1
|
Caveness CF, Orvin AI, Ingram CW, Bouchard JL. Impact of restrictive urinalysis reflex to culture criteria at a large community hospital. Diagn Microbiol Infect Dis 2024; 108:116183. [PMID: 38309086 DOI: 10.1016/j.diagmicrobio.2024.116183] [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: 09/01/2023] [Revised: 11/30/2023] [Accepted: 01/09/2024] [Indexed: 02/05/2024]
Abstract
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.
Collapse
Affiliation(s)
| | - Alison I Orvin
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Christopher W Ingram
- Infection Control and Occupational Health, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| |
Collapse
|
2
|
Hartlage W, Bryson-Cahn C, Castillo AY, Jain R, Lynch JB, Martinez-Paz N, Chan JD, Kassamali Escobar Z. Asymptomatic bacteriuria in critical-access hospitals: Prevalence and patient characteristics driving treatment. Infect Control Hosp Epidemiol 2024; 45:380-383. [PMID: 37929617 PMCID: PMC10933502 DOI: 10.1017/ice.2023.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/26/2023] [Accepted: 08/22/2023] [Indexed: 11/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Whitney Hartlage
- School of Pharmacy, University of Washington, Seattle, Washington
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
| | - Chloe Bryson-Cahn
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Alyssa Y. Castillo
- Division of Infectious Diseases, University of Colorado, Aurora, Colorado
| | - Rupali Jain
- School of Pharmacy, University of Washington, Seattle, Washington
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - John B. Lynch
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Natalia Martinez-Paz
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
| | - Jeannie D. Chan
- School of Pharmacy, University of Washington, Seattle, Washington
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Zahra Kassamali Escobar
- School of Pharmacy, University of Washington, Seattle, Washington
- Center for Stewardship in Medicine, University of Washington, Seattle, Washington
- Fred Hutchinson Cancer Center, Seattle, Washington
| |
Collapse
|
3
|
Belk MG, Hammond OD, Seales CC, Edwards JD, Steuber TD. Effect of microbiology comment nudging on antibiotic use in asymptomatic bacteriuria: A before-and-after quasi-experimental study. Infect Control Hosp Epidemiol 2023; 44:1391-1395. [PMID: 36924157 PMCID: PMC10507501 DOI: 10.1017/ice.2022.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 03/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Madeline G. Belk
- Huntsville Hospital, Department of Pharmacy, Huntsville, Alabama
| | | | | | | | - Taylor D. Steuber
- Huntsville Hospital, Department of Pharmacy, Huntsville, Alabama
- Auburn University Harrison School of Pharmacy, Pharmacy Practice, Huntsville, Alabama
| |
Collapse
|
4
|
Antibiotic prescribing in mental health units across the Veterans' Health Administration: How much and how appropriate? Infect Control Hosp Epidemiol 2023; 44:308-311. [PMID: 34670636 PMCID: PMC9929705 DOI: 10.1017/ice.2021.432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
Collapse
|
5
|
Hojat LS, Saade EA, Hernandez AV, Donskey CJ, Deshpande A. Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections? A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2022; 10:ofac691. [PMID: 36632418 PMCID: PMC9830539 DOI: 10.1093/ofid/ofac691] [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: 10/12/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Leila S Hojat
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Elie A Saade
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA,Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Curtis J Donskey
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, Ohio, USA,Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans’ Affairs Medical Center, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Center for Value Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA,Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Prevalence and treatment of asymptomatic bacteriuria at academic and critical-access hospitals—Opportunities for stewardship efforts. Infect Control Hosp Epidemiol 2022:1-3. [DOI: 10.1017/ice.2022.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
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.
Collapse
|
7
|
Penney JA, Rodday AM, Sebastiani P, Snydman DR, Doron SI. Impact of provider-selected indication requirement on urine test utilization and positivity. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e103. [PMID: 36483372 PMCID: PMC9726588 DOI: 10.1017/ash.2022.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 06/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jessica A. Penney
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Paola Sebastiani
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - David R. Snydman
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| | - Shira I. Doron
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
8
|
Opportunities for antibiotic stewardship in emergency department or hospitalized patients with asymptomatic bacteriuria: identifying risk factors for antibiotic treatment. ANTIMICROBIAL STEWARDSHIP AND HEALTHCARE EPIDEMIOLOGY 2022; 2:e16. [PMID: 36310811 PMCID: PMC9614994 DOI: 10.1017/ash.2022.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 12/04/2022]
Abstract
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.
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Chambliss AB, Van TT. Revisiting approaches to and considerations for urinalysis and urine culture reflexive testing. Crit Rev Clin Lab Sci 2021; 59:112-124. [PMID: 34663175 DOI: 10.1080/10408363.2021.1988048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Allison B Chambliss
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Pathology, Los Angeles County + University of Southern California (LAC + USC) Medical Center, Los Angeles, CA, USA
| | - Tam T Van
- Kaiser Permanente Southern California Permanente Medical Group, Los Angeles, CA, USA
| |
Collapse
|
11
|
Treatment of Asymptomatic Bacteriuria after Implementation of an Inpatient Urine Culture Algorithm in the Electronic Medical Record. PHARMACY 2021; 9:pharmacy9030138. [PMID: 34449690 PMCID: PMC8396163 DOI: 10.3390/pharmacy9030138] [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: 07/01/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
|
12
|
Langford BJ, Brown KA, Diong C, Marchand-Austin A, Adomako K, Saedi A, Schwartz KL, Johnstone J, MacFadden DR, Matukas LM, Patel SN, Garber G, Daneman N. The Benefits and Harms of Antibiotic Prophylaxis for Urinary Tract Infection in Older Adults. Clin Infect Dis 2021; 73:e782-e791. [PMID: 33595621 DOI: 10.1093/cid/ciab116] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Indexed: 11/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Kevin A Brown
- Public Health Ontario, ICES, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | | | | | | | - Kevin L Schwartz
- Public Health Ontario, ICES, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Jennie Johnstone
- Public Health Ontario, Sinai Health, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Larissa M Matukas
- Unity Health Toronto, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Samir N Patel
- Public Health Ontario, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Gary Garber
- Public Health Ontario, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Sunnybrook Health Sciences Center, ICES, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Jindai K, Kusama Y, Gu Y, Honda H, Ohmagari N. Narrative Review: The Process of Expanding the Manual of Antimicrobial Stewardship by the Government of Japan. Intern Med 2021; 60:181-190. [PMID: 32713913 PMCID: PMC7872805 DOI: 10.2169/internalmedicine.4760-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Kazuaki Jindai
- Department of Healthcare Epidemiology, School of Public Health, Kyoto University, Japan
| | - Yoshiki Kusama
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Japan
| | - Yoshiaki Gu
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Japan
| | - Hitoshi Honda
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Japan
| | - Norio Ohmagari
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Japan
| |
Collapse
|
14
|
Bafna P, Deepanjali S, Mandal J, Balamurugan N, Swaminathan RP, Kadhiravan T. Reevaluating the true diagnostic accuracy of dipstick tests to diagnose urinary tract infection using Bayesian latent class analysis. PLoS One 2021; 15:e0244870. [PMID: 33382863 PMCID: PMC7774958 DOI: 10.1371/journal.pone.0244870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/17/2020] [Indexed: 01/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Prashant Bafna
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Surendran Deepanjali
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
- * E-mail:
| | - Jharna Mandal
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Nathan Balamurugan
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Rathinam P. Swaminathan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Tamilarasu Kadhiravan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| |
Collapse
|
15
|
Rutten JJS, van Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, Sloane PD, Veenhuizen RB, van der Wouden JC, Hertogh CMPM. 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. BMC Geriatr 2020; 20:341. [PMID: 32912192 PMCID: PMC7488520 DOI: 10.1186/s12877-020-01662-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
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 .
Collapse
Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Infectious Diseases division, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community care, Radboud Institute for Health Sciences, Radboudumc Alzheimer Center, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Ruth B Veenhuizen
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Johannes C van der Wouden
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| |
Collapse
|
16
|
Fabre V, Pleiss A, Klein E, Demko Z, Salinas A, Jones G, Gadala A, Hicks LA, Neuhauser MM, Srinivasan A, Cosgrove SE. A Pilot Study to Evaluate the Impact of a Nurse-Driven Urine Culture Diagnostic Stewardship Intervention on Urine Cultures in the Acute Care Setting. Jt Comm J Qual Patient Saf 2020; 46:650-655. [PMID: 32891533 DOI: 10.1016/j.jcjq.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/03/2023]
Abstract
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.
Collapse
|
17
|
Safety, effectiveness and sustainability of a laboratory intervention to de-adopt culture of midstream urine samples among hospitalized patients. Infect Control Hosp Epidemiol 2020; 42:43-50. [PMID: 32873350 DOI: 10.1017/ice.2020.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
Collapse
|
18
|
Unintended consequences of a reflex urine culture order set on appropriate antibiotic use. Infect Control Hosp Epidemiol 2020; 41:1090-1092. [PMID: 32624040 DOI: 10.1017/ice.2020.230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
Collapse
|
19
|
Sadigursky D, Sousa M, de Jesus L, Neto J, Lobão DV, Azi M. Risk of infection following total knee arthroplasty in patients with asymptomatic bacteriuria: A meta-analysis. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2020. [DOI: 10.4103/jotr.jotr_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
20
|
Shah PJ, Ike C, Thibeaux M, Rodriguez E, Maddox SE, Daoura N. Impact of Antimicrobial Stewardship Interventions on Antimicrobial Utilization in Asymptomatic Bacteriuria. Hosp Pharm 2019; 56:210-214. [PMID: 34381251 DOI: 10.1177/0018578719888911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Punit J Shah
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Chiamaka Ike
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | | | | | - Shermel-Edwards Maddox
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA.,University of Houston, Sugar Land, TX, USA
| | - Nicolas Daoura
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| |
Collapse
|
21
|
Sadyrbaeva-Dolgova S, Aznarte-Padial P, Jimenez-Morales A, Expósito-Ruiz M, Calleja-Hernández MÁ, Hidalgo-Tenorio C. Pharmacist recommendations for carbapenem de-escalation in urinary tract infection within an antimicrobial stewardship program. J Infect Public Health 2019; 13:558-563. [PMID: 31685404 DOI: 10.1016/j.jiph.2019.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/31/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Pilar Aznarte-Padial
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain
| | | | | | | | | |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
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.
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
No need for a urine culture in elderly hospitalized patients with a negative dipstick test result. Eur J Clin Microbiol Infect Dis 2018; 37:1459-1464. [DOI: 10.1007/s10096-018-3271-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
|
26
|
Urine Culture on Admission Impacts Antibiotic Use and Length of Stay: A Retrospective Cohort Study. Infect Control Hosp Epidemiol 2018; 39:547-554. [DOI: 10.1017/ice.2018.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVETo examine the impact of urine culture testing on day 1 of admission on inpatient antibiotic use and hospital length of stay (LOS).DESIGNWe performed a retrospective cohort study using a national dataset from 2009 to 2014.SETTINGThe study used data from 230 hospitals in the United States.PARTICIPANTSAdmissions 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.METHODSA 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.RESULTSMatching 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.CONCLUSIONSPatients 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
Collapse
|
27
|
Spivak ES, Burk M, Zhang R, Jones MM, Neuhauser MM, Goetz MB, Cunningham FE. Management of Bacteriuria in Veterans Affairs Hospitals. Clin Infect Dis 2018; 65:910-917. [PMID: 28531289 DOI: 10.1093/cid/cix474] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/16/2017] [Indexed: 02/03/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Emily S Spivak
- Department of Medicine, Division of Infectious Diseases, University of Utah School of Medicine.,Veterans Affairs Salt Lake City Health Care System
| | - Muriel Burk
- Center for Medication Safety.,VA Pharmacy Benefits Management Services, Hines, Illinois
| | | | - Makoto M Jones
- Veterans Affairs Salt Lake City Health Care System.,Department of Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | | | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System.,David Geffen School of Medicine at University of California, Los Angeles
| | | | | | | |
Collapse
|
28
|
Flokas ME, Andreatos N, Alevizakos M, Kalbasi A, Onur P, Mylonakis E. Inappropriate Management of Asymptomatic Patients With Positive Urine Cultures: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2017; 4:ofx207. [PMID: 29226170 PMCID: PMC5714225 DOI: 10.1093/ofid/ofx207] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Myrto Eleni Flokas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Nikolaos Andreatos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Alireza Kalbasi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Pelin Onur
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Gralton J, Boston B, Cook C, Thomas K, Taylor P, Kizny Gordon A, Smerdely P, Hughes G, Louey M, Curtis P. A pilot study on improving the appropriateness of urine specimen collection among catheterised patients in acute aged care. Infect Dis Health 2017. [DOI: 10.1016/j.idh.2016.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Trautner BW, Greene MT, Krein SL, Wald HL, Saint S, Rolle AJ, McNamara S, Edson BS, Mody L. Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel. Infect Control Hosp Epidemiol 2017; 38:83-88. [PMID: 27697086 PMCID: PMC5828502 DOI: 10.1017/ice.2016.228] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Barbara W. Trautner
- Houston Veterans Affairs (VA) Health Services R&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - M. Todd Greene
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sarah L. Krein
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Heidi L. Wald
- Division of Health Care Policy Research, University of Colorado School of Medicine, Aurora, Colorado
| | - Sanjay Saint
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Andrew J. Rolle
- Health Research & Educational Trust, American Hospital Association
| | - Sara McNamara
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Barbara S. Edson
- Health Research & Educational Trust, American Hospital Association
| | - Lona Mody
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
32
|
Abduzaimovic A, Aljicevic M, Rebic V, Vranic SM, Abduzaimovic K, Sestic S. Antibiotic Resistance in Urinary Isolates of Escherichia coli. Mater Sociomed 2016; 28:416-419. [PMID: 28144190 PMCID: PMC5239647 DOI: 10.5455/msm.2016.28.416-419] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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 1st to March 31st 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.
Collapse
Affiliation(s)
- Amila Abduzaimovic
- Institute of Microbiology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Mufida Aljicevic
- Institute of Microbiology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Velma Rebic
- Institute of Microbiology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Sabina Mahmutovic Vranic
- Institute of Microbiology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Kadrija Abduzaimovic
- Department of Microbiology, General Hospital Tesanj, Tesanj, Bosnia and Herzegovina
| | - Sabina Sestic
- Department of Microbiology, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina
| |
Collapse
|