Treatment for Positive Urine Cultures in Hospitalized Adults: A Survey of Prevalence and Risk Factors in 3 Medical Centers

Diagnostic accuracy of dipsticks for urinary tract infections in acutely hospitalised patients: a prospective population-based observational cohort study

OBJECTIVE

To determine the added diagnostic value of dipsticks for urinary tract infections (UTI) in acutely hospitalised individuals.

DESIGN

Prospective population-based cohort study.

SETTING

North Denmark.

PARTICIPANTS

All adults (≥18 years) examined with dipsticks at emergency departments in North Denmark Region from September 20 through 23 October 2021.

MAIN OUTCOME MEASURES

UTI was defined as ≥1 symptom of new-onset frequency, dysuria or suprapubic tenderness combined with a positive urine culture. Positive dipsticks were defined as any reaction for leucocyte esterase and/or nitrite.

RESULTS

Dipsticks were used in 1052/2495 (42%) of acutely hospitalised patients with a median age of 73 years (IQR 57-82) and 540 (51%) were female. Overall, 89/1052 (8%) fulfilled the UTI criteria and urine cultures were done in 607/1052 (58%) patients. Among patients examined with both dipstick and urine culture, sensitivity and specificity for UTI were 87% (95% CI 78% to 93%) and 45% (95% CI 41% to 50%). Positive and negative predictive values were 21% (95% CI 17% to 26%) and 95% (95% CI 92% to 98%), whereas positive and negative likelihood ratios were 1.58 (95% CI 1.41 to 1.77) and 0.30 (95% CI 0.18 to 0.51). Pretest probabilities of UTI ranged from 29% to 60% in participants with specific UTI symptoms with corresponding post-test probabilities of 35-69% if dipsticks were positive and 12-27% if dipsticks were negative. Results remained comparable if final clinical diagnosis was used as outcome among all patients examined with dipsticks. Modified Poisson regression yielded an adjusted relative risk of 4.41 (95% CI 2.40 to 8.11) for empirical antibiotics for UTI in participants without specific UTI symptoms and a positive dipstick.

CONCLUSIONS

Dipsticks yielded limited clinical decision support compared with a symptom-driven approach in this study and were independently associated with excess antibiotics for UTI.

Impact of restrictive urinalysis reflex to culture criteria at a large community hospital

Treatment of asymptomatic bacteriuria (ASB) is a common, but often unnecessary, practice. Our objective was to determine the impact of restrictive urinalysis reflex to culture (UARC) criteria on rate of urine cultures (UC) ordered and ASB treatment. Criteria were modified from positive leukocyte esterase, positive nitrites, or white blood cells (WBC) >10 cells to only WBC >10 cells. This pre-post study evaluated UARCs ordered in the emergency department or inpatient units. The primary outcome was the proportion of reflex UCs prevented. Secondary outcomes included the frequency of repeat UARCs and stand-alone UCs, gram-negative rod (GNR) bacteremia, and ASB treatment. In the pre-intervention, there were 4761 UARCs compared to 5420 in the post-intervention; 37.9 % and 21.4 % reflexed to UCs, a 43.5 % reduction in UCs. The rate of repeat UARCs, stand-alone UCs, and GNR bacteremia in the pre- and post-interventions were similar. ASB treatment rate was numerically lower in the post-intervention.

Asymptomatic bacteriuria in critical-access hospitals: Prevalence and patient characteristics driving treatment

We evaluated the prevalence and treatment of asymptomatic bacteriuria (ASB) in 17 critical-access hospitals. Among 891 patients with urine cultures from September 2021 to June 2022, 170 (35%) had ASB. Also, 76% of patients with ASB received antibiotics for a median duration of 7 days, demonstrating opportunities for antimicrobial stewardship.

Effect of microbiology comment nudging on antibiotic use in asymptomatic bacteriuria: A before-and-after quasi-experimental study

OBJECTIVE

To describe the effect of a microbiology comment nudge on antibiotic use for asymptomatic bacteriuria (ASB).

DESIGN

Single-center, before-and-after, quasi-experimental study.

SETTING

Community-based, public, not-for-profit teaching hospital in the southeastern United States.

PARTICIPANTS

Adult inpatients with a positive urine culture and the absence of urinary tract infection signs and symptoms.

INTERVENTION

Implementation of a microbiology comment nudge on urine cultures.

RESULTS

In total, 204 patients were included in the study. Antibiotics were less likely to be continued beyond 72 hours in the postimplementation group: 57 (55%) of 104 versus 38 (38%) of 100 (P = .016). They were less likely to have antibiotics continued beyond 48 hours: 60 (58%) of 104 versus 43 (43%) of 100 (P = .036). They were also less likely to have antibiotics prescribed at discharge 35 (34%) of 104 versus 20 (20%) of 100 (P = .028). In addition, they had fewer total antibiotic days of therapy: 4 (IQR, 1-6) versus 1 (IQR, 0-6) (P = .022).

CONCLUSION

Microbiology comment nudging may contribute to less antibiotic utilization in patients with ASB.

Antibiotic prescribing in mental health units across the Veterans' Health Administration: How much and how appropriate?

We evaluated antibiotic-prescribing across 111 mental health units in the Veterans' Health Administration. We found that accurate diagnosis of urinary tract infections is a major area for improvement. Because non-mental-health clinicians were involved in most antibiotic-prescribing decisions, stewardship interventions for mental health patients should have a broad target audience to be effective.

Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections? A Systematic Review and Meta-Analysis

Background

Urinary tract infection (UTI) is a commonly misdiagnosed infectious syndrome. Diagnostic stewardship interventions can reduce rates of asymptomatic bacteriuria treatment but are often labor intensive, and thus an automated means of reducing unnecessary urine testing is preferred. In this systematic review and meta-analysis, we sought to identify studies describing interventions utilizing clinical decision support (CDS) to optimize UTI diagnosis and to characterize the effectiveness of these interventions.

Methods

We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published before July 2, 2021. Publications describing an intervention intending to enhance UTI diagnosis via CDS were included. The primary outcome was urine culture test rate.

Results

The electronic search identified 5013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion, and a manual reference list review identified 5 additional studies, yielding a total of 14 studies included in the systematic review. The most common CDS intervention was urinalysis with reflex to urine culture based on prespecified urinalysis parameters. All 9 studies that provided statistical comparisons reported a decreased urine culture rate postintervention, 8 of which were statistically significant. A meta-analysis including 4 studies identified a pooled urine culture incidence rate ratio of 0.56 (95% confidence interval, .52-.60) favoring the postintervention versus preintervention group.

Conclusions

In this systematic review and meta-analysis, CDS appeared to be effective in decreasing urine culture rates. Prospective trials are needed to confirm these findings and to evaluate their impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects.

Prevalence and treatment of asymptomatic bacteriuria at academic and critical-access hospitals—Opportunities for stewardship efforts

Asymptomatic bacteriuria (ASB) is common among hospitalized patients and often leads to inappropriate antimicrobial use. Data from critical-access hospitals are underrepresented. To target antimicrobial stewardship efforts, we measured the point prevalence of ASB and detected a high frequency of ASB overtreatment across academic, community, and critical-access hospitals.

Impact of provider-selected indication requirement on urine test utilization and positivity

OBJECTIVE

To evaluate the impact of the addition of an indication specification requirement to isolated urine-culture ordering on testing utilization.

DESIGN

Retrospective study utilizing interrupted time series analysis with negative binomial regression. The preintervention period was October 1, 2018-November 11, 2019, and the postintervention period was November 12, 2019-October 31, 2020. The primary outcome was isolated culture rate per 1,000 patient days. Secondary outcomes were the proportion of all urine tests ordered as isolated urine culture and culture positivity. An exploratory analysis assessed the appropriateness of selected testing indications.

SETTING

A 415-bed, urban, academic medical center.

PATIENTS

Adult patients with urine testing performed during hospital admission. In total, 1,494 unique isolated urine-culture orders were included in the analysis.

INTERVENTIONS

On November 12, 2019, the laboratory order interface was changed to require the ordering provider to select an indication for isolated urine culture.

RESULTS

Isolated urine-culture rates did not significantly change after the intervention (11.2-7.8 cultures per 1,000 patient days; P = .17) nor did culture positivity (26.9% vs 26.8%). Most ordering providers left the indication for testing blank, and of those charts reviewed, 67% did not have a documented condition for which isolated urine culture was the most appropriate initial test.

CONCLUSIONS

The addition of an order-specification requirement for isolated urine-culture testing did not significantly affect ordering practices. The test remains overused as the initial diagnostic evaluation for a suspected urinary tract infection. Further provider education and continued changes in provider workflow are needed to achieve lasting change in practice.

Opportunities for antibiotic stewardship in emergency department or hospitalized patients with asymptomatic bacteriuria: identifying risk factors for antibiotic treatment

Antibiotic treatment of asymptomatic bacteriuria (ASB) is considered inappropriate and may lead to adverse events. This 2-center, retrospective cohort study including emergency department or inpatient adults identified pyuria (odds ratio, 2.43; 95% confidence interval, 1.17–5.01; P = .02) as the only independent risk factor for antibiotic treatment of ASB.

Urinary Tract Infections: 2021 Update

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.

Revisiting approaches to and considerations for urinalysis and urine culture reflexive testing

Urinalysis is considered the world's oldest laboratory test. Today, many laboratories use macroscopic urinalysis as a screening tool to determine when to subject urine samples for a microscopic urinalysis and/or bacterial culture. While reflexive urine microscopy has been practiced for decades, and reflexive urine culture, more recently, evidence-based guidelines regarding optimal reflexive criteria and workflows are lacking. Standard approaches are hindered, in part, by a lack of harmonization of urinalysis and urine culture practices, heterogeneity in patient populations that are studied, and lack of provider adherence to recommended practices. This review summarizes studies that have evaluated the performance of reflexive urine microscopy and reflexive urine culture, particularly in the context of urinary tract infections. It also examines reported clinical outcomes from reflexive urinalysis interventions and their impact on antibiotic stewardship efforts. Finally, it discusses laboratory operational considerations for the implementation of reflexive algorithms.

Treatment of Asymptomatic Bacteriuria after Implementation of an Inpatient Urine Culture Algorithm in the Electronic Medical Record

Ordering urine cultures in patients without pyuria is associated with the inappropriate treatment of asymptomatic bacteriuria (ASB). In 2015, our institution implemented recommendations based on practice guidelines for the management of ASB and revised the urine culture ordering process to limit cultures in immunocompetent patients without pyuria. The purpose of this study was to determine how the treatment of ASB has changed over time since altering the urine culture ordering process to reduce unnecessary cultures at an academic medical center. A quasi-experimental study was conducted for inpatients with urine cultures from January to March of 2014, 2015, 2016 and 2020. The primary outcome was the antibiotic treatment of asymptomatic bacteriuria for over 24 h. The secondary outcomes were the total days of antibiotic therapy, type of antibiotic prescribed and overall urine culture rates at the hospital. A total of 200 inpatients with ASB were included, 50 at random from each year. In both 2014 and 2015, 70% of the patients with ASB received antibiotic treatment. Antibiotics were prescribed to 68% and 54% of patients with ASB in 2016 and 2020, respectively. The average duration of therapy decreased from 5.12 days in 2014 to 3.46 days in 2020. Although the urine cultures were reduced, there was no immediate impact in the prescribing rates for patients with ASB after implementing this institutional guidance and an altered urine culture ordering process. Over time, there was an observed improvement in prescribing and the total days of antibiotic therapy. This could be attributed to increased familiarity with the guidelines, culture ordering practices or improved documentation. Based on these findings, additional provider education is needed to reinforce the guideline recommendations on the management of ASB.

The Benefits and Harms of Antibiotic Prophylaxis for Urinary Tract Infection in Older Adults

BACKGROUND

The role of antibiotics in preventing urinary tract infection (UTI) in older adults is unknown. We sought to quantify the benefits and risks of antibiotic prophylaxis among older adults.

METHODS

We conducted a matched cohort study comparing older adults (≥66 years) receiving antibiotic prophylaxis, defined as antibiotic treatment for ≥30 days starting within 30 days of a positive culture, with patients with positive urine cultures who received antibiotic treatment but did not receive prophylaxis. We matched each prophylaxis recipient to 10 nonrecipients based on organism, number of positive cultures, and propensity score. Outcomes included (1) emergency department (ED) visit or hospitalization for UTI, sepsis, or bloodstream infection within 1 year; (2) acquisition of antibiotic resistance in urinary tract pathogens; and (3) antibiotic-related complications.

RESULTS

Overall, 4.7% (151/3190) of UTI prophylaxis patients and 3.6% (n = 1092/30 542) of controls required an ED visit or hospitalization for UTI, sepsis, or bloodstream infection (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.12-1.57). Acquisition of antibiotic resistance to any urinary antibiotic (HR, 1.31; 95% CI, 1.18-1.44) and to the specific prophylaxis agent (HR, 2.01; 95% CI, 1.80-2.24) was higher in patients receiving prophylaxis. While the overall risk of antibiotic-related complications was similar between groups (HR, 1.08; 95% CI, .94-1.22), the risk of Clostridioidesdifficile and general medication adverse events was higher in prophylaxis recipients (HR [95% CI], 1.56 [1.05-2.23] and 1.62 [1.11-2.29], respectively).

CONCLUSIONS

Among older adults with UTI, the harms of long-term antibiotic prophylaxis may outweigh their benefits.

Narrative Review: The Process of Expanding the Manual of Antimicrobial Stewardship by the Government of Japan

The Ministry of Health, Labour and Welfare has published the Manual of Antimicrobial Stewardship (1st edition) in June 2017 to improve the prescribing practice of antimicrobials for immunocompetent adult and pediatric (both school-aged and older children) patients. Due to the increasing demand for further promoting outpatient antimicrobial stewardship, we conducted a literature and national guideline review to identify the area of need. The results of our review revealed a high antimicrobial prescription rate in the Japanese pediatric population. Furthermore, although the Japanese clinical guidelines/guidance covered the fields of almost all infectious diseases, no system exists to estimate the incidence and treatment patterns of important infectious diseases such as asymptomatic bacteriuria, skin and soft tissue infections, and dental practices in Japan. Therefore, addressing the issues of both establishing surveillance systems and the implementation of guidelines/guidance can be the next step to promote further outpatient antimicrobial stewardship.

Reevaluating the true diagnostic accuracy of dipstick tests to diagnose urinary tract infection using Bayesian latent class analysis

OBJECTIVE

Previous studies on diagnostic accuracy of dipstick testing for leukocyte esterase (LE) and nitrite to diagnose urinary tract infection (UTI) had used urine culture, which is an imperfect gold standard. Estimates of diagnostic accuracy obtained using the classical gold standard framework might not reflect the true diagnostic accuracy of dipstick tests.

METHODS

We used the dataset from a prospective, observational study conducted in the emergency department of a teaching hospital in southern India. Patients with a clinical suspicion of UTI underwent dipstick testing for LE and nitrite, urine microscopy, and urine culture. Based on the results of urine microscopy and culture, UTI was classified into definite, probable, and possible. Patients with microscopic pyuria and a positive urine culture were adjudicated as definite UTI. Unequivocal imaging evidence of emphysematous pyelonephritis or perinephric collections was also considered definite UTI. We estimated the diagnostic accuracy of LE and nitrite tests using the classical analysis (assuming definite UTI as gold standard) and two different Bayesian latent class models (LCMs; 3-tests in 1-population and 2-tests in 2-populations models).

RESULTS

We studied 149 patients. Overall, 64 (43%) patients had definite, 76 (51%) had probable, and 2 (1.3%) had possible UTI; 7 (4.6%) had alternate diagnoses. In classical analysis, LE was more sensitive than nitrite (87.5% versus 70.5%), while nitrite was more specific (24% versus 58%). The 3-tests in 1-population Bayesian LCM indicated a substantially better sensitivity and specificity for LE (98.1% and 47.6%) and nitrite (88.2% and 97.7%). True sensitivity and specificity of urine culture as estimated by the model was 48.7% and 73.0%. Estimates of the 2-tests in 2-populations model were in agreement with the 3-tests in 1-population model.

CONCLUSIONS

Bayesian LCMs indicate a clinically important improvement in the true diagnostic accuracy of urine dipstick testing for LE and nitrite. Given this, a negative dipstick LE would rule-out UTI, while a positive dipstick nitrite would rule-in UTI in our study setting. True diagnostic accuracy of urine dipstick testing for UTI in various practice settings needs reevaluation using Bayesian LCMs.

Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial

BACKGROUND

Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process.

METHODS

A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals.

DISCUSSION

This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care.

TRIAL REGISTRATION

The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555 .

A Pilot Study to Evaluate the Impact of a Nurse-Driven Urine Culture Diagnostic Stewardship Intervention on Urine Cultures in the Acute Care Setting

BACKGROUND

The role of nurses in diagnostic stewardship in hospitals remains largely unknown.

METHODS

In this before-after study, researchers assessed the impact of a nurse-driven urine culture (UrCx) stewardship intervention for adults with and without urinary catheters on a general medicine unit of a large hospital. The intervention included education on principles of diagnostic stewardship, identification of a nurse champion to serve as liaison between nursing and the antibiotic stewardship program, and implementation of an algorithm to guide discussions with hospitalists about situations when UrCx may not be needed. The primary outcome was the total number of UrCx. The secondary outcome was the rate of inappropriate UrCx. Changes in UrCx rates per 100 patient-days before and after the intervention were calculated using incidence rate ratios (IRRs). Balancing metrics included readmission within 30 days of unit discharge, length of hospital stay, and all-cause in-hospital mortality.

RESULTS

With the intervention, the mean UrCx rate per 100 patient-days decreased from 2.30 to 1.52 (IRR = 0.66, 95% confidence interval [CI] = 0.50-0.87, p < 0.01), while in the control unit it increased from 2.17 to 3.10 (IRR = 1.50, 95% CI = 1.22-1.84, p < 0.01). In the intervention unit, the rate of inappropriate UrCx was 0.83 and 0.71 before and after algorithm implementation (IRR = 0.88, 95% CI = 0.58-1.33, p = 0.55).

CONCLUSION

Nursing education and a clinical tool to enhance discussions on the necessity of UrCx among nurses and hospitalists were associated with a reduction in UrCx.

Safety, effectiveness and sustainability of a laboratory intervention to de-adopt culture of midstream urine samples among hospitalized patients

OBJECTIVE

To assess the safety, sustainability, and effectiveness of a laboratory intervention to reduce processing of midstream urine (MSU) cultures.

DESIGN

Prospective observational cohort.

SETTING

Medical and surgical inpatients in a tertiary-care hospital.

PARTICIPANTS

The study included 1,678 adult inpatients with an order for MSU culture.

METHODS

From 2013 to 2019, ordered MSU cultures were not processed unless the laboratory was called. Patients were interviewed on days 0 and 4; from 2017 to 2019, day-30 follow-up was added. Primary outcome was serious adverse events due to not processing MSU cultures. Secondary outcomes were nonserious adverse events due to not processing MSU cultures, rates of MSU cultures submitted, proportion of MSU cultures processed, proportion of patients prescribed urinary tract infection (UTI)-directed antibiotics, and laboratory workload.

RESULTS

Among 912 and 459 patients followed to days 4 and 30, respectively, no serious adverse events attributable to not processing MSU cultures were identified. However, 6 patients (0.66%) had prolonged urinary symptoms potentially associated with not processing MSU cultures. We estimated that 4 patients missed having empiric antibiotics stopped in response to negative MSU cultures, and 99 antibiotic courses for asymptomatic bacteriuria (ASB) and 8 antibiotic-associated adverse events were avoided. The rate of submitted MSU samples and proportion of patients receiving empiric UTI-directed antibiotics did not change. The proportion of MSU cultures processed declined from 59% to 49% (P < .0001), and total laboratory workload was reduced by 185 hours.

CONCLUSIONS

De-adopting the processing of MSU cultures from medical and surgical inpatient units is safe and sustainable, and it reduces antibiotic prescriptions for ASB at a cost of prolonged urinary symptoms in a small proportion of patients.

Unintended consequences of a reflex urine culture order set on appropriate antibiotic use

We evaluated the impact of reflex urine culture screen results on antibiotic initiation. More patients with positive urine screen but negative culture received antibiotics than those with a negative screen (30.5 vs 7.1%). Urine screen results may inappropriately influence antibiotic initiation in patients with a low likelihood of infection.

Impact of Antimicrobial Stewardship Interventions on Antimicrobial Utilization in Asymptomatic Bacteriuria

Background: Antimicrobial therapy for asymptomatic bacteriuria (ASB) is often unnecessary and is a common reason for inappropriate antimicrobial use in hospitalized patients. Unnecessary ASB treatment leads to collateral damage such as resistance, and Clostridium difficile infections. This study evaluated the impact of interdisciplinary antimicrobial stewardship interventions on antimicrobial utilization in ASB. Methods: This was a quasi-experimental institutional review board (IRB)-approved study evaluating the impact of antimicrobial stewardship on antibiotic utilization for ASB in a pilot medical-surgical unit. The control phase was from August-October 2017 and the postintervention phase was from December-March 2018. In the control phase, electronic medical records of patients with positive urine cultures were retrospectively reviewed. Patients were classified as either having ASB or urinary tract infection (UTI) based on the absence or presence of UTI symptoms documented in the medical record. The intervention phase consisted of educational in-services to providers, nurses, and pharmacists. Clinical pharmacists for the pilot unit utilized an electronic real-time surveillance system to identify patients with positive urine cultures. With nurses' collaboration, clinical pharmacists classified these patients as either having UTI or ASB. Stewardship interventions were made in real-time to discontinue antibiotics in patients with ASB. Results: There were 65 and 77 patients with bacteriuria in the pre- and postintervention phases. Among these, ASB was present in 29 (45%) and 27 (35%) patients, respectively. After excluding those receiving antibiotics for concurrent nonurinary indications, the combination of education with pharmacist and nursing interventions decreased unnecessary ASB treatment from 18 (62%) to 6 (22%) patients (relative risk: 0.36, 95% confidence interval: 0.16-0.72, P = .003). Conclusion: The findings of this study highlight the importance of interdisciplinary interventions in reducing unnecessary antimicrobial therapy for the treatment of ASB. With increasing antimicrobial resistance, healthcare institutions should evaluate the role of these interdisciplinary interventions to reduce unnecessary treatment for ASB.

Pharmacist recommendations for carbapenem de-escalation in urinary tract infection within an antimicrobial stewardship program

BACKGROUND

Carbapenem antibiotics are considered the treatment of choice for serious extended-spectrum beta-lactamase-producing Gram-negative bacteria infections. Our objectives were to analyze the results of carbapenem de-escalation therapy in complicated urinary tract infections (UTIs) attended in a third-level Spanish hospital and to evaluate the impact of pharmacist recommendation in this practice, the outcomes obtained, and associated factors.

METHODS

This prospective observational study of carbapenem prescriptions and de-escalation performance was conducted in a third-level hospital between August 1 2013 and July 31, 2014. Data were gathered on carbapenem treatment duration, de-escalation, length of hospital stay, mortality rate, and associated re-admissions.

RESULTS

De-escalation, which was only ordered for patients with positive cultures, was conducted in 49.7% of the 163 patients with complicated UTI. More than half (69.1%) of pharmacist interventions were accepted. De-escalation reduced the median hospital stay by five days (p=0.030). Crude hospital mortality was lower in the de-escalation group (7.4% vs. 29.3%, p<0.001), although their exposure to carbapenems was lower (4 vs 6 days, p<0.001). Factors associated with de-escalation were ICU stay for at least 48h, pharmacist recommendation and ESBL or AmpC producing Enterobacteriaceae. Factors associated with in-hospital mortality were age, previous admission and duration of hospital stay, but not pharmacist recommendation. Otherwise, carbapenem de-escalation was associated as a protective factor against in-hospital mortality.

CONCLUSIONS

Carbapenem de-escalation in accordance with pharmacist recommendation proved to be a safe approach in complicated UTI, reducing the hospital stay of patients without affecting the re-admission rate.

National Patterns of Urine Testing During Inpatient Admission

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.

Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center

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 &lt; .001), clean catch (30.0 vs 18.7; P &lt; .001) and catheterized urine (7.8 vs 1.9; P &lt; .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P &lt; .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.

Urinary Catheter-Associated Infections

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.

Urine Culture on Admission Impacts Antibiotic Use and Length of Stay: A Retrospective Cohort Study

OBJECTIVE

To examine the impact of urine culture testing on day 1 of admission on inpatient antibiotic use and hospital length of stay (LOS).

DESIGN

We performed a retrospective cohort study using a national dataset from 2009 to 2014.

SETTING

The study used data from 230 hospitals in the United States.

PARTICIPANTS

Admissions for adults 18 years and older were included in this study. Hospitalizations were matched with coarsened exact matching by facility, patient age, gender, Medicare severity-diagnosis related group (MS-DRG), and 3 measures of disease severity.

METHODS

A multilevel Poisson model and a multilevel linear regression model were used to determine the impact of an admission urine culture on inpatient antibiotic use and LOS.

RESULTS

Matching produced a cohort of 88,481 patients (n=41,070 with a culture on day 1, n=47,411 without a culture). A urine culture on admission led to an increase in days of inpatient antibiotic use (incidence rate ratio, 1.26; P<.001) and resulted in an additional 36,607 days of inpatient antibiotic treatment. Urine culture on admission resulted in a 2.1% increase in LOS (P=.004). The predicted difference in bed days of care between admissions with and without a urine culture resulted in 6,071 additional bed days of care. The impact of urine culture testing varied by admitting diagnosis.

CONCLUSIONS

Patients with a urine culture sent on day 1 of hospital admission receive more days of antibiotics and have a longer hospital stay than patients who do not have a urine culture. Targeted interventions may reduce the potential harms associated with low-yield urine cultures on day 1.

Infect Control Hosp Epidemiol 2018;39:547–554

Management of Bacteriuria in Veterans Affairs Hospitals

Background

Bacteriuria contributes to antibiotic overuse through treatment of asymptomatic bacteriuria (ASB) and long durations of therapy for symptomatic urinary tract infections (UTIs), yet large-scale evaluations of bacteriuria management among inpatients are lacking.

Methods

Inpatients with bacteriuria were classified as asymptomatic or symptomatic based on established criteria applied to data collected by manual chart review. We examined frequency of treatment of ASB, factors associated with treatment of ASB, durations of therapy, and frequency of complications including Clostridium difficile infection, readmission, and all-cause mortality within 28 days of discharge.

Results

Among 2225 episodes of bacteriuria, 64% were classified as ASB. After excluding patients with non-UTI indications for antibiotics, 72% of patients with ASB received antibiotics. When evaluating only patients not meeting SIRS criteria, 68% of patients with ASB received antibiotics. The mean (±SD) days of antibiotic therapy for ASB, cystitis, CA-UTI and pyelonephritis were 10.0 (4.5), 11.4 (4.7), 12.0 (6.1), and 13.6 (5.3), respectively. In sum, 14% of patients with ASB were treated for greater than 14 days, and fluoroquinolones were the most commonly used empiric antibiotic for ASB [245/691 (35%)]. Complications were rare but more common among patients with ASB treated with antibiotics.

Conclusions

The majority of bacteriuria among inpatient veterans is due to ASB with high rates of treatment of ASB and prolonged durations of therapy for ASB and symptomatic UTIs.

Inappropriate Management of Asymptomatic Patients With Positive Urine Cultures: A Systematic Review and Meta-analysis

BACKGROUND

Mismanagement of asymptomatic patients with positive urine cultures (referred to as asymptomatic bacteriuria [ASB] in the literature) promotes antimicrobial resistance and results in unnecessary antimicrobial-related adverse events and increased health care costs.

METHODS

We conducted a systematic review and meta-analysis of studies that reported on the rate of inappropriate ASB treatment published from 2004 to August 2016. The appropriateness of antimicrobial administration was based on guidelines published by the Infectious Diseases Society of America.

RESULTS

A total of 2142 nonduplicate articles were identified, and among them 30 fulfilled our inclusion criteria. The pooled prevalence of antimicrobial treatment among 4129 cases who did not require treatment was 45% (95% CI, 39-50). Isolation of gram-negative pathogens (odds ratio [OR], 3.58; 95% CI, 2.12-6.06), pyuria (OR, 2.83; 95% CI, 1.9-4.22), nitrite positivity (OR, 3.83; 95% CI, 2.24-6.54), and female sex (OR, 2.11; 95% CI, 1.46-3.06) increased the odds of receiving treatment. The rates of treatment were higher in studies with ≥100 000 cfu/mL cutoff values compared with <10 000 cfu/mL for bacterial growth (P, .011). The implementation of educational and organizational interventions designed to eliminate the overtreatment of ASB resulted in a median absolute risk reduction of 33% (rangeARR, 16-36%, medianRRR, 53%; rangeRRR, 25-80%).

CONCLUSION

The mismanagement of ASB remains extremely frequent. Female sex and the overinterpretation of certain laboratory data (positive nitrites, pyuria, isolation of gram-negative bacteria and cultures with higher microbial count) are associated with overtreatment. Even simple stewardship interventions can be particularly effective, and antimicrobial stewardship programs should focus on the challenge of differentiating true urinary tract infection from ASB.

Urinary Tract Infections

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.

Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel

OBJECTIVE To assess knowledge about infection prevention among nursing home personnel and identify gaps potentially addressable through a quality improvement collaborative. DESIGN Baseline knowledge assessment of catheter-associated urinary tract infection, asymptomatic bacteriuria, antimicrobial stewardship, and general infection prevention practices for healthcare-associated infections. SETTING Nursing homes across 14 states participating in the national "Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infection." PARTICIPANTS Licensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel. METHODS Each facility aimed to obtain responses from at least 10 employees (5 licensed and 5 unlicensed). We assessed the percentage of correct responses. RESULTS A total of 184 (78%) of 236 participating facilities provided 1 response or more. Of the 1,626 respondents, 822 (50.6%) were licensed; 117 facilities (63.6%) were for-profit. While 99.1% of licensed personnel recognized the definition of asymptomatic bacteriuria, only 36.1% knew that pyuria could not distinguish a urinary tract infection from asymptomatic bacteriuria. Among unlicensed personnel, 99.6% knew to notify a nurse if a resident developed fever or confusion, but only 27.7% knew that cloudy, smelly urine should not routinely be cultured. Although 100% of respondents reported receiving training in hand hygiene, less than 30% knew how long to rub hands (28.5% licensed, 25.2% unlicensed) or the most effective agent to use (11.7% licensed, 10.6% unlicensed). CONCLUSIONS This national assessment demonstrates an important need to enhance infection prevention knowledge among healthcare personnel working in nursing homes to improve resident safety and quality of care. Infect. Control Hosp. Epidemiol. 2016;1-6.

Antibiotic Resistance in Urinary Isolates of Escherichia coli

Objectives:

The aim of this study was to examine the presence of antimicrobial resistance / susceptibility strains of Escherichia coli in inpatients and outpatients.

Materials and methods:

It is a retrospective study carried out at the Department of Microbiology, Parasitology and Virology Faculty of Medicine, University of Sarajevo. In cooperation with the Microbiological laboratory of the Cantonal Hospital Zenica and the Microbiological laboratory of the General Hospital Tesanj, 3863 urine samples were processed in the period from March 1^st to March 31^st 2016.

Results:

Our study showed that E. coli had the highest antimicrobial resistance to trimethoprim / sulfamethoxazole (38.61%), followed by amoxicillin / clavulanic acid (19.62%), ciprofloxacin (9.49%), gentamicin (8.86%), cephalexin (8.23%), nitrofurantoin (8.23%), cefuroxime (7.52%), ceftazidime (6.33%), cefuroxime (89.87%), amikacin (4.43%).

Conclusions:

The isolated strains of E. coli showed the highest resistance to trimethoprim / sulfamethoxazole and amoxicillin / clavulanic acid. The isolated strains of E. coli showed the greatest susceptibility to amikacin and ceftazidime. Gender distribution of positive E. coli isolates showed statistically significant differences in favor of females.