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Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term care

  • Marissa Valentine-King
    Correspondence
    Address correspondence to Marissa Valentine-King, PhD, Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Dr, Suite 600, Houston, TX 77098.
    Affiliations
    Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX

    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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  • John Van
    Affiliations
    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
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  • Casey Hines-Munson
    Affiliations
    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
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  • Laura Dillon
    Affiliations
    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
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  • Christopher J. Graber
    Affiliations
    Infectious Diseases Section, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA

    Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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  • Payal K. Patel
    Affiliations
    Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI

    Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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  • Dimitri Drekonja
    Affiliations
    Department of Medicine, University of Minnesota, Minneapolis, MN

    Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
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  • Paola Lichtenberger
    Affiliations
    Infectious Diseases Section, Veterans Affairs Miami Medical Center, Miami, FL

    Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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  • Bhavarth Shukla
    Affiliations
    Infectious Diseases Section, Veterans Affairs Miami Medical Center, Miami, FL

    Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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  • Jennifer Kramer
    Affiliations
    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
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  • David Ramsey
    Affiliations
    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
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  • Barbara Trautner
    Affiliations
    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
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  • Larissa Grigoryan
    Affiliations
    Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX

    Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Published:February 11, 2022DOI:https://doi.org/10.1016/j.ajic.2022.02.010

      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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