Sustained impact of an antibiotic stewardship initiative targeting asymptomatic bacteriuria and pyuria in the emergency department

Abstract

Objective: To determine whether a multifaceted initiative resulted in maintained reduction in inappropriate treatment of asymptomatic pyuria (ASP) or bacteriuria (ASB) in the emergency department (ED). Design: Single-center, retrospective study. Methods: Beginning in December 2015, a series of interventions were implemented to decrease the inappropriate treatment of ASP or ASB in the ED. Patients discharged from the ED from August to October 2015 (preintervention period), from December 2016 to February 2017 (postintervention period 1), and from November 2019 to January 2020 (postintervention period 2) were included if they had pyuria and/or bacteriuria without urinary symptoms. The primary outcome was the proportion of patients prescribed antibiotics within 72 hours of discharge from the ED. The secondary outcome was the number of patients returning to the ED with symptomatic UTI within 30 days of discharge. Results: We detected a significant decrease in the proportion of patients with ASP or ASB who were inappropriately treated when comparing the preintervention group and post-intervention group 1 (100% vs 32.4%; P < .001). This reduced frequency of inappropriate treatment was noted 3 years after the intervention, with 28% of patients receiving treatment for ASP or ASB in postintervention group 2. (P was not significant fin the comparison with postintervention group 1.) Among the 3 groups analyzed, we detected no difference in the numbers of patients returning to the ED with a symptomatic UTI within 30 days of ED discharge regardless of whether patients received antibiotics. Conclusions: A multifaceted intervention resulted in a significant decrease in inappropriate use of antibiotics for ASP and/or ASB that was maintained 3 years after implementation.

Antimicrobial Stewardship in the Emergency Department Observation Unit: Definition of a New Indicator and Evaluation of Antimicrobial Use and Clinical Outcomes

“…Comparing the results of our ASP with other stewardship strategies is challenging because of the heterogeneity in the indicators used to monitor antimicrobial use, as well as the fact that most previous experiences with ASP in the ED have been geared towards improving specific infectious syndromes (e.g., urinary tract infections, community-acquired pneumonia, or skin and soft tissue infections, among others), populations (e.g., pediatric patients), or antibiotic classes [18,19]. Borde et al [14] implemented a multifaceted ASP focused on broad-spectrum cephalosporin and fluoroquinolone use in a medical ED.…”

“…The average yearly number of blood cultures collected in the ED was 16 per 100 ED visits (range [13][14][15][16][17][18], and this number increased over the study period (p < 0.0001) (Table S2, see online Supplementary Materials).…”

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

“…Patients with a urinary drainage catheter may have “positive” urine culture results owing to inevitable biofilm formation on the device. Numerous studies show that antibiotic treatment of patients with asymptomatic bacteriuria is not indicated except in specific circumstances, such as pregnancy or transurethral instrumentation, because it can increase the likelihood of subsequent urinary tract infections that can become resistant to common antibiotics [ 159 , 160 ].…”

Ten golden rules for optimal antibiotic use in hospitals: based on the publication statement of the International Network Group of the World Antimicrobial Resistance

“…Asymptomatic bacteriuria in patients with a urinary catheter that drains should not be treated with antibiotics, except in special circumstances such as pregnancy or the use of transurethral instruments. This is because antibiotic therapy may increase the likelihood of further urinary tract infections that may become resistant to conventional antibiotics [159,160].…”