ImportanceHospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events.ObjectiveTo determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB.Design, Setting, and ParticipantsThis 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022.ExposureParticipation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion.Main Outcomes and MeasuresOverall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration.ResultsOf the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00).Conclusions and RelevanceThis quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

A 79-year-old man suddenly developed right lower extremity (RLE) pain and swelling a few days after receiving his 1st dose of the mRNA-1273 COVID-19 vaccine. Despite this, he proceeded to receive the 2nd dose of his mRNA-1273 COVID-19 vaccine. Investigations confirmed extensive acute deep venous thrombosis and a concurrent acute pulmonary embolism. Therapeutic anticoagulation was initiated and he was eventually discharged home on supplemental oxygen. The overall benefits of the vaccine in curbing severe disease overwhelmingly outweigh the handful of cases of reported adverse events. To our knowledge, this is one of the first few cases of provoked venous thrombosis after receiving the mRNA-1273 COVID-19 vaccine during the pharmacovigilance period.

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Background Up to one-third of hospitalized patients treated for urinary tract infection (UTI) have asymptomatic bacteriuria (ASB). Both diagnostic (avoiding inappropriate urine cultures) and antibiotic stewardship (reducing unnecessary antibiotic use in asymptomatic patients) have been proposed to reduce unnecessary antibiotic use for ASB. However, it's unclear which method is most effective. Methods The Michigan Hospital Medicine Safety Consortium aimed to improve antibiotic use and outcomes of hospitalized patients with a positive urine culture between 7/1/2017—3/31/2020 (see Table 1 for patient characteristics) by benchmarking performance across 46 Michigan hospitals, sharing best practices, and implementing pay-for-performance metrics related to unnecessary treatment of ASB (see Figure 1). Using logistic regression models controlling for hospital clustering, we assessed change over time in percentage of hospitalized patients treated for UTI who had ASB (i.e., had no documented signs or symptoms of UTI) and hospital characteristics associated with baseline or change in unnecessary antibiotic prescribing. We then estimated the percentage of avoided ASB treatment attributable to diagnostic (decrease in urine cultures ordered on asymptomatic patients) vs. antibiotic stewardship (decrease duration or avoidance of antibiotic treatment). Results Across 46 hospitals, there were 15,493 patients with a positive urine culture. Of 13,805 patients treated for a UTI, 23.2% (3,197) had ASB. The percentage of patients treated for UTI who had ASB declined over time from 29.0% (95% CI: 26.1%, 32.0%) to 16.9% (95% CI: 14.2%, 20.1%; aOR 0.94 per quarter, 95% CI: 0.92-0.96; Figure 1) with hospitals not belonging to a larger healthcare system having the largest decrease over time (Table 2). Neither the proportion of patients with ASB who were treated with antibiotics (P=0.07) nor the duration of therapy for ASB changed over time (P=0.09); thus, nearly all avoided antibiotic therapy for ASB appeared due to diagnostic stewardship. Conclusions Across 46 hospitals, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement. Disclosures Payal K. Patel, MD, MPH, Qiagen: Honoraria.