Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among Noncatheterized Inpatients: A Proof-of-Concept Study

Leis, Jerome A; Rebick, Gabriel; Daneman, Nick; Gold, Wayne L.; Poutanen, Susan M.; Lo, Pauline; Larocque, M.; Shojania, Kaveh G; McGeer, Allison

doi:10.1093/cid/ciu010

Cited by 136 publications

(155 citation statements)

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“…During the intervention period, rather than routinely reporting positive urine cultures from noncatheterized inpatients, technicians appended a comment to electronic medical records to request clinicians to call the laboratory for culture results if UTI is strongly suspected. Of the 37 modified reports, results were requested for only 5 (14%) patients, decreasing the rate of antibiotic therapy from 48% to 12% in noncatheterized patients with ASB (12).…”

Section: Counterpointmentioning

confidence: 99%

“…A study in the Netherlands of 1993 nonpregnant women with symptoms consistent with a UTI demonstrated that 94% with a nitrite-positive specimen and 71% with a positive LE result received antimicrobial therapy but that only 20% of those with negative results for these tests were prescribed antibiotics (11). Similarly, a Canadian study of 231 women with symptoms of a UTI demonstrated that evaluation for pyuria would reduce the frequency of unnecessary antimicrobial prescription by one-third (12).…”

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confidence: 99%

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Point-Counterpoint: Reflex Cultures Reduce Laboratory Workload and Improve Antimicrobial Stewardship in Patients Suspected of Having Urinary Tract Infections

Humphries

Bard

2016

J Clin Microbiol

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POINT How often misused tests generate misleading thoughts:an argument for the appropriate use of the urinalysis to rule out urinary tract infections.-Adapted from Herbert Spencer O ptimum use of laboratory testing requires that providers order tests only for patients with an appropriate indication; urine cultures are no exception to this rule. Guidelines published by the Infectious Diseases Society of American support urine testing and sterilization in the absence of symptoms for only two groups: pregnant women and those about to undergo urologic surgery (1). For the remainder of patients, such testing should be done only in the context of symptoms consistent with a urinary tract infection (UTI): fever, urgency, frequency, dysuria, suprapubic tenderness, altered mental status, or hypotension. And yet, up to half of patients for whom a urine test is ordered in the emergency department (ED) or general medicine services (2) do not have symptoms consistent with a UTI. Unfortunately, several studies have demonstrated that these test results, and not the patient's symptoms, drive antibiotic utilization (2-4). Such overuse of testing is problematic on several fronts, including potential misdiagnosis (i.e., early case closing and failure to evaluate for other causes of symptoms by the physician), overuse of antimicrobials and their associated risks, and a high burden of testing for the laboratory. A rapid diagnostic strategy to diagnose UTI is therefore desirable but does not exist at present. However, UA (performed either with a dipstick or an automated instrument) is thought by many to be a useful screen by which to rule out UTI in a symptomatic patient. I will demonstrate that the detection of pyuria or bacteria by UA is a screening test that, when used appropriately, is associated with a high negative predictive value (NPV) that should impart confidence to the physician that a urine culture will not yield additional, clinically relevant information (i.e., the culture will be negative), and that a UTI is unlikely to be the cause of their patient's symptoms. However, it should be emphasized that the appropriate use of UA to rule out UTI is in the context of a patient with symptoms consistent with a UTI.The absence of pyuria upon UA is an excellent predictor of a negative urine culture. One of the challenges associated with implementing a UA reflex-to-culture algorithm is the absence of evidence-based guidance on which UA parameters best predict urine culture results. Several studies have evaluated the predictive values of both indirect markers of infection: a positive result for nitrite (a marker for the presence of Enterobacteriaceae in the urine) or leukocyte esterase (LE; a marker for the presence of leukocytes) or direct observation of white blood cells (i.e., pyuria) or bacteria in the urine by microscopy. When evaluated in a population with a low prevalence of positive bacterial cultures, such as outpatients suspected of having a UTI, the NPV of any of these factors individually is excellent. For instance, a la...

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Section: Counterpointmentioning

confidence: 99%

mentioning

confidence: 99%

Point-Counterpoint: Reflex Cultures Reduce Laboratory Workload and Improve Antimicrobial Stewardship in Patients Suspected of Having Urinary Tract Infections

Humphries

Bard

2016

J Clin Microbiol

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“…This problem may require a slightly different strategy to address. For example, in a prospective before-and-after proof-ofconcept study, nonreporting of urine culture and susceptibility results for noncatheterized medical and surgical inpatients resulted in a significantly reduced rate of ASB treatment (16). This more aggressive variant of selective reporting will likely be further validated in future studies and may have a substantial impact on overutilization in many settings.…”

Section: Discussionmentioning

confidence: 99%

Antimicrobial Stewardship in the Microbiology Laboratory: Impact of Selective Susceptibility Reporting on Ciprofloxacin Utilization and Susceptibility of Gram-Negative Isolates to Ciprofloxacin in a Hospital Setting

et al. 2016

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The objective of this study was to determine the impact of selective susceptibility reporting on ciprofloxacin utilization and Gram-negative susceptibility to ciprofloxacin in a hospital setting. Historically at our institution, the microbiology laboratory practice was to report ciprofloxacin susceptibility for all Enterobacteriaceae regardless of susceptibility to other agents. A selective reporting policy was implemented which involved the suppression of ciprofloxacin susceptibility to Enterobacteriaceae when there was lack of resistance to the antibiotics on the Gram-negative panel. Ciprofloxacin utilization (measured in defined daily doses [DDD] per 1,000 patient days) was collected before and after the intervention and compared to moxifloxacin, trimethoprim-sulfamethoxazole, nitrofurantoin, and amoxicillin-clavulanate. Monthly susceptibility of Pseudomonas aeruginosa and Escherichia coli to ciprofloxacin was tabulated. An interrupted time series analysis using segmented regression was performed. The mean monthly ciprofloxacin utilization decreased from 87 (95% CI, 83.7 to 91.2) to 39 (95% CI, 35.0 to 44.0) DDD per 1,000 patient days before and after the implementation of selective reporting, respectively. There was an immediate and sustained reduction in ciprofloxacin usage at 1, 3, 6, 12, and 24 months postintervention (P < 0.001). A compensatory increase in amoxicillin-clavulanate use was noted starting at 6 months postintervention and persisted for the study period (P < 0.027). Susceptibility of E. coli, but not that of P. aeruginosa, to ciprofloxacin was higher than predicted starting 12 months after the intervention (P < 0.05). In conclusion, selective reporting of ciprofloxacin susceptibly may be a useful intervention to reduce targeted antimicrobial utilization and improve Gram-negative susceptibility to ciprofloxacin. This approach should be considered as part of a broader multimodal antimicrobial stewardship program. According to the World Health Organization, antimicrobial resistance (AMR) is considered one of the most serious threats to public health globally (http://www.who.int /mediacentre/multimedia/amr-transcript.pdf). Given the lack of new antimicrobial classes available, preservation of existing classes is a key measure to managing and preventing AMR. Fluoroquinolones (FLQ) are broad-spectrum antibiotics useful for a wide range of bacterial infections. Hence, they have been used extensively since their introduction. As with other antibiotic classes, overuse of these agents is common. A recent prospective analysis in a tertiary medical center found that 39% of FLQ days of therapy were unnecessary (1). As a result of overuse, resistance to this class emerged rapidly after these agents became available (2). FLQ have also been linked with Clostridium difficile infection (CDI) (3), cardiac arrhythmia (4), and collagen-associated adverse events, such as tendon rupture and aortic aneurysm (5). Given these concerns, limiting the use of FLQ is a prudent strategy.Antimicrobial stewardship is a multim...

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“…Since AMR may emerge in bacteria as a response to selective antimicrobial pressure (i.e., when bacteria is in the presence of an antimicrobial drug), there is a potential risk that fewer and fewer antimicrobials will remain effective in the future. Unnecessary antibiotic treatment has been shown to account for a substantial burden of inappropriate antimicrobial use in Canada (1)(2)(3)(4). Due to growing concern about the link between antimicrobial usage (AMU) and AMR, a shift towards more prudent use of antimicrobials has been one of the areas emphasized in combatting the spread of AMR (5)(6)(7)(8).…”

Section: Introductionmentioning

confidence: 99%

Advancing antimicrobial stewardship: Summary of the 2015 CIDSC Report

et al. 2016

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Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among Noncatheterized Inpatients: A Proof-of-Concept Study

Cited by 136 publications

References 10 publications

Point-Counterpoint: Reflex Cultures Reduce Laboratory Workload and Improve Antimicrobial Stewardship in Patients Suspected of Having Urinary Tract Infections

Point-Counterpoint: Reflex Cultures Reduce Laboratory Workload and Improve Antimicrobial Stewardship in Patients Suspected of Having Urinary Tract Infections

Antimicrobial Stewardship in the Microbiology Laboratory: Impact of Selective Susceptibility Reporting on Ciprofloxacin Utilization and Susceptibility of Gram-Negative Isolates to Ciprofloxacin in a Hospital Setting

Advancing antimicrobial stewardship: Summary of the 2015 CIDSC Report

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