Our patient is a 32-year-old male with chronic silicosis who presented with one week of worsening dyspnea and cough in the setting of a 40 pound weight loss over 3 months.

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BackgroundDiagnosis of urinary tract infections (UTI) vs. asymptomatic bacteriuria (ASB) is challenging and inappropriate treatment of ASB is common. PAIF to prescribers decreases inappropriate antimicrobial use.We postulated that a quality improvement strategy using PAIF aimed at interpretation of UCx would reduce antimicrobials for ASB.MethodsSingle-center QI project to evaluate PAIF for positive UCx on Veterans admitted from December 11/2018 - 3/27/2019 to medicine teaching services at a VA Medical Center. Residents and hospitalists received an educational conference on UTI diagnosis one month prior to PAIF initiation. Using available software (Theradoc®), an electronic alert was created to notify 3 project physicians of every positive UCx ( >10K CFU). Chart review was performed against a diagnostic algorithm for UTI based on the 2011 IDSA guidelines. Feedback was provided by a phone call to residents caring for these patients.ResultsCharts of all 211 patients with positive UCx (mean age 74 y, 98% male) were audited within 72 hours of culture positivity. Of this group, 38% (80/211) were diagnosed as UTI by auditors vs. 45% (94/211) diagnosed as UTI by providers (P = 0.24). Between auditor diagnosis at 72 hours and provider diagnosis at discharge, an absolute inter-rater agreement of 94% (Cohen’s kappa 0.86) was observed. In 7% (14/211) of cases, the auditor diagnosed ASB, but the patient later received treatment for UTI. Auditors recommended discontinuation of antimicrobials for 8 of these 14 patients. For these 8 patients who received feedback, antimicrobials were discontinued in 4 cases. In the other 6 inappropriately treated ASB, providers had not started antimicrobials at the time of the audit, but later treated for UTI. No recommendation for starting antimicrobials was made by auditors.ConclusionProviders who had been exposed to academic detail on ASB, appropriately diagnosed UTI in the majority of their patients. Auditor and provider disagreements were rare, thus need for intervention was low. However, a small portion of patients still received antimicrobials for ASB. We are now exploring PAIF for urinalysis interpretation—an earlier upstream clinical decision point—and reviewing outcomes on those assessed as ASB.Disclosures All authors: No reported disclosures.