Treatment for Positive Urine Cultures in Hospitalized Adults: A Survey of Prevalence and Risk Factors in 3 Medical Centers

BACKGROUNDAntibiotic treatment for asymptomatic bacteriuria (ASB) is prevalent but often contrary to published guidelines.OBJECTIVETo evaluate risk factors for treatment of ASB.DESIGNRetrospective observational study.SETTINGA tertiary academic hospital, county hospital, and community hospital.PATIENTSHospitalized adults with bacteriuria.METHODSPatients without documented symptoms of urinary tract infection per Infectious Diseases Society of America (IDSA) criteria were classified as ASB. We examined ASB treatment risk factors as well as broad-spectrum antibiotic usage and quantified diagnostic concordance between IDSA and National Healthcare Safety Network criteria.RESULTSAmong 300 patients with bacteriuria, ASB was present in 71% by IDSA criteria. By National Healthcare Safety Network criteria, 71% of patients had ASB; within-patient diagnostic concordance with IDSA was moderate (kappa, 0.52). After excluding those given antibiotics for nonurinary indications, antibiotics were given to 38% (62/164) with ASB. Factors significantly associated with ASB treatment were elevated urine white cell count (65 vs 24 white blood cells per high-powered field, P<.01), hospital identity (hospital C vs A, odds ratio, 0.34 [95% CI, 0.14–0.80], P =.01), presence of leukocyte esterase (5.48 [2.35–12.79], P<.01), presence of nitrites (2.45 [1.11–5.41], P=.03), and Escherichia coli on culture (2.4 [1.2–4.7], P=.01). Of patients treated for ASB, broad-spectrum antibiotics were used in 84%.CONCLUSIONSASB treatment was prevalent across settings and contributed to broad-spectrum antibiotic use. Associating abnormal urinalysis results with the need for antibiotic treatment regardless of symptoms may drive unnecessary antibiotic use.Infect. Control Hosp. Epidemiol. 2016;37(3):319–326

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

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa537 ◽

2020 ◽

Vol 7 (12) ◽

Author(s):

Lindsay A Petty ◽

Valerie M Vaughn ◽

Scott A Flanders ◽

Twisha Patel ◽

Anurag N Malani ◽

...

Keyword(s):

Emergency Department ◽

Antibiotic Treatment ◽

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

Altered Mental Status ◽

Estimating Equation ◽

Hospitalized Patients ◽

Clostridioides Difficile ◽

Cord Injury ◽

Clostridioides Difficile Infection

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 emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 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; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .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.

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Quantifying Empiric Antibiotic Use in US Children’s Hospitals

Hospital Pediatrics ◽

10.1542/hpeds.2021-005950 ◽

2021 ◽

Author(s):

Kathleen Chiotos ◽

Lauren D’Arinzo ◽

Eimear Kitt ◽

Rachael Ross ◽

Jeffrey S. Gerber

Keyword(s):

Broad Spectrum ◽

Antibiotic Use ◽

Level Variation ◽

Hospital Level ◽

Broad Spectrum Antibiotic ◽

Children's Hospitals ◽

Broad Spectrum Antibiotics ◽

Children’S Hospitals ◽

Days Of Therapy ◽

Rule Out

OBJECTIVES Empirical broad-spectrum antibiotics are routinely administered for short durations to children with suspected bacteremia while awaiting blood culture results. Our aim for this study was to estimate the proportion of broad-spectrum antibiotic use accounted for by these “rule-outs.” METHODS The Pediatric Health Information System was used to identify children aged 3 months to 20 years hospitalized between July 2016 and June 2017 who received broad-spectrum antibiotics for suspected bacteremia. Using an electronic definition for a rule-out, we estimated the proportion of all broad-spectrum antibiotic days of therapy accounted for by this indication. Clinical and demographic characteristics, as well as antibiotic choice, are reported descriptively. RESULTS A total of 67 032 episodes of suspected bacteremia across 42 hospitals were identified. From these, 34 909 (52%) patients were classified as having received an antibiotic treatment course, and 32 123 patients (48%) underwent an antibiotic rule-out without a subsequent treatment course. Antibiotics prescribed for rule-outs accounted for 12% of all broad-spectrum antibiotic days of therapy. Third-generation cephalosporins and vancomycin were the most commonly prescribed antibiotics, and substantial hospital-level variation in vancomycin use was identified (range: 16%–58% of suspected bacteremia episodes). CONCLUSIONS Broad-spectrum intravenous antibiotic use for rule-out infections appears common across children’s hospitals, with substantial hospital-level variation in the use of vancomycin in particular. Antibiotic stewardship programs focused on intervening on antibiotics prescribed for longer durations may consider this novel opportunity to further standardize antibiotic regimens and reduce antibiotic exposure.

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Pediatric antibiotic stewardship: successful interventions to reduce broad-spectrum antibiotic use on general pediatric wards

Infection ◽

10.1007/s15010-017-1009-0 ◽

2017 ◽

Vol 45 (4) ◽

pp. 493-504 ◽

Cited By ~ 25

Author(s):

Katharina Kreitmeyr ◽

Ulrich von Both ◽

Alenka Pecar ◽

Johannes P. Borde ◽

Rafael Mikolajczyk ◽

...

Keyword(s):

Broad Spectrum ◽

Antibiotic Stewardship ◽

Antibiotic Use ◽

Broad Spectrum Antibiotic

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Association of broad-spectrum antibiotic use with faecal carriage of oxyiminocephalosporin-resistant enterobacteriaceae in an intensive care unit

Journal of Hospital Infection ◽

10.1016/j.jhin.2005.12.017 ◽

2006 ◽

Vol 63 (3) ◽

pp. 306-315 ◽

Cited By ~ 11

Author(s):

R. Vignoli ◽

E. Calvelo ◽

N.F. Cordeiro ◽

R. Lucero ◽

E. Ingold ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Broad Spectrum ◽

Antibiotic Use ◽

Broad Spectrum Antibiotic ◽

Faecal Carriage

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Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

Hospital Pharmacy ◽

10.1177/00185787211055797 ◽

2021 ◽

pp. 001857872110557

Author(s):

Jessica L. Colmerauer ◽

Kristin E. Linder ◽

Casey J. Dempsey ◽

Joseph L. Kuti ◽

David P. Nicolau ◽

...

Keyword(s):

Broad Spectrum ◽

Antibiotic Use ◽

Community Acquired Pneumonia ◽

Intervention Period ◽

Provider Education ◽

Broad Spectrum Antibiotic ◽

Post Intervention ◽

Post Intervention Period ◽

Days Of Therapy ◽

Order Set

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

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