Impact of a urinary tract infection diagnostic and treatment algorithm for psychiatric inpatients with a communication barrier

Abstract

Introduction Differentiating between a urinary tract infection and asymptomatic bacteriuria is an important distinction to make, especially in noncommunicative patients. An algorithm meant to aid in the diagnosis and treatment of urinary tract infections in this population was implemented within a psychiatric emergency department in January 2019. The primary objective of this project was to assess the impact of the algorithm (the intervention) regarding symptom documentation and antibiotic use. Secondary objectives included assessing changes in inappropriate prescribing and urine culture orders. Methods Preintervention outcomes were measured from August 1, 2018, through November 30, 2018, while the postintervention cohort included patients admitted after January 31, 2019 and discharged before June 1, 2019. Adults admitted to psychiatry with a urinalysis ordered in the emergency department and an ICD-10 code representing dementia, delirium, autism spectrum disorder, or intellectual disability were included; pregnant patients were excluded. Results The preintervention (n = 56) and postintervention (n = 34) cohorts were well balanced with an average age of 66.5 and 70 years, respectively. Neurocognitive disorder was the diagnosis for inclusion in approximately two-thirds of both groups. Numerically, postalgorithm implementation, symptoms were documented more frequently (20.6% vs 10.7%, P = .23) and antibiotics used less often (2.9% vs 14.3%, P = .15). Inappropriate prescribing occurred in 12.5% of preintervention cohort compared to no patients postintervention (P = .04). Discussion The creation and implementation of an algorithm assisting in the diagnosis and treatment of urinary tract infections in noncommunicative patients was associated with a trend toward increased symptom documentation and decreased overall antibiotic use, and significantly increased appropriate antibiotic prescribing.

Treatment of asymptomatic pyuria in psychiatric patients discharged from the emergency department following antimicrobial stewardship implementation

“…In addition, local guidelines were developed for the appropriate treatment of patients meeting the diagnostic criteria for UTI. Following the implementation of the algorithm, they found that fewer patients received antibiotic therapy (14.3% vs 2.9%, P = .15) and that those treated for UTI were more likely to receive appropriate therapy based on local guidelines (87.5% vs 100%, P = .04) 22 . These findings, combined with our own, highlight the importance of multidisciplinary collaboration in implementing successful stewardship initiatives.…”

“…A limited number of studies have evaluated interventions to reduce the inappropriate treatment of asymptomatic pyuria and bacteriuria in the ED, specifically in patients with psychiatric emergencies 22 . A recent study by Rarrick and colleagues demonstrated the impact of implementing a UTI diagnostic and treatment algorithm for patients presenting to a psychiatric emergency department who were non‐communicative 22 . Multidisciplinary collaboration occurred between ED, psychiatric, internal medicine, urology, and ASP leaders, including both physicians and pharmacists.…”

Asymptomatic Urinary Tract Infection Treatment in Adults Admitted to Inpatient Psychiatry: A Retrospective COHORT study

“…Rarrick and Hebbard developed an innovative UTI treatment algorithm for psychiatric inpatients with communication barriers that reduced inappropriate antibiotic prescribing from 12.5% to 0% in adults with dementia, delirium, autism spectrum disorder, or intellectual disability. 18,19 Based on the results of our study, these stewardship directives may also benefit patients with serious mental illness.…”

Impact of Board Certified Psychiatric Pharmacists on improving urinary tract infection antibiotic appropriateness at an acute psychiatric hospital

“…These results reaffirm a similar study conducted in a psychiatric emergency department that showed a BCPP-developed algorithm helped significantly improve UTI antibiotic appropriateness. 16 Although antibiotic appropriateness was defined differently, both studies showed an increase in appropriate orders.…”