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Coffey KC, Claeys K, Morgan DJ. Diagnostic Stewardship for Urine Cultures. Infect Dis Clin North Am 2024; 38:255-266. [PMID: 38575490 DOI: 10.1016/j.idc.2024.03.004] [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] [Indexed: 04/06/2024]
Abstract
Urinary tract infections are among the most common infectious diagnoses in health care, but most urinary tract infections are diagnosed inappropriately in patients without signs or symptoms of infection. Asymptomatic bacteriuria leads to inappropriate antibiotic prescribing and negative downstream effects, including antimicrobial resistance, health care-associated infections, and adverse drug events. Diagnostic stewardship is the process of modifying the ordering, performing, or reporting of test results to improve clinical care. Diagnostic stewardship impacts the diagnostic pathway to decrease inappropriate detection and treatment of asymptomatic bacteriuria. This article reviews diagnostic stewardship methods and closes with a case study illustrating these principles in practice.
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Affiliation(s)
- K C Coffey
- Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine Street, Baltimore, MD 21201, USA.
| | - Kimberley Claeys
- Department of Practice and Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daniel J Morgan
- Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine Street, Baltimore, MD 21201, USA
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2
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Singh HK, Claeys KC, Advani SD, Ballam YJ, Penney J, Schutte KM, Baliga C, Milstone AM, Hayden MK, Morgan DJ, Diekema DJ. Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics. Infect Control Hosp Epidemiol 2024; 45:405-411. [PMID: 38204365 PMCID: PMC11007360 DOI: 10.1017/ice.2023.284] [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: 11/06/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024]
Abstract
Diagnostic stewardship seeks to improve ordering, collection, performance, and reporting of tests. Test results play an important role in reportable HAIs. The inclusion of HAIs in public reporting and pay for performance programs has highlighted the value of diagnostic stewardship as part of infection prevention initiatives. Inappropriate testing should be discouraged, and approaches that seek to alter testing solely to impact a reportable metric should be avoided. HAI definitions should be further adapted to new testing technologies, with focus on actionable and clinically relevant test results that will improve patient care.
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Affiliation(s)
- Harjot K. Singh
- Division of Infectious Diseases, Weill Cornell Medicine, New York City, New York
| | - Kimberly C. Claeys
- Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Sonali D. Advani
- Department of Medicine–Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Yolanda J. Ballam
- Infection Prevention and Control, Children’s Mercy Kansas City, Missouri
| | - Jessica Penney
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Kirsten M. Schutte
- Medical Director, Infectious Disease, eviCore Healthcare, Bluffton, South Carolina
| | - Christopher Baliga
- Section of Infectious Diseases, Department of Medicine, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins Medicine, Baltimore, Maryland
| | - Mary K. Hayden
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- Veterans’ Affairs Maryland Healthcare System, Baltimore, Maryland
| | - Daniel J. Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Division of Infectious Diseases, Department of Medicine, Maine Medical Center, Portland, Maine
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3
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Albin OR, Troost JP, Saravolatz L, Thomas MP, Hyzy RC, Konkle MA, Weirauch AJ, Dickson RP, Rao K, Kaye KS. A quasi-experimental study of a bundled diagnostic stewardship intervention for ventilator-associated pneumonia. Clin Microbiol Infect 2024; 30:499-506. [PMID: 38163481 DOI: 10.1016/j.cmi.2023.12.023] [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: 09/06/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Diagnostic error in the use of respiratory cultures for ventilator-associated pneumonia (VAP) fuels misdiagnosis and antibiotic overuse within intensive care units. In this prospective quasi-experimental study (NCT05176353), we aimed to evaluate the safety, feasibility, and efficacy of a novel VAP-specific bundled diagnostic stewardship intervention (VAP-DSI) to mitigate VAP over-diagnosis/overtreatment. METHODS We developed and implemented a VAP-DSI using an interruptive clinical decision support tool and modifications to clinical laboratory workflows. Interventions included gatekeeping access to respiratory culture ordering, preferential use of non-bronchoscopic bronchoalveolar lavage for culture collection, and suppression of culture results for samples with minimal alveolar neutrophilia. Rates of adverse safety outcomes, positive respiratory cultures, and antimicrobial utilization were compared between mechanically ventilated patients (MVPs) in the 1-year post-intervention study cohort (2022-2023) and 5-year pre-intervention MVP controls (2017-2022). RESULTS VAP-DSI implementation did not associate with increases in adverse safety outcomes but did associate with a 20% rate reduction in positive respiratory cultures per 1000 MVP days (pre-intervention rate 127 [95% CI: 122-131], post-intervention rate 102 [95% CI: 92-112], p < 0.01). Significant reductions in broad-spectrum antibiotic days of therapy per 1000 MVP days were noted after VAP-DSI implementation (pre-intervention rate 1199 [95% CI: 1177-1205], post-intervention rate 1149 [95% CI: 1116-1184], p 0.03). DISCUSSION Implementation of a VAP-DSI was safe and associated with significant reductions in rates of positive respiratory cultures and broad-spectrum antimicrobial use. This innovative trial of a VAP-DSI represents a novel avenue for intensive care unit antimicrobial stewardship. Multicentre trials of VAP-DSIs are warranted.
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Affiliation(s)
- Owen R Albin
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jonathan P Troost
- Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Louis Saravolatz
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael P Thomas
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert C Hyzy
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark A Konkle
- Department of Adult Respiratory Care, Michigan Medicine, Ann Arbor, MI, USA
| | - Andrew J Weirauch
- Department of Adult Respiratory Care, Michigan Medicine, Ann Arbor, MI, USA
| | - Robert P Dickson
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Keith S Kaye
- Department of Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Jhaveri TA, Weiss ZF, Winkler ML, Pyden AD, Basu SS, Pecora ND. A decade of clinical microbiology: top 10 advances in 10 years: what every infection preventionist and antimicrobial steward should know. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e8. [PMID: 38415089 PMCID: PMC10897726 DOI: 10.1017/ash.2024.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 02/29/2024]
Abstract
The past 10 years have brought paradigm-shifting changes to clinical microbiology. This paper explores the top 10 transformative innovations across the diagnostic spectrum, including not only state of the art technologies but also preanalytic and post-analytic advances. Clinical decision support tools have reshaped testing practices, curbing unnecessary tests. Innovations like broad-range polymerase chain reaction and metagenomic sequencing, whole genome sequencing, multiplex molecular panels, rapid phenotypic susceptibility testing, and matrix-assisted laser desorption ionization time-of-flight mass spectrometry have all expanded our diagnostic armamentarium. Rapid home-based testing has made diagnostic testing more accessible than ever. Enhancements to clinician-laboratory interfaces allow for automated stewardship interventions and education. Laboratory restructuring and consolidation efforts are reshaping the field of microbiology, presenting both opportunities and challenges for the future of clinical microbiology laboratories. Here, we review key innovations of the last decade.
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Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Zoe Freeman Weiss
- Division of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
- Division of Geographic Medicine & Infectious Disease, Tufts Medical Center, Boston, MA, USA
| | - Marisa L. Winkler
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexander D. Pyden
- Division of Pathology and Laboratory Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
- Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA, USA
| | - Sankha S. Basu
- Division of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - Nicole D. Pecora
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
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Advani SD, Claeys K. Behavioral Strategies in Diagnostic Stewardship. Infect Dis Clin North Am 2023; 37:729-747. [PMID: 37537001 DOI: 10.1016/j.idc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Claeys KC, Weston LE, Pineles L, Morgan DJ, Krein SL. Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment. Infect Control Hosp Epidemiol 2023; 44:1932-1941. [PMID: 37424224 PMCID: PMC10776821 DOI: 10.1017/ice.2023.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation. METHODS Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans' Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites. RESULTS We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist. CONCLUSION Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.
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Affiliation(s)
- Kimberly C. Claeys
- department of Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Lauren E. Weston
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Arbor, Michigan
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel J. Morgan
- VA Maryland Healthcare System, Department of Epidemiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Arbor, Michigan
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
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Ku TSN, Al Mohajer M, Newton JA, Wilson MH, Monsees E, Hayden MK, Messacar K, Kisgen JJ, Diekema DJ, Morgan DJ, Sifri CD, Vaughn VM. Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship. Infect Control Hosp Epidemiol 2023; 44:1901-1908. [PMID: 37665212 DOI: 10.1017/ice.2023.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.
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Affiliation(s)
- Tsun Sheng N Ku
- Billings Clinic, Billings, Montana
- Rocky Vista University Montana College of Osteopathic Medicine, Billings, Montana
| | - Mayar Al Mohajer
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Infectious Diseases Section, Baylor St. Luke's Medical Center, Houston, Texas
- Infection Prevention, Diagnostic Stewardship and Antibiotic Stewardship, CommonSpirit Health Texas Division, Houston, Texas
| | - James A Newton
- Department of Antibiotic Stewardship, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Marie H Wilson
- Infection Prevention & Control, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elizabeth Monsees
- Performance Excellence, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri School of Medicine, Kansas City, Missouri
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Kevin Messacar
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado/Children's Hospital Colorado, Aurora, Colorado
| | | | - Daniel J Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Maine Medical Center, Portland, Maine
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- VA Maryland Healthcare System, Baltimore, Maryland
| | - Costi D Sifri
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Yarrington ME, Reynolds SS, Dunkerson T, McClellan F, Polage CR, Moehring RW, Smith BA, Seidelman JL, Lewis SS, Advani SD. Using clinical decision support to improve urine testing and antibiotic utilization. Infect Control Hosp Epidemiol 2023; 44:1582-1586. [PMID: 36987849 PMCID: PMC10539479 DOI: 10.1017/ice.2023.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE Urine cultures collected from catheterized patients have a high likelihood of false-positive results due to colonization. We examined the impact of a clinical decision support (CDS) tool that includes catheter information on test utilization and patient-level outcomes. METHODS This before-and-after intervention study was conducted at 3 hospitals in North Carolina. In March 2021, a CDS tool was incorporated into urine-culture order entry in the electronic health record, providing education about indications for culture and suggesting catheter removal or exchange prior to specimen collection for catheters present >7 days. We used an interrupted time-series analysis with Poisson regression to evaluate the impact of CDS implementation on utilization of urinalyses and urine cultures, antibiotic use, and other outcomes during the pre- and postintervention periods. RESULTS The CDS tool was prompted in 38,361 instances of urine cultures ordered in all patients, including 2,133 catheterized patients during the postintervention study period. There was significant decrease in urine culture orders (1.4% decrease per month; P < .001) and antibiotic use for UTI indications (2.3% decrease per month; P = .006), but there was no significant decline in CAUTI rates in the postintervention period. Clinicians opted for urinary catheter removal in 183 (8.5%) instances. Evaluation of the safety reporting system revealed no apparent increase in safety events related to catheter removal or reinsertion. CONCLUSION CDS tools can aid in optimizing urine culture collection practices and can serve as a reminder for removal or exchange of long-term indwelling urinary catheters at the time of urine-culture collection.
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Affiliation(s)
- Michael E. Yarrington
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | | | - Tray Dunkerson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Fabienne McClellan
- Continuous Improvement Department, Duke University Health System, Durham, North Carolina
| | - Christopher R. Polage
- Clinical Microbiology Laboratory, Duke University Health System, Durham, North Carolina
- Department of Pathology, Duke University of Medicine, Durham, North Carolina
| | - Rebekah W. Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Becky A. Smith
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Jessica L. Seidelman
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Sarah S. Lewis
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Sonali D. Advani
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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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.
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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
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Claeys KC, Johnson MD. Leveraging diagnostic stewardship within antimicrobial stewardship programmes. Drugs Context 2023; 12:dic-2022-9-5. [PMID: 36843619 PMCID: PMC9949764 DOI: 10.7573/dic.2022-9-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Practice Science and Health Outcomes Research, Baltimore, MD, USA
| | - Melissa D Johnson
- Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA,Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center Durham, NC, USA
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11
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Rowe TA, Brown T, Lee JY, Linder JA, Meeker D, Doctor JN, Goldstein NJ, Fox CR, Persell SD. Development and pilot testing of EHR-nudges to reduce overuse in older primary care patients. Arch Gerontol Geriatr 2023; 104:104794. [PMID: 36115068 PMCID: PMC9682472 DOI: 10.1016/j.archger.2022.104794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Unnecessary testing and treatment of common conditions in older adults can lead to significant morbidity and mortality. The primary objective of this study was to develop and pilot test a set of clinical decision support (CDS) alerts informed by social psychology to address overuse in three areas related to ambulatory care of older adults. METHODS We developed three electronic health record (EHR) CDS alerts to address overuse and pilot tested them from January 17, 2019 to July 17, 2019. We enrolled 14 primary care physicians from three practices within a large health system who cared for adults aged 65 years and older. Three measures of overuse applied to patients meeting the following criteria: ordering of prostate-specific antigen (PSA) for prostate cancer screening in adult men aged 76 years and older, ordering of urinalysis or urine cultures (UA or UC) for non-specific reasons to identify bacteriuria in women aged 65 years and older, and overtreatment of diabetes with insulin or oral hypoglycemic medications in adults aged at 75 years and older (DM). Clinicians received CDS alerts when criteria for any of the three overuse measures were met. We then surveyed clinicians to evaluate their experience with the CDS alerts. RESULTS The number of clinical encounters that triggered CDS alerts was 19 for PSA, 48 for UA/UC and 128 for DM. For PSA encounters, 4 (21%) orders were not performed after the alert. In the UA/UC encounters 29 (60%) orders were not performed after the alert. For the DM encounters, 21 (34%) had diabetes therapy reduced following the alert. Survey respondents indicated that the alerts were clinically accurate and sometimes led them to change their clinical action. CONCLUSIONS These CDS alerts were feasible to implement and may minimize unnecessary testing and treatment of common conditions in older adults.
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Affiliation(s)
- Theresa A Rowe
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
| | - Tiffany Brown
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ji Young Lee
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jeffrey A Linder
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniella Meeker
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States
| | - Jason N Doctor
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States
| | - Noah J Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States
| | - Craig R Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States
| | - Stephen D Persell
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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12
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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.
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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
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13
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Humphrey M, MacDonald G, Neville H, Helwig M, Ramsey T, MacKinnon H, Sketris I, Johnston L, Black EK. A Systematic Review of Antimicrobial Stewardship Interventions to Improve Management of Bacteriuria in Hospitalized Adults. Ann Pharmacother 2022:10600280221134539. [DOI: 10.1177/10600280221134539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To determine whether implementation of antimicrobial stewardship (AMS) interventions improve management of bacteriuria in hospitalized adults. Data Sources: EMBASE, MEDLINE, CINAHL, and Clinical Trials Registries via Cochrane CENTRAL were searched from inception through May 2021. Reference lists of included studies were searched, and Scopus was used to retrieve articles that cited included references. Study Selection and Data Extraction: Randomized and nonrandomized trials, controlled before-after studies, interrupted time-series studies, and repeated measures studies evaluating AMS interventions for hospitalized adult inpatients with bacteriuria were included. Risk of bias was assessed independently by 3 team members and compared. Results were summarized descriptively. Data Synthesis: The search yielded 5509 articles, of which 13 met inclusion criteria. Most common interventions included education (N = 8) and audit and feedback (N = 5) alone or in combination with other interventions. Where assessed, resource and antimicrobial use primarily decreased and appropriateness of antimicrobial use improved; however, impact on guideline adherence was variable. All studies were rated as having unclear or serious risk of bias. This review summarizes and assesses the quality of evidence for AMS interventions to improve the management of bacteriuria. Results provide guidance to both AMS teams and researchers aiming to develop and/or evaluate AMS interventions for management of bacteriuria. Conclusions: This review demonstrated benefit of AMS interventions on management of bacteriuria. However, most studies had some risk of bias, and an overall effect across studies is unclear due to heterogeneity in outcome measures.
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Affiliation(s)
- Mari Humphrey
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Gemma MacDonald
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Heather Neville
- Department of Pharmacy, Nova Scotia Health, Halifax, NS, Canada
| | - Melissa Helwig
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada
| | - Tasha Ramsey
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
- Department of Pharmacy, Nova Scotia Health, Halifax, NS, Canada
- Division of Infectious Diseases, Nova Scotia Health, Halifax, NS, Canada
| | - Holly MacKinnon
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Ingrid Sketris
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Lynn Johnston
- Division of Infectious Diseases, Nova Scotia Health, Halifax, NS, Canada
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Emily K. Black
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
- Department of Pharmacy, IWK Health, Halifax, NS, Canada
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14
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Ho VT, Aikens RC, Tso G, Heidenreich PA, Sharp C, Asch SM, Chen JH, Shah NK. Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. J Am Med Inform Assoc 2022; 29:1941-1948. [PMID: 36018731 PMCID: PMC10161518 DOI: 10.1093/jamia/ocac139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. MATERIALS AND METHODS We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. RESULTS Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). DISCUSSION Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. CONCLUSION Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. TRIAL REGISTRATION NCT02709772.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Rachael C Aikens
- Department of Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Geoffrey Tso
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Christopher Sharp
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Neil K Shah
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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15
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Applying Diagnostic Stewardship to Proactively Optimize the Management of Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11030308. [PMID: 35326771 PMCID: PMC8944608 DOI: 10.3390/antibiotics11030308] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/05/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
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16
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Claeys KC, Trautner BW, Leekha S, Coffey KC, Crnich CJ, Diekema D, Fakih MG, Goetz MB, Gupta K, Jones MM, Leykum L, Liang SY, Pineles L, Pleiss A, Spivak ES, Suda KJ, Taylor J, Rhee C, Morgan DJ. Optimal Urine Culture Diagnostic Stewardship Practice- Results from an Expert Modified-Delphi Procedure. Clin Infect Dis 2021; 75:382-389. [PMID: 34849637 DOI: 10.1093/cid/ciab987] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped in three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed in a virtual meeting, and a then second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS 165 questions were reviewed with the panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional reflex urine cultures and urine white blood cell as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS These 18 guidance statements can optimize use of the imperfect urine culture for better patient outcomes.
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Affiliation(s)
- Kimberly C Claeys
- Infectious Diseases, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - K C Coffey
- Associate Hospital Epidemiologist, VA Maryland Healthcare System, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher J Crnich
- Chief of Medicine, Hospital Epidemiologist, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Dan Diekema
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - Mohamad G Fakih
- Chief Quality Officer, Quality Department, Clinical & Network Services, Ascension Healthcare, Grosse Pointe Woods and Wayne State University School of Medicine, Detroit, MI, USA
| | - Matthew Bidwell Goetz
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kalpana Gupta
- Associate Chief of Staff and Chief, Section of Infectious Diseases, VA Boston Healthcare System, of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Makoto M Jones
- Salt Lake City Veterans Affairs Healthcare System, Internal Medicine - Associate Professor, Division of Epidemiology, The University of Utah, Salt Lake City, UT, USA
| | - Luci Leykum
- Department of Internal Medicine, University of Texas at Austin Dell School of Medicine, Austin, TX, USA
| | - Stephen Y Liang
- Medicine, Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ashley Pleiss
- Lead Clinical Nurse, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily S Spivak
- Co-Director of the Antimicrobial Stewardship, University of Utah Health and the Salt Lake City Veterans Affairs Healthcare System, Salt Lake City, UT, USA
| | - Katie J Suda
- VA Pittsburgh Healthcare System, Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh and the, Pittsburgh, PA, USA
| | | | - Chanu Rhee
- Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Associate Hospital Epidemiologist, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel J Morgan
- Chief Hospital, VA Maryland Healthcare System, Epidemiologist Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
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17
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Booth LD, Sick-Samuels AC, Milstone AM, Fackler JC, Gnazzo LK, Stockwell DC. Culture Ordering for Patients with New-onset Fever: A Survey of Pediatric Intensive Care Unit Clinician Practices. Pediatr Qual Saf 2021; 6:e463. [PMID: 34476315 PMCID: PMC8389917 DOI: 10.1097/pq9.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/02/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Accurate assessment of infection in critically ill patients is vital to their care. Both indiscretion and under-utilization of diagnostic microbiology testing can contribute to inappropriate antibiotic administration or delays in diagnosis. However, indiscretion in diagnostic microbiology cultures may also lead to unnecessary tests that, if false-positive, would incur additional costs and unhelpful evaluations. This quality improvement project objective was to assess pediatric intensive care unit (PICU) clinicians' attitudes and practices around the microbiology work-up for patients with new-onset fever. METHODS We developed and conducted a self-administered electronic survey of PICU clinicians at a single institution. The survey included 7 common clinical vignettes of PICU patients with new-onset fever and asked participants whether they would obtain central line blood cultures, peripheral blood cultures, respiratory aspirate cultures, cerebrospinal fluid cultures, urine cultures, and/or urinalyses. RESULTS Forty-seven of 54 clinicians (87%) completed the survey. Diagnostic specimen ordering practices were notably heterogeneous. Respondents unanimously favored a decision-support algorithm to guide culture specimen ordering practices for PICU patients with fever (100%, N = 47). A majority (91.5%, N = 43) indicated that a decision-support algorithm would be a means to align PICU and consulting care teams when ordering culture specimens for patients with fever. CONCLUSION This survey revealed variability of diagnostic specimen ordering practices for patients with new fever, supporting an opportunity to standardize practices. Clinicians favored a decision-support tool and thought that it would help align patient management between clinical team members. The results will be used to inform future diagnostic stewardship efforts.
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Affiliation(s)
- Lauren D. Booth
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Anna C. Sick-Samuels
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Md
| | - Aaron M. Milstone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Md
| | - James C. Fackler
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | | | - David C. Stockwell
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
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18
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Magill SS, O’Leary E, Ray SM, Kainer MA, Evans C, Bamberg WM, Johnston H, Janelle SJ, Oyewumi T, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sharmin S, Pierce R, Zhang AY, Ocampo V, Maloney M, Greissman S, Wilson LE, Dumyati G, Edwards JR, Chea N, Neuhauser MM. Assessment of the Appropriateness of Antimicrobial Use in US Hospitals. JAMA Netw Open 2021; 4:e212007. [PMID: 33734417 PMCID: PMC7974639 DOI: 10.1001/jamanetworkopen.2021.2007] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.
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Affiliation(s)
- Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin O’Leary
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Lantana Consulting Group, Thetford, Vermont
| | - Susan M. Ray
- Department of Medicine, Emory University, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur
| | - Marion A. Kainer
- Tennessee Department of Health, Nashville
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Infectious Diseases, Western Health, Melbourne, Victoria, Australia
| | | | - Wendy M. Bamberg
- Colorado Department of Public Health and Environment, Denver
- Medical Epidemiology Consulting, Denver, Colorado
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver
| | | | - Tolulope Oyewumi
- Colorado Department of Public Health and Environment, Denver
- Department of Healthcare Management, University of Denver, Colorado
| | | | | | - Linn Warnke
- Minnesota Department of Health, St Paul
- Hennepin County Public Health, Minneapolis, Minnesota
| | | | - Deborah L. Thompson
- New Mexico Department of Health, Santa Fe
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Shamima Sharmin
- New Mexico Department of Health, Santa Fe
- Infection Prevention and Control Department, University of New Mexico Hospital, Albuquerque
| | | | | | | | - Meghan Maloney
- Connecticut Emerging Infections Program, Hartford and New Haven
| | - Samantha Greissman
- Connecticut Emerging Infections Program, Hartford and New Haven
- Department of Medicine, Columbia–New York Presbyterian Hospital
| | - Lucy E. Wilson
- Maryland Department of Health, Baltimore
- University of Maryland Baltimore County, Baltimore
| | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester
- University of Rochester Medical Center, Rochester, New York
| | - Jonathan R. Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nora Chea
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melinda M. Neuhauser
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Chahine EB, Durham SH, Mediwala KN, Chastain DB, Gauthier TP, Hill BK, Jones BM, Kisgen JJ, Marx AH, Stover KR, Worley MV, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2018. Open Forum Infect Dis 2019; 6:ofz450. [PMID: 31700942 PMCID: PMC6825802 DOI: 10.1093/ofid/ofz450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/06/2019] [Indexed: 02/06/2023] Open
Abstract
With an increasing number of antimicrobial stewardship–related articles published each year, attempting to stay current is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship–related peer-reviewed literature that detailed an actionable intervention for 2018. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the actionable intervention used by antimicrobial stewardship programs to provide key stewardship literature for teaching and training as well as to identify potential intervention opportunities within one’s institution.
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Affiliation(s)
- Elias B Chahine
- Palm Beach Atlantic University Lloyd L. Gregory School of Pharmacy, West Palm Beach, Florida, USA
| | - Spencer H Durham
- Auburn University Harrison School of Pharmacy, Auburn, Alabama, USA
| | | | | | | | - Brandon K Hill
- University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bruce M Jones
- St. Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Jamie J Kisgen
- Sarasota Memorial Health Care System, Sarasota, Florida, USA
| | - Ashley H Marx
- UNC Medical Center, Chapel Hill, North Carolina, USA
| | - Kayla R Stover
- University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Marylee V Worley
- Nova Southeastern University College of Pharmacy, Fort Lauderdale, Florida, USA
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20
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Meddings J, Manojlovich M, Fowler KE, Ameling JM, Greene L, Collier S, Bhatt J, Saint S. A Tiered Approach for Preventing Catheter-Associated Urinary Tract Infection. Ann Intern Med 2019; 171:S30-S37. [PMID: 31569226 DOI: 10.7326/m18-3471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jennifer Meddings
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., S.S.)
| | | | - Karen E Fowler
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (K.E.F.)
| | | | - Linda Greene
- University of Rochester Highland Hospital, Rochester, New York (L.G.)
| | - Sue Collier
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., J.B.)
| | - Jay Bhatt
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., J.B.)
| | - Sanjay Saint
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., S.S.)
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21
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Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Curr Infect Dis Rep 2019; 21:29. [PMID: 31342180 DOI: 10.1007/s11908-019-0683-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to perform a systematic review over the past 5 years on the role and effectiveness of clinical decision support systems (CDSSs) on antibiotic stewardship. RECENT FINDINGS CDDS interventions found a significant impact on multiple outcomes relevant to antibiotic stewardship. There are various types of CDSS implementations, both active and passive (provider initiated). Passive interventions were associated with more significant outcomes; however, both interventions appeared effective. In the reviewed literature, CDSSs were consistently associated with decreasing antibiotic consumption and narrowing the spectrum of antibiotic usage. Generally, guideline adherence was improved with CDSS, although this was not universal. The effect on other outcomes, such as mortality, Clostridiodes difficile infections, length of stay, and cost, inconsistently showed a significant difference. Overall, CDDS implementation has effectively decreased antibiotic consumption and improved guideline adherence across the various types of CDSS. Other positive outcomes were noted in certain settings, but were not universal. When creating a new intervention, it is important to identify the optimal structure and deployment of a CDSS for a specific setting.
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Affiliation(s)
- Barry Rittmann
- Virginia Commonwealth University Health Systems, Richmond, USA. .,, 825 Fairfax Avenue, 4th Floor, Norfolk, VA, 23507, USA.
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22
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Coughlin RF, Peaper D, Rothenberg C, Golden M, Landry ML, Cotton J, Parwani V, Shapiro M, Ulrich A, Venkatesh AK. Electronic Health Record-Assisted Reflex Urine Culture Testing Improves Emergency Department Diagnostic Efficiency. Am J Med Qual 2019; 35:252-257. [PMID: 31296024 DOI: 10.1177/1062860619861947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors evaluated the effectiveness of an electronic health record (EHR)-based reflex urine culture testing algorithm on urine test utilization and diagnostic yield in the emergency department (ED). The study implemented a reflex urine culture order with EHR decision support. The primary outcome was the number of urine culture orders per 100 ED visits. The secondary outcome was the diagnostic yield of urine cultures. After the intervention, the mean number of urine cultures ordered was 5.95 fewer per 100 ED visits (9.3 vs 15.2), and there was a decrease in normal, or negative, cultures by 2.42 per 100 ED visits. There also was a statistically significant decrease in urine culture utilization and an increase in the positive proportion of cultures. Simple EHR clinical decision-support tools along with reflex urine culture testing can significantly reduce the number of urine cultures performed while improving diagnostic yield in the ED.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Arjun K Venkatesh
- Yale New Haven Hospital, New Haven, CT.,Yale New Haven Health System, New Haven, CT
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24
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The evolution of catheter-associated urinary tract infection (CAUTI): Is it time for more inclusive metrics? Infect Control Hosp Epidemiol 2019; 40:681-685. [PMID: 30915925 DOI: 10.1017/ice.2019.43] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Catheter-associated urinary tract infection (CAUTI) has long been considered a preventable healthcare-associated infection. Many federal agencies, the Centers for Medicare and Medicaid Services (CMS), and public and private healthcare organizations have implemented strategies aimed at preventing CAUTIs. To monitor progress in CAUTI prevention, the National Healthcare Safety Network (NHSN) CAUTI metric has been adopted nationally as the primary outcome measure and has been refined over the past decades. However, this surveillance metric may underestimate infectious and noninfectious catheter harm. We suggest evolving to more inclusive performance metrics to better reflect quality improvement efforts underway in hospitals. The standardized device utilization ratio (SUR) provides a good surrogate for preventable catheter harm. On the other hand, a population-based metric that combines both standardized infection ratio (SIR) and SUR would address both infectious and noninfectious harm, while adjusting for population risk. Finally, electronically captured catheter-associated bacteriuria may contribute essential information on local testing stewardship.
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25
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Claeys KC, Blanco N, Morgan DJ, Leekha S, Sullivan KV. Advances and Challenges in the Diagnosis and Treatment of Urinary Tract Infections: the Need for Diagnostic Stewardship. Curr Infect Dis Rep 2019; 21:11. [PMID: 30834993 DOI: 10.1007/s11908-019-0668-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Urinary tract infections (UTIs), including catheter-associated UTIs, are among the most common bacterial infections in both inpatient and outpatient settings. Diagnosis of true UTI remains a clinical challenge, and excessive antimicrobial treatment of asymptomatic bacteriuria (ASB) or contaminated urine cultures is common. RECENT FINDINGS Challenges with the appropriate diagnosis of UTIs include the lack of specific signs and symptoms, no definitive diagnostic criteria, high incidence of ASB, contamination of samples, and frequent lack of indications for ordering urine cultures. Promising interventions include education and feedback, indication requirements when ordering cultures, and use of reflex culture policies that limit urine cultures. Antimicrobial and diagnostic stewardship interventions can work synergistically to decrease ordering of urine cultures without clear indication and prevent excessive antimicrobial administration in patients without clearly defined UTI.
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Affiliation(s)
- Kimberly C Claeys
- Infectious Diseases, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, 20 N. Pine Street, Baltimore, MD, 21201, USA
| | - Natalia Blanco
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Kaede V Sullivan
- Department of Pathology and Laboratory Medicine, Lewis Katz School of Medicine at Temple University, 3500 N. Broad St, Philadelphia, PA, 19140, USA.
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26
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Use of diagnostic stewardship practices to improve urine culturing among SHEA Research Network hospitals. Infect Control Hosp Epidemiol 2018; 40:228-231. [PMID: 30522544 DOI: 10.1017/ice.2018.325] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This survey investigated interventions used by acute-care hospitals to reduce the detection of asymptomatic bacteriuria. Half of the respondents reported using reflex urine cultures but with varied urinalysis criteria and perceived outcomes. Other diagnostic stewardship interventions for urine culture ordering and specimen quality were less common.
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27
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Chida N, Brown C, Mathad J, Carpenter K, Nelson G, Schechter MC, Giles N, Rebolledo PA, Ray S, Fabre V, Cantillo DS, Longworth S, Amorosa V, Petrauskis C, Boulanger C, Cain N, Gupta A, McKenzie-White J, Bollinger R, Melia MT. Internal Medicine Residents' Knowledge and Practice of Pulmonary Tuberculosis Diagnosis. Open Forum Infect Dis 2018; 5:ofy152. [PMID: 30046640 PMCID: PMC6054198 DOI: 10.1093/ofid/ofy152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
Background Internal medicine physicians are often the first providers to encounter patients with a new diagnosis of tuberculosis. Given the public health risks of missed tuberculosis cases, assessing internal medicine residents’ ability to diagnose tuberculosis is important. Methods Internal medicine resident knowledge and practice patterns in pulmonary tuberculosis diagnosis at 7 academic hospitals were assessed utilizing (a) a 10-item validated pulmonary tuberculosis diagnosis assessment tool and (b) a retrospective chart review of 343 patients who underwent a pulmonary tuberculosis evaluation while admitted to a resident-staffed internal medicine or infectious disease service. Our primary outcomes were the mean score and percentage of correct responses per assessment tool question, and the percentage of patients who had Centers for Disease Control and Prevention–recommended tuberculosis diagnostic tests obtained. Results Of the 886 residents who received the assessment, 541 responded, yielding a response rate of 61%. The mean score on the assessment tool (SD) was 4.4 (1.6), and the correct response rate was 57% (311/541) or less on 9 of 10 questions. On chart review, each recommended test was obtained for ≤43% (148/343) of patients, other than chest x-ray (328/343; 96%). A nucleic acid amplification test was obtained for 18% (62/343) of patients, whereas 24% (83/343) had only 1 respiratory sample obtained. Twenty patients were diagnosed with tuberculosis. Conclusions Significant knowledge and practice gaps exist in internal medicine residents’ abilities to diagnose tuberculosis. As residents represent the future providers who will be evaluating patients with possible tuberculosis, such deficiencies must be addressed.
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Affiliation(s)
- Natasha Chida
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Brown
- Department of Medicine, Weill Medical College of Cornell, New York, New York
| | - Jyoti Mathad
- Department of Medicine, Weill Medical College of Cornell, New York, New York
| | - Kelly Carpenter
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - George Nelson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marcos C Schechter
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie Giles
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Paulina A Rebolledo
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Susan Ray
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Valeria Fabre
- Department of Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Diana Silva Cantillo
- Department of Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Sarah Longworth
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Valerianna Amorosa
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Petrauskis
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Catherine Boulanger
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Natalie Cain
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Amita Gupta
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jane McKenzie-White
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert Bollinger
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael T Melia
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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