Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria

When antimicrobial stewardship begins with microbiological test requests: the case of asymptomatic bacteriuria

PURPOSE OF REVIEW

We aim to review the rationale, methods, and experiences with diagnostic stewardship targeted at urinary tract infection (UTI) and related urinary syndromes.

RECENT FINDINGS

In the last 18 months, several articles have demonstrated the impact of diagnostic stewardship interventions at limiting inappropriate diagnosis of UTIs or inappropriate antibiotic-prescribing, targeting the urinary tract. Antimicrobial stewardship programs may create and implement interventions at the point of urine test ordering, urine test resulting, or at the point of prescribing antibiotics after results have returned. Specific design and implementation of stewardship interventions depends on context. To maximize their impact, interventions should be accompanied by education and garner buy-in from providers.

SUMMARY

Diagnostic stewardship can decrease unnecessary antibiotics and inappropriate diagnosis of UTI with multifaceted interventions most likely to be effective. Remaining questions include how to reduce ASB treatment in new populations, such as those with immune compromise, and persistent unknowns regarding UTI diagnosis and diagnostics.

Eliciting Clinician Perspectives on Asymptomatic Bacteriuria to Identify Targets for Antimicrobial Stewardship Education and Decision Support

Background

The aim of this study was to elicit clinicians' perspectives to help reduce antibiotic prescribing for asymptomatic bacteriuria and improve a patient-centered educational brochure for older adults with urinary tract infections or asymptomatic bacteriuria.

Methods

Between October 2023 and April 2024, we conducted semi-structured qualitative interviews of clinicians who treat patients aged ≥65 years for urinary tract infections or bacteria in the urine, at infectious disease clinics, community senior living facilities, memory care clinics, and general practice. We developed an interview guide based on a behavior change framework and thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques.

Results

We identified several common themes surrounding management of asymptomatic bacteriuria from clinicians. These included an emphasis on ordering and interpreting urine tests, tension between guidelines and individual patient care for older adults, use of epidemiologic data to influence prescribing practices, pre-prepared communication talking points, and interest in educational materials for patients and clinical teams.

Conclusions

Education about the need for symptoms to supplement urine testing, data about the impact of overuse of antibiotics, and oral and written communication strategies should be addressed to reduce antibiotic prescribing for asymptomatic bacteriuria.

Older adults' and caregivers' perceptions about urinary tract infection and asymptomatic bacteriuria guidelines: a qualitative exploration

Objective

To explore older adults' and caregivers' knowledge and perceptions of guidelines for appropriate antibiotics use for bacteria in the urine.

Design

Semi-structured qualitative interviews.

Setting

Infectious disease clinics, community senior living facilities, memory care clinics, and general public.

Participants

Patients 65 years or older diagnosed with a urinary tract infection (UTI) in the past two years, or caregivers of such patients.

Methods

We conducted interviews between March and July 2023. We developed an interview guide based on the COM-B (capability, opportunity, motivation-behavior) behavior change framework. We thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques.

Results

Thirty participants (21 patients, 9 caregivers) enrolled. Most participants understood UTI symptoms such as pain during urination and frequent urination. However, communication with multiple clinicians, misinformation, and unclear symptoms that overlapped with other health issues clouded their understanding of asymptomatic bacteriuria (ASB) and UTIs. Some participants worried that clinicians would be dismissive of symptoms if they suggested a diagnosis of ASB without prescribing antibiotics. Many participants felt that the benefits of taking antibiotics for ASB outweighed harms, though some mentioned fears of personal antibiotic resistance if taking unnecessary antibiotics. No participants mentioned the public health impact of potential antibiotic resistance. Most participants trusted information from clinicians over brochures or websites but wanted to review information after clinical conversations.

Conclusion

Clinician-focused interventions to reduce antibiotic use for ASB should also address patient concerns during clinical visits, and provide standardized high-quality educational materials at the end of the visit.