits requiring a callback for positive urine culture (1.84% to 1.12%, p<0.001) and a decrease in antimicrobial prescriptions for urinary indication among admitted patients (20.6% to 10.9%, p<0.01). There was a false omission rate of 1.35% (95% CI 0.7% to 2.2%), yet no identified cases of untreated urinary tract infection (UTI), or significant change in repeat ED visits or ED length of stay. Conclusions Changing to two-step urine culture ordering in the ED resulted in a decrease in UCs processed, callbacks for positive results and antimicrobial use without evidence of untreated UTIs. This model of care has strong potential to improve the use of hospital resources while minimising detection and inappropriate treatment of ASB.
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Affiliation(s)
- Amanda Stagg
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Haydon Lutz
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Sakshi Kirpalaney
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - John Justin Matelski
- Department of Internal Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Adam Kaufman
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Jerome Leis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,University of Toronto, Center for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
| | - Janine McCready
- Michael Garron Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeff Powis
- Michael Garron Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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