Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Abstract

Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by EM clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the emergency department (ED) with ASB (2/2018-2/2020). Using generalized estimating equation models, we assessed a) for factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, b) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N=1830) received antibiotics. EM clinicians ordered urine cultures in 80.0% (N=1970) of patients and initiated treatment in 68.5% (1253/1830). Predictors of EM clinician treatment of ASB vs. no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993/1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; RR 1.16; 95% CI, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% (N=11) vs. 0% (N=0); P=0.02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

Antibiotic prescribing in mental health units across the Veterans’ Health Administration: How much and how appropriate?

“…Because antibiotic-prescribing was not consistently better when these services were involved, antibiotic stewardship interventions to improve antibiotic prescribing in VHA mental health units must target both mental health clinicians as well as these other physician disciplines. 6 Our findings are in line with prior work that has described the frequent misdiagnosis of UTIs. 7,8 We speculate that a major contributor to the overdiagnosis of UTIs is the seemingly routine performance of urinalyses in admitted patients.…”

Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments

“…Lastly, we did not capture “appropriateness” of FQ prescribing or variables that may have impacted antibiotic selection such as patient allergies, previous urine culture sensitivities, drug interactions, or comorbidities. 38 Despite these limitations, our findings provide important insight into ED stewardship interventions and help define future steps for ASP efforts in the ED.…”

Leveraging diagnostic stewardship within antimicrobial stewardship programmes

“…For instance, in a 43-hospital cohort study of patients presenting to the emergency department with positive urine cultures but no documented signs or symptoms of a UTI, 74.4% received antimicrobial therapy. 20 Factors associated with antimicrobial prescribing in the emergency department consisted of the presence of altered mental status, leucocytosis and abnormal results on urinalysis. Importantly, once antimicrobials were started, they often continued into patients’ hospital stay for at least 3 days; this was associated with longer hospitalization and development of CDI.…”