Sage Journals: Discover world-class research

Abstract

Background:

Asymptomatic bacteriuria (ASB) is often overtreated, risking patient harm through unnecessary antimicrobial use and fostering antimicrobial resistance. Despite this, patients continue to be treated for ASB requiring targeted intervention for antimicrobial stewardship teams across health systems.

Objectives:

This study assessed the impact of a multistep urinary tract infection (UTI)-focused stewardship initiative by comparing the incidence of asymptomatic urinary presentation (AUP) treatment before and after implementation.

Design:

Retrospective cohort study.

Methods:

Patients ⩾18 years at University of Kentucky HealthCare who received antimicrobial therapy with a urinalysis (UA) and/or urine culture (UCx) collected for a presumed UTI between January 2023 and March 2023 (pre-implementation) and January 2024 and March 2024 (post-implementation) were included in the study. Our primary outcome was to compare the frequency of AUP treatment between groups.

Results:

Overall, 288 patients were included in the study, with 144 patients in both the pre- and post-implementation groups. Treatment of AUPs significantly decreased by 12% after initiative implementation (47% pre-implementation vs 35% post-implementation, p = 0.042). Additionally, we observed a significant difference in guideline-adherent management between the two groups (29% pre-implementation vs 44% post-implementation, p = 0.007). Patients were more likely to receive guideline-adherent UTI treatment durations (38% vs 53%, p = 0.009) and guideline-adherent definitive antibiotics (18% vs 35%, p < 0.001) post-implementation compared to pre-implementation.

Conclusion:

Our stewardship initiative resulted in reduced treatment of AUPs and improved adherence to UTI management guidelines. Overall, a multifaceted stewardship initiative is a successful intervention to decrease the treatment of AUPs and unnecessary antibiotic utilization. However, additional frontline stewardship initiatives are likely warranted to decrease the unnecessary ordering of UAs.

Keywords

antimicrobial stewardship asymptomatic bacteriuria UTI

Background

Asymptomatic bacteriuria (ASB) is a commonly overtreated condition within the health care system.¹ ASB is defined as the isolation of ⩾10⁵ colony-forming units (CFU) per milliliter of bacteria in a urine specimen from a patient without signs or symptoms of a urinary tract infection (UTI) such as dysuria, urinary frequency or urgency, suprapubic pain, or flank pain.¹ The Infectious Diseases Society of America guidelines recommend only pregnant women and individuals undergoing endoscopic urologic procedures associated with mucosal trauma be screened and treated appropriately for ASB.² Literature suggests that treatment of ASB in patients who do not fall under the above categories does not improve treatment outcomes.^2,3 In addition, treatment of ASB involves inappropriate antimicrobial use that is often associated with collateral damage such as increased adverse drug effects, antimicrobial resistance, risk for recurrent UTIs, Clostridioides difficile-associated diarrhea, and results in an overall increase in healthcare associated costs.^2,4 Despite this literature, patients continue to be treated for ASB when presenting to various healthcare settings.^5–7 A meta-analysis performed in 2017 reported that ~45% of hospitalized patients within academic medical centers received treatment for ASB.⁸ In addition, in 2022, an institution reported that roughly 70% of patients within the health system were treated for ASB.⁹

Disease state stewardship interventions are highlighted as one of the core elements of hospital antibiotic stewardship programs by the Centers for Disease Control and Prevention (CDC).¹⁰ There have been many studies that have looked at individual stewardship interventions and their impact on ASB treatment and antibiotic prescribing.^11–15 Lamb and colleagues analyzed the impact of removing routine urine culture screening in patients undergoing joint arthroplasty and found a reduction in the number of urine cultures ordered as well as the number of antimicrobial prescriptions sent for asymptomatic bacteriuria.¹¹ Other studies implemented stewardship educational sessions within their health system and observed a reduction in urine culture utilization as well as prescribing of antibiotics.^13,14 Many of these studies have focused on a single intervention related to diagnostic stewardship or antimicrobial stewardship, but not both.^11–14 Given the lack of data in this area, the University of Kentucky HealthCare (UKHC) Antimicrobial Stewardship Team (AST) implemented a multistep UTI stewardship initiative that included interventions pertaining to both diagnostic and antimicrobial stewardship. The purpose of our study was to evaluate the effectiveness of the multistep UTI-focused disease state stewardship intervention on the reduction of treatment of asymptomatic urinary presentations (AUPs).

Methods

Study design

This was a retrospective cohort study evaluating adult patients at UKHC between January and March of 2023 and 2024 who received antibiotics for a UTI indication. Data was collected through the University of Kentucky Center for Clinical and Translational Science Enterprise Data Trust (CCTS), and UKHC’s electronic health record (EHR), Epic. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Supplemental File 1).¹⁶

Eligibility criteria

Patients 18 years of age or older who were admitted to UKHC, received antimicrobials with a documented indication as treatment of a UTI, and had a urinalysis (UA) or urine culture (UCx) collected within 48 h of antibiotic initiation between January 2023 and March 2023 and January 2024 and March 2024 were included in our analysis. Patients were excluded if they were pregnant, underwent any urologic procedure during their admission, were transferred from an outside hospital already on antimicrobials or did not complete their prescribed antimicrobials with a documented indication for treatment of a UTI due to death or transfer to hospice.

Stewardship initiative implementation

Beginning in August 2023, UKHC implemented a four-phase UTI stewardship initiative (Table 1). Phase I included Informational Technology (IT) optimization with the AST identifying order sets that included a UA and/or UCx. The AST collaborated with primary team pharmacists and physicians to remove default UAs and/or UCxs from admission order sets and optimized UA and UCx order indications. Phase II of the study took place during the fall of 2023 and included provider education sessions focused on the appropriate diagnosis and treatment of UTIs versus ASB, the new UA with reflex to UCx, and the updated institutional UTI management guideline approved by the Antimicrobial Stewardship Subcommittee. There were over twenty educational sessions completed, and these were presented to a variety of treatment teams, including neurosurgery, trauma/general surgery, family medicine, urology, hematology, and hospitalist teams. Since a clinical pharmacist is a member of each of these teams, education was also geared toward the pharmacy team. The focus of these sessions involved the appropriate diagnosis of UTIs with a focus on UA utility, candiduria and its association with colonization, ASB and who should not be screened or treated, the proper approach to ASB in complex populations such as altered mental status and spinal cord injury, and the harmful consequences of ASB treatment. The UTI management guideline presented to these teams included guidance on the appropriate diagnosis of UTIs (and distinguishing them from ASB) as well as optimal treatment based on our local antibiogram and antimicrobial stewardship principles. Additional education was provided to the nursing team on proper urine collection techniques. The new UA with reflex to UCx order was implemented in phase III in November 2023 and education about this new order was provided at the educational sessions described previously. This order required the collection of two urine specimens, one for a UA and one for a UCx, as the UCx was only processed if the UA demonstrated > 10 white blood cells (WBC)/high power field (HPF) to decrease the treatment of ASB in the absence of inflammation. This cutoff was agreed upon by the UKHC AST based on primary literature suggesting that this cutoff was best associated with true pyuria.^17–19 Phase IV of the initiative involved prospective audit and feedback (PAAF) of patients receiving antibiotics for a UTI indication. AST members would review patients and determine if management was consistent with the institutional UKHC “Guideline for the Management of Urinary Tract Infections in Adult” (Supplemental File 2). If management was discordant, AST members would intervene by contacting the primary team managing the patient to provide recommendations for optimization. Patients who received antibiotics for a UTI indication from January to March 2023 were the pre-implementation cohort, while those who received UTI therapy from January 2024 to March 2024 were the post-implementation group.

Table 1.

UTI stewardship initiative timeline.

Phase	Intervention
I (August 2023)	Informational Technology (IT) optimization
II (September–November 2023)	Provider education sessions
III (November 2023)	Implementation of new UA with reflex to urine culture order
IV (January–March 2024)	Prospective audit and feedback (PAAF)

UA, urinalysis; UTI, urinary tract infection.

Outcomes

The primary outcome was the frequency of treatment of AUPs, which was defined as those who received at least one dose of an antimicrobial who presented without institutional guideline-approved urinary symptoms. Patients who were found to be treated for an AUP were classified into separate categories based on culture results and other clinical factors. Categories included asymptomatic bacteriuria, asymptomatic pyuria, and other asymptomatic presentations. Asymptomatic bacteriuria was defined as those with ⩾10 WBC/HPF seen on UA, who received antibiotics for a UTI indication without guideline-approved symptoms and an organism isolated on the urine culture, regardless of colony count. Asymptomatic pyuria was defined as those with ⩾10 WBC/HPF seen on UA, who received antibiotics for a UTI indication without guideline-approved symptoms, but did not have an organism isolated on the urine culture. The other asymptomatic presentation classification included patients without urinary symptoms but did not fit into either of the previous two categories due to having mixed urogenital flora or a fungal organism isolated on the urine culture. Secondary outcomes included 30-day and 90-day readmission rates; incidence of Clostridioides difficile infection, defined as having both a positive C. difficile PCR and positive toxin EIA; incidence of infections due to resistant pathogens or colonization due to resistant pathogens; 90-day mortality, defined as death within 90 days after the UCx and/or UA was obtained; hospital length of stay; intensive care unit (ICU) length of stay; exposure to anti-pseudomonal beta-lactams, defined as receiving at least one dose of cefepime, piperacillin-tazobactam or meropenem; carbapenems, defined as receiving at least one dose of ertapenem or meropenem; or fluoroquinolones, defined as receiving at least one dose of ciprofloxacin or levofloxacin; incidence of UTI treatment with altered mental status as the only reported symptom; and the incidence of guideline-adherent management.

Guideline-adherent management was accomplished if all of the following criteria were met: (1) UA and UCx indicated, (2) empirical and definitive antibiotics indicated, (3) empirical and definitive antibiotic selection guideline-adherent, and (4) guideline-adherent treatment duration. A UA was considered indicated if the patient presented with any guideline-approved UTI-related symptom. Patients were considered to have an indicated UCx if they presented with an approved symptom and >10 WBC/HPF on the UA. Empiric antibiotics were indicated if the patient presented with an approved symptom and >10 WBC/HPF on the UA. Definitive antibiotics were indicated if the patient presented with an approved symptom, >10 WBC/HPF on the UA, and an organism isolated on the urine culture. Empiric antibiotic selection was guideline-adherent based on patient-specific risk factors highlighted from the institutional UTI guideline (Supplemental File 2). The definitive antibiotic selection was guideline-adherent if the antibiotic(s) chosen aligned with the susceptibility results on the UCx, and the narrowest antibiotic was chosen. Treatment duration was considered guideline-adherent if the patient received antibiotics for the suggested duration based on the institutional UTI guideline, according to their UTI classification +/− 1 day of therapy.

Additional secondary outcomes included the individual components within the guideline-adherent management outcome. Patient demographics that were collected included age, weight, sex, height, comorbidities, body mass index (BMI), the service line that ordered the UA and/or UCx, and the facility where treatment occurred.

Statistical analysis

A sample size of 139 patients in each cohort was calculated to observe an anticipated 15% decrease in the treatment of AUPs from 36% to 21% based on previous internal data. To account for differences between the two cohorts, patients were matched based on age, Charlson comorbidity index, gender, race, and whether they were treated at our main hospital, Chandler Medical Center, or our affiliate, Good Samaritan Hospital using matched pairing. Patient demographics and treatment outcomes were analyzed using a Student’s t-test or Mann–Whitney U test for parametric and non-parametric continuous variables, respectively. Pearson’s chi-square and Fisher’s exact test were used for categorical variables. Medians with interquartile ranges were used for skewed results, while means with standard deviations were used for variables with approximately normal distributions. For categorical variables, counts and percentages were reported.

Results

Baseline characteristics

Overall, 288 patients were included in the study with 144 patients in both the pre-implementation and post-implementation groups (Figure 1). Patients had a median age of 69 years (interquartile range (IQR), 57–77) (Table 2). The majority of patients were Caucasian (88.9%), female (66.6%) and admitted to Chandler Hospital (66%). Fewer patients were classified as having complicated cystitis in the pre-implementation group compared to those in the post-implementation group (12% vs 26%, p = 0.008). In addition, more patients in the pre-implementation group were classified as having “other asymptomatic presentation” (23% vs 9%, p = 0.008). Only 4% of the cohort was admitted to the ICU at the time of the index UA or UCx was ordered. There were no differences in the Charlson comorbidity index between the two groups (7.17 pre-implementation vs 6.63 post-implementation, p = 0.220). Fewer patients were transferred from an outside hospital in the pre-implementation group when compared to the post-implementation group (19% vs 30%, p = 0.028). Overall, the emergency medicine service ordered the majority of the index UAs or UCx for the patient cohorts (51%). Fewer patients in the pre-implementation group were admitted to one of our institution’s hospitalist medicine teams compared to our post-implementation group (34% vs 45%, p = 0.044). In addition, there were more patients admitted to our institution’s non-medicine team in our pre-implementation group compared to our post-implementation group (28% vs 15%, p = 0.044). A smaller percentage of patients in the pre-implementation group received treatment for a concomitant infection compared to the post-implementation group (1% vs 5%, p = 0.067), which was defined as those receiving antimicrobials for a bloodstream infection or any other nonbacterial infection.

Figure 1.

Flowchart of exclusion criteria.

Table 2.

Baseline characteristics, comorbidities, and baseline laboratory concentrations.

Baseline characteristic	Pre-implementationN = 144	Post-implementationN = 144	p -Value
Age^a (years)	69 (57–77)	69 (57–76)	0.853
Gender^b (male)	48 (33.3)	48 (33.3)	1.000
Race^b (Caucasian)	128 (88.9)	128 (88.9)	1.000
Weight^a (kg)	76.2 (62.0–88.5)	77.8 (61.8–92.8)	0.622
Body mass index^a (kg/m²)	26.5 (22.3–32.4)	26.7 (22.5–33.4)	0.453
eGFR^c (ml/min)	62.0 ± 35.0	70.3 ± 33.1	0.052
ICU^b	6 (4)	7 (5)	0.777
Charlson Comorbidity Index^c	7.2 ± 3.9	6.6 ± 3.5	0.220
OSH transfer^b	27 (19)	43 (30)	0.028
Concomitant infection^b	1 (1)	7 (5)	0.067
History of dementia^b	23 (16)	28 (19)	0.440
History of hemiplegia or paraplegia^b	19 (13)	22 (15)	0.613
Ordering provider team^b	EM: 74 (51) Surgery: 14 (10) Medicine: 56 (39)	EM: 73 (51) Surgery: 10 (7) Medicine: 61 (42)	0.642
Treatment provider team^b	Medicine: 49 (34) Non-medicine: 40 (28) Heme/Transplant: 6 (4) GSH: 49 (34)	Medicine: 65 (45) Non-medicine: 22 (15) Heme/Transplant: 9 (6) GSH: 48 (33)	0.044
Hospital (Chandler)^b	95 (66)	95 (66)	1.000
UTI symptoms^b	Unexplained suprapubic pain: 8 (6) Unexplained flank pain: 14 (10) Dysuria: 30 (21) Urinary urgency: 4 (3) Increased urinary frequency: 1 (1) Fever with kidney transplant: 0 (0) Fever with urinary obstruction: 0 (0) Unexplained AMS: 15 (10) Septic shock without cause: 3 (2) Spinal cord injury with symptoms: 1 (1)	Unexplained suprapubic pain: 16 (11) Unexplained flank pain: 15 (10) Dysuria: 32 (22) Urinary urgency: 2 (1) Increased urinary frequency: 4 (3) Fever with kidney transplant: 2 (1) Fever with urinary obstruction: 1 (1) Unexplained AMS: 8 (6) Septic shock without cause: 3 (2) Spinal cord injury with symptoms: 8 (6)	0.061
UTI classification^b	Uncomplicated cystitis: 24 (17) Complicated cystitis: 18 (12) Pyelonephritis: 21 (14) CAUTI: 4 (3) ASB: 23 (16) Asymptomatic pyuria: 12 (8) Other asymptomatic: 33 (23) Other: 9 (6)	Uncomplicated cystitis: 23 (16) Complicated cystitis: 38 (26) Pyelonephritis: 19 (13) CAUTI: 8 (6) ASB: 28 (19) Asymptomatic pyuria: 10 (7) Other asymptomatic: 13 (9) Other: 5 (4)	0.008

Median (IQR).

Number (%).

Mean ± SD.

ASB, asymptomatic bacteriuria; CAUTI, catheter-associated urinary tract infection; eGFR, estimated glomerular filtration rate; EM, emergency medicine; GSH, Good Samaritan Hospital; ICU, intensive care unit; IQR, interquartile range; OSH, outside hospital; SD, standard deviation; UTI, urinary tract infection.

Outcomes

The treatment of AUPs decreased by 12% and occurred in 47% of the pre-implementation group and 35% of the post-implementation group (p = 0.042). In addition, we observed a statistically significant difference in guideline-adherent management between the two groups (Table 3). Guideline-adherent management occurred in 29% of the pre-group and 44% of the post group (p = 0.007). There were also statistically significant differences between the groups in regard to each of the following individual guideline-adherent criteria: definitive antibiotics indicated (42% pre-implementation vs 55% post-implementation, p = 0.025), definitive antibiotic selection (18% vs 35%, p < 0.001), and duration (38% vs 53%, p = 0.009).

Table 3.

Primary and secondary outcomes.

Outcome	Pre-implementationN = 144	Post-implementationN = 144	p-Value
Treatment of AUP^b	68 (47)	51 (35)	0.042
Guideline-adherent management^b	41 (29)	63 (44)	0.007
UA indicated^b	76 (53)	91 (63)	0.073
Urine culture indicated^b	72 (50)	86 (60)	0.097
Empiric antibiotics indicated^b	74 (51)	88 (61)	0.096
Empiric antibiotic selection guideline-adherent^b	68 (47)	77 (54)	0.289
Definitive antibiotics indicated^b	60 (42)	79 (55)	0.025
Definitive antibiotic selection guideline-adherent^b	26 (18)	51 (35)	<0.001
Guideline-adherent duration^b	54 (38)	76 (53)	0.009
30-day readmission^b	29 (20)	32 (22)	0.665
90-day readmission^b	52 (36%)	51 (35%)	0.902
Hospital length of stay^a	6.8 (4.0–13.0)	8.8 (5.2–13.4)	0.047
ICU length of stay^a	7.5 (5.1–18.3)	6.0 (3.6–6.6)	0.234
Development of Clostridioides difficile infection^b	0 (0)	2 (1)	0.498
Anti-pseudomonal beta-lactam use^b	30 (21)	44 (31)	0.059
Carbapenem use^b	9 (6)	19 (13)	0.047
Fluoroquinolone use^b	6 (4)	13 (9)	0.097
Incidence of infections due to resistant pathogens or colonization due to resistant pathogens^b	6 (4)	4 (3)	0.750
AMS as only reported symptom^b	13 (9)	8 (6)	0.257
Mortality^b	18 (13)	14 (10)	0.453

Median (IQR).

Number (%).

AMS, altered mental status; AUP, asymptomatic urinary presentation; ICU, intensive care unit; UA, urinalysis.

We did not find any statistically significant difference in 30- and 90-day readmission rates, development of C. difficile infection, incidence of infections due to resistant pathogens or colonization due to resistant pathogens, or 90-day mortality. Although not statistically significant, we did observe a decrease in patients treated for a UTI with altered mental status as the only reported symptom (9% in the pre-implementation group vs 6% in the post-implementation group) (Table 3). In addition, fewer patients received an anti-pseudomonal beta-lactam in the pre-implementation group compared to the post-implementation group (21% vs 31%, p = 0.059), as well as fluoroquinolones (4% vs 9%, p = 0.097), and carbapenems during their course of therapy (6% vs 13%, p = 0.047).

Discussion

Our study involved a multifaceted UTI stewardship intervention consisting of both diagnostic and treatment interventions, including IT optimization, education, implementation of a new UA with reflex to culture order, and PAAF. We saw a significant decrease in the treatment of AUPs from 47% to 35%. This is similar to previous studies that looked at the implementation of various stewardship interventions. McMaughan et al.²⁰ implemented a clinical decision support tool in several nursing homes, resulting in a reduction of the treatment of ASB from approximately 80% to 60%. The extent of this reduction varied based on the level of education provided to the healthcare staff regarding the tool. In addition, Irfan et al.²¹ observed a reduction in the treatment of ASB from 48% to 8% following the implementation of education, a treatment algorithm, and PAAF. The smaller reduction seen in our study remains unclear but may be attributable to several factors, including a need for additional, targeted education to treatment teams or due to previous AST initiatives focused on UTI management having already impacted the reduction. Despite providing educational sessions to most specialties within the hospital, we were unable to determine the percentage of specialties that implemented practices recommended by our institutional guidelines. In addition, sporadic PAAF by the AST occurred in 2023 which could have had a lingering impact on our outcomes within the preinitiative group.

In addition to decreased treatment of ASB, our initiative was successful in increasing guideline adherence. Overall, improvement in the appropriate selection of definitive antibiotics, indicated definitive antibiotics and guideline-adherent duration were observed. Many studies have analyzed the changes in guideline adherence after the implementation of a UTI management guideline. Zalmanovich et al.²² implemented a bundled stewardship initiative in the emergency department that included guideline implementation, education, implementation of order sets and PAAF. The authors observed an increase in guideline adherence of antibiotic selection and duration from 41% to 84%. In addition, Percival et al.²³ implemented UTI management guidelines in their institution and found an increase in adherence from 45% to 83%. Dissimilar to our study, the authors observed an increase in appropriate empiric antibiotic selection for patients treated for a UTI. It is possible that we did not observe a difference in empiric antibiotic selection because, although we educated on our guideline and the appropriate treatment of UTIs, the PAAF portion of our initiative occurred after antibiotic selection, which prevented us from making an impact on the selection upfront. Overall, our initiative has provided additional evidence to support the implementation of a multifaceted stewardship initiative to improve guideline management of UTIs.

Approximately 50% of all index UAs and UCx within our study were ordered in the emergency department. It is known that unnecessary ordering of urine cultures contributes to the unnecessary treatment of ASB.^19,24,25 Since the patient’s first point of contact is often within the emergency department, where UAs and UCxs may be obtained as part of routine initial workup, antimicrobial stewardship teams should consider initiatives targeted to these specific areas. Previous studies related to the implementation of stewardship interventions within the ED have shown improved prescribing practices, reduced ED visits, and decreased broad-spectrum antimicrobial utilization.^22,26–28

Furthermore, we were unable to observe a reduction in broad-spectrum antibiotics such as fluoroquinolones, anti-pseudomonal beta-lactams and carbapenems. As previously stated, most literature surrounding the implementation of stewardship initiatives has shown a reduction in broad-spectrum antimicrobial utilization.^22,28 At our institution, carbapenems are not restricted to ID consult or AST approval, but are considered protected, criteria-based antimicrobials, meaning that specific criteria are listed within the order for use of these agents. Specifically, the only two indications listed for carbapenem use are for “suspected or documented infections only susceptible to carbapenems” or “severe type II-IV beta-lactam, non-carbapenem, allergy when beta-lactam therapy indicated,” to help guide appropriate prescribing. Carbapenem use is reviewed periodically through PAAF. Although our patients in the pre-implementation and post-implementation groups were matched using matched pairing, we believe the increased utilization of carbapenems, fluoroquinolones and anti-pseudomonal beta-lactams could be due to the patient population included within our study. The post-implementation group consisted of more patients with complicated UTIs, which may have caused providers to initiate broad-spectrum antibiotics empirically before additional information was obtained or may have been based on past culture results, especially if patients had frequent recurrent UTIs. We did not observe a difference in the appropriateness of empiric antibiotic selection (47.2% vs 53.5%) and saw an increase in appropriateness of definitive antibiotic selection (18.1% vs 35.4%) in the post group, suggesting that utilization of these broader agents was likely appropriate.

While our study highlights the impact of stewardship initiatives on the treatment of AUPs, it is not without limitations. UTI or AUP classification was dependent on the clinical judgment of the study evaluator as well as documentation within the EHR. It is possible that some classifications may be discordant with the patient’s true clinical status or interpreted differently depending on the clinician. However, given the pragmatic approach that we took for this study, using objective definitions for UTI classifications, we believe this to be an accurate representation of antimicrobial stewardship initiatives across health care systems and mitigated any risk of inter-evaluator variability in UTI or AUP classification. In addition, because our intervention included multiple steps and was implemented at various time points during 2023, we were unable to assess the effectiveness of individual interventions. Lastly, technical barriers with the implementation of the UA with reflex to urine culture order led to slow utilization despite provider interest in ordering the new lab. Knowledge acquired from encountering these issues will be used to prevent similar problems with future initiatives. Despite these limitations, the findings within our study highlight the major impact ASTs can have with the implementation of a multistep initiative.

Conclusion

Our stewardship initiative resulted in a reduction of the treatment of AUPs and improved UTI guideline-adherent management. Overall, a multifaceted stewardship initiative was a successful intervention to decrease the treatment of AUPs and decrease unnecessary antibiotic utilization. While beneficial, this study also highlights the continued need to address diagnostic stewardship at the forefront, as 35% of patients were still treated for an AUP in the post group. Additional stewardship initiatives should consider ways to improve the appropriate ordering of urine cultures and urinalyses in the emergency department.

Supplemental Material

sj-docx-1-tai-10.1177_20499361251391259 – Supplemental material for Impact of a multistep urinary tract infection-focused disease state stewardship initiative on the treatment of asymptomatic urinary presentations: a retrospective cohort study

Supplemental material, sj-docx-1-tai-10.1177_20499361251391259 for Impact of a multistep urinary tract infection-focused disease state stewardship initiative on the treatment of asymptomatic urinary presentations: a retrospective cohort study by Christian Tyler Pitcock, Danielle Casaus, Sarah E. Garvey, Katie Ruf, Donna R. Burgess, Jeremy D. VanHoose, David S. Burgess, Ryan Mynatt, Armaghan-e-Rehman Mansoor, Nicholas Van Sickels, Mitu Karki Maskey, Thein Myint, Aric Schadler and Katie L. Wallace in Therapeutic Advances in Infectious Disease

Supplemental Material

sj-docx-2-tai-10.1177_20499361251391259 – Supplemental material for Impact of a multistep urinary tract infection-focused disease state stewardship initiative on the treatment of asymptomatic urinary presentations: a retrospective cohort study

Supplemental material, sj-docx-2-tai-10.1177_20499361251391259 for Impact of a multistep urinary tract infection-focused disease state stewardship initiative on the treatment of asymptomatic urinary presentations: a retrospective cohort study by Christian Tyler Pitcock, Danielle Casaus, Sarah E. Garvey, Katie Ruf, Donna R. Burgess, Jeremy D. VanHoose, David S. Burgess, Ryan Mynatt, Armaghan-e-Rehman Mansoor, Nicholas Van Sickels, Mitu Karki Maskey, Thein Myint, Aric Schadler and Katie L. Wallace in Therapeutic Advances in Infectious Disease

Footnotes

Acknowledgements

We would like to thank Dr. John R. Bell, Dr. Donald P. Bell, and the University of Kentucky Antimicrobial Stewardship team for their assistance in implementing the UTI initiative.

Declarations

ORCID iDs

Christian Tyler Pitcock

Jeremy D. VanHoose

Armaghan-e-Rehman Mansoor

Nicholas Van Sickels

Katie L. Wallace

Supplemental material

Supplemental material for this article is available online.

References

Luu

Albarillo

FS.

Asymptomatic bacteriuria: prevalence, diagnosis, management, and current antimicrobial stewardship implementations. Am J Med 2022; 135: e236–e244.

Nicolle

Gupta

Bradley

, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019; 68: e83–e110.

Harding

Zhanel

Nicolle

, et al. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med 2002; 347: 1576–1583.

Advani

Polage

Fakih

MG.

Deconstructing the urinalysis: a novel approach to diagnostic and antimicrobial stewardship. Antimicrob Steward Healthc Epidemiol 2021;1: e6.

Petty

Vaughn

Flanders

, et al. Risk factors and outcomes associated with treatment of asymptomatic bacteriuria in hospitalized patients. JAMA Intern Med 2019; 179: 1519–1527.

Sloane

Kistler

Reed

, et al. Urine culture testing in community nursing homes: gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol 2017; 38: 524–531.

Spivak

Burk

Zhang

, et al. Management of bacteriuria in veterans affairs hospitals. Clin Infect Dis 2017; 65: 910–917.

Flokas

Andreatos

Alevizakos

, et al. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis 2017; 4: ofx207.

Liu

MacDonald

Jain

, et al. Prevalence and treatment of asymptomatic bacteriuria at academic and critical-access hospitals-opportunities for stewardship efforts. Infect Control Hosp Epidemiol 2023; 44: 979–981.

10.

Pollack

Srinivasan

Core elements of hospital antibiotic stewardship programs from the centers for disease control and prevention. Clin Infect Dis 2014; 59(Suppl. 3): S97–S100.

11.

Lamb

Baillie

Pajak

, et al. Elimination of screening urine cultures prior to elective joint arthroplasty. Clin Infect Dis 2017; 64: 806–809.

12.

Stagg

Lutz

Kirpalaney

, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2018; 27: 140–147.

13.

Hartman

EAR

van de Pol

Heltveit-Olsen

, et al. Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries. BMJ 2023; 380: e072319.

14.

Al-Bizri

Vahia

Rizvi

, et al. Effect of a urine culture stewardship initiative on urine culture utilization and catheter-associated urinary tract infections in intensive care units. Infect Control Hosp Epidemiol 2022; 43: 1032–1035.

15.

Vaughn

Gupta

Petty

, et al. A statewide quality initiative to reduce unnecessary antibiotic treatment of asymptomatic bacteriuria. JAMA Intern Med 2023; 183: 933–941.

16.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344–349.

17.

Humphries

Dien Bard

Point-counterpoint: reflex cultures reduce laboratory workload and improve antimicrobial stewardship in patients suspected of having urinary tract infections. J Clin Microbiol 2016; 54(2): 254–258.

18.

Garcia

Spitzer

ED.

Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections. Am J Infect Control 2017; 45(10): 1143–1153.

19.

Schulz

Hoffman

Pothof

, et al. Top ten myths regarding the diagnosis and treatment of urinary tract infections. J Emerg Med 2016; 51(1): 25–30.

20.

McMaughan

Nwaiwu

Zhao

, et al. Impact of a decision-making aid for suspected urinary tract infections on antibiotic overuse in nursing homes. BMC Geriatr 2016; 16: 81.

21.

Irfan

Brooks

Mithoowani

, et al. A controlled quasi-experimental study of an educational intervention to reduce the unnecessary use of antimicrobials for asymptomatic bacteriuria. PLoS One 2015; 10: e0132071.

22.

Zalmanovich

Katzir

Chowers

, et al. Improving urinary tract infection treatment through a multifaceted antimicrobial stewardship intervention in the emergency department. Am J Emerg Med 2021; 49: 10–13.

23.

Percival

Valenti

Schmittling

, et al. Impact of an antimicrobial stewardship intervention on urinary tract infection treatment in the ED. Am J Emerg Med 2015; 33: 1129–1133.

24.

Redwood

Knobloch

Pellegrini

, et al. Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrob Resist Infect Control 2018; 7: 4.

25.

Fridkin

Baggs

Fagan

, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep 2014; 63: 194–200.

26.

Jorgensen

SCJ

Yeung

Zurayk

, et al. Leveraging antimicrobial stewardship in the emergency department to improve the quality of urinary tract infection management and outcomes. Open Forum Infect Dis 2018; 5: ofy101.

27.

Hecker

Fox

Son

, et al. Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting. PLoS One 2014; 9: e87899.

28.

Ingalls

Veillette

Olson

, et al. Impact of a multifaceted intervention on antibiotic prescribing for cystitis and asymptomatic bacteriuria in 23 community hospital emergency departments. Hosp Pharm 2023; 58: 401–407.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB

0.98 MB