Highlights
- •Asymptomatic bacteriuria was highly prevalent (64%) in this Veteran population.
- •Twenty-eight percent of asymptomatic bacteriuria cases were inappropriately prescribed antimicrobials.
- •Abdominal pain, falls, decreased urine output and voiding issues were related to treatment.
- •Stewardship programs can incorporate these findings to reduce unnecessary treatment.
Abstract
Background
Chart reviews often fall short of determining what drove antibiotic treatment of asymptomatic
bacteriuria (ASB). To overcome this shortcoming, we searched providers’ free-text
for documentation of their decision-making and for misleading signs and symptoms that
may trigger unnecessary treatment of ASB.
Methods
We reviewed a random sample of 10 positive urine cultures per month, per facility,
from patients in acute or long-term care wards at 8 Veterans Affairs facilities. Cultures
were classified as urinary tract infection (UTI) or ASB, and as treated or untreated.
Charts were searched for 13 potentially misleading symptoms, and free-text documentation
of providers’ decision-making was classified into 5 categories. We used generalized
estimating equations logistic regression to identify factors associated with ASB treatment.
Results
One hundred fifty-eight (27.5%) of 575 ASB cases were inappropriately treated with
antibiotics. Significant factors associated with inappropriate treatment included:
abdominal pain, falls, decreased urine output, urine characteristics, abnormal vital
signs, laboratory values, and voiding issues. Providers prescribed an average of 1.4
antimicrobials to patients with ASB, with cephalosporins (41%) and fluoroquinolones
(21%) being the most common classes prescribed.
Conclusions
Chart reviews of providers’ decision-making highlighted new factors associated with
inappropriate ASB treatment. These findings can help design antibiotic stewardship
interventions for ASB.
Key Words
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References
- Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America.Clin Infect Dis. 2019; 68: 1611-1615
- Asymptomatic bacteriuria: prevalence rates of causal microorganisms, etiology of infection in different patient populations, and recent advances in molecular detection.FEMS Microbiol Lett. 2013; 346: 1-10
- Screening for asymptomatic bacteriuria in adults: US preventive services task force recommendation statement.JAMA. 2019; 322: 1188-1194
- Benefits and harms of treatment of asymptomatic bacteriuria: a systematic review and Meta-analysis by the European Association of Urology Urological Infection Guidelines Panel.Eur Urol. 2017; 72: 865-868
- Association of adverse events with antibiotic use in hospitalized patients.JAMA Intern Med. 2017; 177: 1308-1315
- Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital.J Commun Hosp Intern Med Perspect. 2012; 2: 1-6
- Risk factors and outcomes associated with treatment of asymptomatic bacteriuria in hospitalized patients.JAMA Intern Med. 2019; 179: 1519-1527
- Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis.Open Forum Infect Dis. 2017; 4: ofx207
- Assessment of testing and treatment of asymptomatic bacteriuria initiated in the emergency department.Open Forum Infect Dis. 2020; 7: ofaa537
- Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity.Arch Intern Med. 2003; 163: 972-978
- Unnecessary use of fluoroquinolone antibiotics in hospitalized patients.BMC Infect Dis. 2011; 11: 187
- Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes.BMC Fam Pract. 2011; 12: 36
- Nurse decision-making for suspected urinary tract infections in nursing homes: potential targets to reduce antibiotic overuse.J Am Med Dir Assoc. 2021; 22: 156-163
- Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria.BMC Med Inform Decis Mak. 2013; 13: 48
- Content analysis in mass communication: assessment and reporting of intercoder reliability.Hum Commun Res. 2002; 28: 587-604
- Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.Clin Infect Dis. 2010; 50: 625-663
- The R Package geepack for Generalized Estimating Equations. 15. 2005: 11 (2005)
- Management of bacteriuria in veterans affairs hospitals.Clin Infect Dis. 2017; 65: 910-917
- VHA Directive 1031: Antimicrobial Stewardship Programs (ASP).2019
- The relationship of urinary tract infections and falls in a nursing home.Director. 2007; 15: 22-26
- Lack of positive association between falls and bacteriuria plus pyuria in older nursing home residents.J Am Geriatr Soc. 2013; 61: 653-654
- Falls in the elderly secondary to urinary symptoms.Rev Urol. 2016; 18: 28-32
- Geriatrics-falls in older people.(editor)in: Falk S Merck Manual Professional Version. Merck Sharp & Dohme Corp, 2021
- Urinalysis in acute care of adults: pitfalls in testing and interpreting results.Open Forum Infect Dis. 2014; 1: 1-8
- Consequences of asymptomatic bacteriuria in the elderly.Int J Antimicrob Agents. 1994; 4: 107-111
Wald R. Urinalysis in the diagnosis of kidney disease. In: Curhan GC, editor. UpToDate. Waltham, MA: UpToDate; 2021.
- Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria.Infect Control Hosp Epidemiol. 2019; 40: 963-967
- Risk factors of extended-spectrum beta-lactamases-producing Escherichia coli community acquired urinary tract infections: A Systematic Review.Infect Drug Resist. 2020; 13: 3945-3955
- Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes.BMC Geriatr. 2012; 12
- FDA adds "black box" warning label to fluoroquinolone antibiotics.BMJ. 2008; 337: a816
- FDA Reinforces Safety Information About Serious low Blood Sugar Levels and Mental Health Side Effects With Fluoroquinolone Antibiotics; Requires Label Changes.U.S. Food and Drug Administration, 2018
- The association of antibiotic stewardship with fluoroquinolone prescribing in Michigan Hospitals: a multi-hospital cohort study.Clin Infect Dis. 2019; 69: 1269-1277
- Decreased outpatient fluoroquinolone prescribing using a multimodal antimicrobial stewardship initiative.Open Forum Infect Dis. 2020; 7: 1-7
- Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention.Am J Infect Control. 2008; 36: 476-480
Article info
Publication history
Published online: February 11, 2022
Footnotes
Conflicts of Interest: We have listed all funding sources and any potential conflicts of interest in the submitted ICMJE forms; however, we believe none of these pose conflicts of interest to this work.
Funding: This work is supported by VA HSR&D IIR 16-025 (to BWT) and by the Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413) at the Michael E. DeBakey VA Medical Center, Houston, Texas, USA. MVK is supported in part by the Health Resources and Services Administration, an agency of the US Department of Health and Human Services (grant number T32 HP10031). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the US Department of Veterans Affairs.
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© 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
