Asymptomatic bacteriuria: Impact of an antimicrobial stewardship bundle to reduce unnecessary antibiotics in patients without urinary catheters ...
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AJHP RESIDENTS EDITION
Asymptomatic bacteriuria: Impact of an antimicrobial
stewardship bundle to reduce unnecessary antibiotics
in patients without urinary catheters
Matthew Rico, PharmD, Department of
Pharmacy Services, Beaumont Hospital, Purpose. The purpose of this study was to evaluate the effect of an anti-
Royal Oak, MI, USA
microbial stewardship bundle on the management of asymptomatic bac-
Rand Sulaiman, PharmD, BCIDP, teriuria (ASB).
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Michigan Division, Ascension Health,
St. Louis, MO, USA.
Methods. In this quasi-experimental study, patients were selected by
Rachel MacLeod, PharmD, BCIDP,
AAHIVP, Department of Pharmacy retrospective, consecutive sampling of patients with a positive urine culture
Services, Ascension Genesys Hospital, report in 3 separate groups: preintervention, postdiagnostic intervention,
Grand Blanc, MI, USA and posteducation. Patients met the prespecified criteria for non–catheter-
associated ASB. The diagnostic intervention involved a new urinalysis/
urine culture ordering process in place of urinalysis with reflex to urine
culture. Additionally, an educational intervention involved pharmacist-led
sessions to educate providers with patient cases and guideline-based re-
commendations. The primary outcome of this study was the difference
in the rate of inappropriate management of ASB, defined as the use of
antimicrobial agents intended to treat ASB. Secondary outcomes included
length of antimicrobial therapy, length of stay, and change in urine culture
orders per 1,000 patient-days.
Results. A total of 120 patients were included. There was a signifi-
cant reduction in the inappropriate management of ASB between the
preintervention and postdiagnostic intervention groups (P = 0.0349).
This was not seen when comparing the postdiagnostic intervention and
posteducation groups (P = 0.93). Additionally, there was a significant dif-
ference in urinalysis/urine culture ordering between the preintervention
and postdiagnostic intervention groups (370 vs 224 urinalysis orders
per 1,000 days present, P < 0.0001; 131 vs 54 urine culture orders per
1,000 days present, P < 0.0001).
Conclusion. An antimicrobial stewardship bundle involving a diagnostic
stewardship intervention and pharmacist-led education reduced treatment
of ASB in patients without urinary catheters.
Keywords: antimicrobial stewardship, asymptomatic bacteriuria,
diagnostic stewardship, pharmacist education, UTI
Am J Health-Syst Pharm. 2021;78(suppl 3):S83-S87
Address correspondence to Dr. Rico
B ecause of the increasing prevalence
of antimicrobial resistance in the
United States, implementing antimicro-
on treatment of ASB as an update to
their 2005 guidelines, further reiterating
the unnecessary nature of antimicro-
(matt.rico8@gmail.com).
bial stewardship initiatives has become bial use in the management of ASB in
Twitter: @voRIC0nazole
a key focus across health systems. One most patient populations.3 Despite these
target for many inpatient antimicrobial efforts, studies have reported that up-
Published by Oxford University Press stewardship programs is to limit the wards of 65% of patients are treated with
on behalf of the American Society of
Health-System Pharmacists 2021. This use of antimicrobials for asymptom- antimicrobials for ASB.4
work is written by (a) US Government atic bacteriuria (ASB).1,2 The Infectious Several antimicrobial stewardship
employee(s) and is in the public domain
in the US. Diseases Society of America (IDSA) re- programs across the United States have
DOI 10.1093/ajhp/zxab220
cently published new recommendations described the use of multifactorial
AM J HEALTH-SYST PHARM | VOLUME 78 | SUPPLEMENT 3 | September 1, 2021 S83AJHP RESIDENTS EDITION ANTIMICROBIAL INTERVENTION FOR ASYMPTOMATIC BACTERIURIA
approaches to reduce the use of Michigan with institutional review
antimicrobials in this patient popula- board approval. Patients included in
tion. Two different institutions used the study were hospitalized adults
real-time clinical surveillance software who were 18 years or older and met
to identify patients with positive urine the definition of being treated for ASB.
cultures and/or abnormal urinalysis Patients were identified by consecu-
results, in turn prompting pharmacist- tive sampling of patients with positive
driven intervention to assess the appro- urine culture reports and retrospective
priateness of antimicrobial therapy in chart review. ASB was defined as the
each case. Results for the 2 studies were identification of bacteria in a urine
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similar, showing an average reduction culture without documented signs or
of 3 days of inappropriate treatment.5,6 symptoms of urinary infection. A non–
Other interventions entailed pharma- catheter-associated UTI was defined
cist education of various healthcare as meeting the following 3 criteria: (1)
providers to assess for changes in in- no catheter used for 2 or more days
appropriate management of ASB. These on the inpatient setting; (2) at least 1
educational sessions commonly in- Matthew Rico, PharmD, is the of the following symptoms: fever of
cluded guideline-based recommenda- current postgraduate year 2 more than 100.4°F, suprapubic tender-
infectious diseases pharmacy
tions, information on diagnostic testing, resident at Beaumont Hospital in
ness, costovertebral angle tenderness,
and treatment algorithms to assist phys- Royal Oak, MI. Dr. Rico received urinary urgency, urinary frequency,
icians in understanding the proper treat- his bachelor of science degree or dysuria; and (3) 2 or fewer species
in biology in 2016 and doctor
ment of urinary tract infections (UTIs).7 of pharmacy degree in 2019 of bacteria (>100,000 colony-forming
Additionally, some institutions have from Ferris State University in units/mL) in the urine culture. Patients
Big Rapids, MI. He completed a
targeted a reduction in antimicrobial postgraduate year 1 pharmacy were excluded if they were pregnant,
use based on modifying their electronic residency at Ascension Genesys had a history of urinary stents, had a
health record (EHR) to discourage the Hospital in Grand Blanc, MI. His planned urologic procedure, had a con-
current research interests are in the
inappropriate ordering of urine cultures. areas of antimicrobial stewardship, comitant infection, or had a history of
Keller and colleagues8 implemented an therapeutic drug monitoring, and spinal cord injury.
Gram-negative resistance.
alert to providers that accompanied all Before the intervention, urine spe-
urinalysis orders, urine culture orders, cimen ordering included the option
and orders of common antimicrobials for a provider to order a urinalysis with
used to treat UTIs that recommended which can lead to the overuse of a urine culture reflex. If the urinalysis
against urinary tests if the patient did antimicrobials. Much of the current was found to have leukocyte esterase
not present with symptoms. This led to data are from pharmacist-driven inter- (positive), nitrites (positive), or white
an overall reduction in urine culture or- ventions that show promise for the blood cells (11-25 white blood cells/
ders and antimicrobial ordering within reduction of inappropriate manage- high-power field), the urine would be
the first 24 hours after receipt of urin- ment of ASB. This study sought to fur- further tested using a urine culture.
alysis results. Furthermore, Narayanan ther clarify the effect of pharmacist-led Urinalyses were not assessed for con-
and colleagues9 implemented guided education coupled with a diagnostic tamination (ie, squamous cells); if a
urine culture ordering in their EHR stewardship intervention. urine culture grew 3 or more organ-
that forced prescribers to select indica- The primary objective of the study isms, the organisms were not identi-
tions for urine culture orders. This was was to evaluate the effect of our anti- fied and susceptibility testing was not
coupled with pharmacist-driven educa- microbial stewardship bundle, which performed. However, a message was
tion encompassing ASB and appropriate primarily focused on diagnostic entered under the urine culture result
utilization of urine culture ordering that stewardship and pharmacist-driven edu- indicating probable contamination.
took place over a 1-month time period cation, on the management of ASB. Our To reduce the inappropriate treat-
shortly after implementation of the study assessed the prescribing patterns ment of ASB, a new protocol was put
EHR modifications. The authors saw an of antimicrobial therapy for ASB before into place that sought to eliminate urin-
overall reduction in the percentage of and after implementation of a diagnostic alysis with reflex to urine culture. This
patients who received antimicrobials stewardship intervention as well as after protocol included collection of a urine
for ASB in the posteducation period as targeted educational sessions. specimen in a sterile cup along with a
compared to baseline (35% vs 42%). separate tube for urine that was to be
Current literature suggests the con- Methods preserved for 48 hours. The urine col-
tinued need for strategies to limit in- This study was conducted at a 441- lected in the sterile cup was used for
appropriate ordering of urine cultures, bed community teaching hospital in urinalysis. If necessary, the provider
S84 AM J HEALTH-SYST PHARM | VOLUME 78 | SUPPLEMENT 3 | September 1, 2021ANTIMICROBIAL INTERVENTION FOR ASYMPTOMATIC BACTERIURIA AJHP RESIDENTS EDITION
could order a urine culture on the re- medicine, family medicine, and the de- variables included in this study; these
maining urine in the test tube if there partment of medicine to give an update tests were performed using R (ver-
was a suspected or confirmed UTI on the institution’s overall progress sion 4.0.0; R Foundation for Statistical
within the next 48 hours. Alternatively, in 3 separate sessions in March 2020. Computing, Vienna, Austria) and
an immediate urine culture could be The educational sessions included a evaluated at a significance level of 0.05.
ordered if the patient presented with PowerPoint presentation (Microsoft
a confirmed UTI, based on clinician Corporation, Redmond, WA) in which Results
judgement. Of note, the collection providers were reminded of how to A total of 120 patients were included
method for the urine specimen was appropriately manage ASB as well as in the analysis. Fifty patients each were
included as a mandatory checkbox how to utilize the new protocol’s order included in the preintervention and
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(clean-catch, straight catheter, etc), sets. Furthermore, 2 patient cases were postdiagnostic intervention groups,
with free text as an alternative option. included in the presentation to pro- while 20 patients were identified for
In addition to the intervention mote the identification of ASB through inclusion in the posteducation group.
within the electronic medical record, case-based questions. These questions Patient demographics are listed in
communication with preidentified pro- were focused on identifying UTIs vs Table 1. Patients in the preintervention
vider champions was also an element ASB. Providers received copies of the group were significantly older than
of the bundle; this communication fo- PowerPoint presentation, which in- those in the postdiagnostic interven-
cused on helping institutional leaders cluded the urinalysis/urine culture or- tion and posteducation groups.
understand our progress toward re- dering algorithm, and were encouraged When comparing the preinter
ducing inappropriate management to follow up with the corresponding au- vention group and the posteducation
of ASB. These champions included thor on further questions. Additional group to assess the primary outcome,
department leadership, nursing lead- patient data collection began 1 week there was a difference in the percentage
ership, and the chief medical officer. after completion of the educational of cases with inappropriate manage-
Before initiation of the study, internal sessions to assess the effect of the ment of ASB (88% vs 55%, P = 0.005).
medicine, family medicine, and emer- sessions on ASB management. Additionally, there was a difference in
gency department providers were edu- The primary outcome of this study median length of antimicrobial therapy
cated about the treatment of ASB. This was the difference in the rate of in- for ASB between these groups (5.75 vs
educational session was conducted by appropriate management of ASB, de- 4.45 days, P = 0.035). There was no sig-
a pharmacist who provided an update fined as the use of antimicrobial agents nificant difference in length of total in-
on the IDSA recommendations for ASB intended to treat ASB. Secondary out- patient stay between the groups (102.32
management along with a detailed de- comes included length of therapy for vs 94.20 hours, P = 0.79).
scription of the diagnostic stewardship ASB, length of stay, urine cultures per Urinalysis and urine culture or-
intervention. These formal educational 1,000 days present, and urinalysis or- ders (Table 3) showed a significant de-
sessions were performed separately ders per 1,000 days present. cline between the preintervention and
over 3 months; a log of providers who Statistical analysis. Data from postdiagnostic intervention groups
attended the sessions was not col- the Michigan Hospital Medicine Safety (data obtained from October 2018 to
lected. Providers were also supplied Consortium (HMS) indicated a site- January 2019 and from October 2019
with a flyer that included a summary specific predicted treatment rate for to January 2020, respectively) when
of the updated IDSA recommenda- ASB of 83% between 2018 and 2019. evaluating orders per 1,000 days pre-
tions for ASB management along with The goal set for HMS participants was a sent (urinalyses: 370 vs 224, P < 0.0001;
an overview of the changes that would rate of less than 70%. It was determined urine cultures: 131 vs 54, P < 0.0001).
be made to the urinalysis/urine culture that 100 patients needed to be included Further results of the analyses com-
ordering process. to detect a 20% difference in inappro- paring the 3 groups can be found in
Preintervention data were collected priate ASB management between the Table 2. There was a significant differ-
from admissions between October 2018 preintervention and postdiagnostic ence in inappropriate management of
and January 2019, while postdiagnostic intervention groups at 90% power ASB between the preintervention and
intervention data were collected be- (with a significance level ofAJHP RESIDENTS EDITION ANTIMICROBIAL INTERVENTION FOR ASYMPTOMATIC BACTERIURIA
Table 1. Patient Demographics
Postdiagnostic P Valuea
Preintervention Intervention Posteducation
Characteristic (n = 50) (n = 50) (n = 20) PI vs PE PI vs PDI PDI vs PE
Age, median (IQR), years 81 (76-85.75) 67.5 (61.25-79) 65 (63.5-69.5)ANTIMICROBIAL INTERVENTION FOR ASYMPTOMATIC BACTERIURIA AJHP RESIDENTS EDITION
reduction. Pharmacist education may between the cessation of education and References
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ginning of the postdiagnostic interven- termine whether education was com-
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During the postdiagnostic inter- in the overuse of antimicrobial agents in
vention to decrease unneces-
vention phase, a pharmacist-driven this patient population. sary antimicrobial use in patients
ceftriaxone utilization initiative began. with asymptomatic bacteriuria.
Pharmacists received an electronic Acknowledgments Infect Control Hosp Epidemiol.
alert when patients were on ceftriaxone 2016;37(9):1044-1051.
The authors thank David Blair, PharmD.
8. Keller SC, Feldman L, Smith J, et al.
for an indication of UTI or community-
The use of clinical decision support in
acquired pneumonia for greater than Disclosures reducing diagnosis of and treatment of
48 hours. This could have uninten- asymptomatic bacteriuria. J Hosp Med.
The authors have declared no potential con-
tionally been a significant confounder flicts of interest. 2018;13(6):392-395.
in the results of this group in terms of 9. Narayanan P, Knoph K, Chen N, et al.
Decreasing treatment of asymptom-
inappropriate ASB management and Previous affiliations atic bacteriuria: an interprofessional
length of antimicrobial therapy. At the time of the study, Dr. Rico was in the approach to antibiotic stewardship.
Furthermore, owing to the time Department of Pharmacy Services, Ascension J Clin Outcomes Manag.
constraints of this study, the time Genesys Hospital, Grand Blanc, MI. 2019;26(4):169-174.
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