Overtreatment of Asymptomatic Bacteriuria: Identifying Targets for Improvement

2015 ◽  
Vol 36 (4) ◽  
pp. 470-473 ◽  
Author(s):  
Sarah Hartley ◽  
Staci Valley ◽  
Latoya Kuhn ◽  
Laraine L. Washer ◽  
Tejal Gandhi ◽  
...  
Keyword(s):  
Mental Status ◽  
Antimicrobial Therapy ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Altered Mental Status ◽  
Hospitalized Patients ◽  
Infect Control Hosp ◽  
Alternative Source

Treatment of asymptomatic bacteriuria contributes to antimicrobial overuse in hospitalized patients. Indications for urine culture, treatment, and targets for improvement were evaluated in 153 patients. Drivers of antimicrobial overuse included fever with an alternative source, altered mental status, and leukocytosis, which led 435 excess days of antimicrobial therapy.Infect Control Hosp Epidemiol 2014;00(0): 1–4

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

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.

scholarly journals 1111. Characterization of Antibiotic Ordering in Patients with Mental Status Changes and Presumed Urinary Tract Infection in Patients 65 and Older

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S395-S396
Author(s):  
Nicole Harrington ◽  
Jessica Leri ◽  
Scott Shoop
Keyword(s):  
Internal Medicine ◽  
Emergency Department ◽  
Urinary Tract ◽  
Mental Status ◽  
Asymptomatic Bacteriuria ◽  
Altered Mental Status ◽  
Practice Change ◽  
Antibiotic Selection ◽  
Common Diagnosis ◽  
Tract Infections

Abstract Background Altered mental status (AMS) is the most common diagnosis among those 65 and older who present to the emergency department (ED). Urinary tract infections (UTIs) account for 15.5% of hospitalizations in this population. The purpose of this study was to determine the incidence of initiation of antibiotics in the ED in patients 65 years and older with mental status changes and asymptomatic bacteriuria or negative urine cultures. Methods A retrospective chart review was performed to evaluate patients aged 65 and older from January 2017 through June 2018 who presented to the ED from home with AMS, a urinalysis that reflexed to culture, and were admitted to an internal medicine unit. The primary outcome was defined as the percentage of patients with AMS who received antibiotics in the ED with asymptomatic bacteriuria or negative urine cultures. Secondary outcomes included adherence to the CCHS UTI antibiotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to ordered antibiotic, and disposition after discharge. Results A total of 91 patients were included in this study. Seventy-five patients had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%) of these patients. Fourteen patients had no growth on culture and seven of these patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics (n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%) of patients. Thirty-one patients (33.7%) were discharged to a skilled nursing facility. Conclusion These results indicate that the majority of patients aged 65 and older who presented to the emergency department with altered mental status and no other UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibiotics. When antibiotics are initiated the majority of providers are adhering to organizational guidelines for antibiotic selection and duration. The results will be shared with Emergency Department and Internal Medicine leadership to foster practice change. Disclosures All authors: No reported disclosures.

scholarly journals 1106. Assessment of Fluoroquinolone Appropriateness for Hospitalized Patients with Asymptomatic Bacteriuria and Cystitis: A Multi-Hospital Cohort Study

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S393-S394
Author(s):  
Tejal N Gandhi ◽  
Lindsay A Petty ◽  
Valerie M Vaughn ◽  
Twisha S Patel ◽  
David Ratz ◽  
...  
Keyword(s):  
Cohort Study ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Hospitalized Patients ◽  
Audit And Feedback ◽  
Definitive Treatment ◽  
Resistant Bacteria ◽  
Prospective Audit ◽  
Antibiotic Susceptibilities ◽  
Prospective Audit And Feedback

Abstract Background Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis. Methods This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering. Results Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2). Conclusion Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use. Disclosures All authors: No reported disclosures.

Thiamine supplementation in hospitalized patients with altered mental status: does it help?

2021 ◽  
Author(s):  
Daniel J. Zhou ◽  
Kaeli K. Samson ◽  
Navya Joseph ◽  
Ismail Fahad ◽  
Matthew V. Purbaugh ◽  
...  
Keyword(s):  
Mental Status ◽  
Altered Mental Status ◽  
Hospitalized Patients

Importance of Urinary Tract Infection to Antibiotic Use Among Hospitalized Patients

2009 ◽  
Vol 30 (2) ◽  
pp. 193-195 ◽  
Author(s):  
Tejal Gandhi ◽  
Scott A. Flanders ◽  
Erica Markovitz ◽  
Sanjay Saint ◽  
Daniel R. Kaul
Keyword(s):  
Urinary Tract Infection ◽  
Urinary Tract ◽  
Tract Infection ◽  
Broad Spectrum ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Antibiotic Use ◽  
Hospitalized Patients ◽  
Broad Spectrum Antibiotics

Many patients with asymptomatic bacteriuria receive extended courses of broad-spectrum antibiotics. Antibiotic use was analyzed in patients admitted to the hospital with urinary tract infection. Strategies to optimize antibiotic use for such patients are discussed and include implementing a process whereby a urine culture is automatically performed if a urinalysis result suggests infection.

scholarly journals 466. Symptom Profile of Hospitalized, Adult Patients with COVID-19 – Findings From COVID-Net Database

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S335-S335
Author(s):  
Chun T Siu ◽  
Amogh Joshi
Keyword(s):  
Retrospective Analysis ◽  
Mental Status ◽  
Signs And Symptoms ◽  
Altered Mental Status ◽  
Hospitalized Patients ◽  
Shortness Of Breath ◽  
Neurologic Manifestation ◽  
Symptom Profile ◽  
Patient Reported ◽  
Control And Prevention

Abstract Background According to the Center for Disease Control and Prevention (CDC), there is a disproportional number of COVID-19 deaths in hospitalized patients that increases based on age. Among COVID-19 related deaths in hospitalized patients, 8 of 10 patients are age 65 years and older. By looking at the latest data, the objective of this retrospective analysis is to evaluate the symptom profile in patients hospitalized with COVID-19 and determine if certain symptoms are seen more in older patients. Methods We performed a retrospective analysis using the COVID-Net database. This database contains information involving COVID-19 laboratory-confirmed hospitalization across 14 states. Medical history, signs, and symptoms at admission were collected by COVID-NET surveillance officers and reported during the period of March 1st to May 31st. For our analysis, we only included adults patients age 18 and above. Further descriptive statistics were stratified by age into two groups: age 18-64, and age ≥ 65. Results We identified 60,363 patients age 18 and above with COVID-19 confirmed hospitalizations. Cough, shortness of breath, and fevers/chills were the most common symptoms at respectively 67%, 66%, and 65%. Patients age ≥ 65, when compared to patients age 18-64, were less likely to have cough (56.7% vs 73.8%), shortness of breath (58.1% vs 72.1%), fever/chills (54.7% vs 71.%), dysgeusia (2.3% vs 7%), and anosmia (1.2% vs 6%). The only presentation that was more common in patients age 65+, than in patients age 18-64, was altered mental status (26.9% vs 5.2%). Overall inpatient mortality was higher in the age ≥ 65 group (8.9% vs 2%). Among the 2,922 COVID-19 decedents, 75.3% were age ≥65. Conclusion Published in April 2020, preliminary data from COVID-Net on approximately 180 patient reported that only 8.2% of patients age ≥ 65 had altered mental status2. Since then, our analysis noted that altered mental status is more commonly seen in the age group ≥ 65 than previously reported. The percentage of decedents age ≥ 65 in this analysis is similar to the 74.8% (N= 10,647) reported in a large study that focused specifically on COVID-19-related deaths3. Our analysis highlights that altered mental status is a common neurologic manifestation in elderly patients hospitalized with COVID-19. Disclosures All Authors: No reported disclosures

Altered Mental Status

2018 ◽  
pp. 463-466
Author(s):  
James Burke
Keyword(s):  
Mental Status ◽  
Clinical Manifestations ◽  
Altered Mental Status ◽  
Hospitalized Patients

This chapter guides the reader on the general principles, clinical manifestations, and management of altered mental status in hospitalized patients.

Approach to Acute Altered Mental Status and Seizures (DRAFT)

2018 ◽  
Author(s):  
Jody Manners ◽  
Kiruba Dharaneeswaran ◽  
Ruchira Jha
Keyword(s):  
Mental Status ◽  
Altered Mental Status ◽  
Hospitalized Patients ◽  
Morbidity And Mortality ◽  
Rapid Evaluation ◽  
Metabolic Derangement ◽  
Medical Comorbidities ◽  
Life Threatening

Altered mental status (AMS) is a common presenting symptom or complication in hospitalized patients. The etiology of AMS includes potential primary neurologic entities as well as systemic disturbances such as infection, intoxication, or metabolic derangement. A systematic and rapid evaluation of potentially life threatening conditions is necessary to guide appropriate management. Seizures (particularly non-convulsive episodes) are an important cause of AMS frequently encountered in acutely ill patients with multiple medical comorbidities and need to be recognized and treated early to minimize morbidity and mortality. This chapter outlines an approach to the evaluation of acute altered mental status with an emphasis on seizure management.

scholarly journals Inappropriate Testing for Urinary Tract Infection in Hospitalized Patients: An Opportunity for Improvement

2013 ◽  
Vol 34 (11) ◽  
pp. 1204-1207 ◽  
Author(s):  
Sarah Hartley ◽  
Staci Valley ◽  
Latoya Kuhn ◽  
Laraine L. Washer ◽  
Tejal Gandhi ◽  
...  
Keyword(s):  
Urinary Tract Infection ◽  
Urinary Tract ◽  
Tract Infection ◽  
Mental Status ◽  
Urinary Catheter ◽  
Altered Mental Status ◽  
Hospitalized Patients ◽  
Orthopedic Procedures ◽  
Clinical Scenarios ◽  
Current Guidelines

Urine cultures are frequently obtained for hospitalized patients. We reviewed documented indications for culture and compared these with professional society guidelines. Lack of documentation and important clinical scenarios (before orthopedic procedures and when the patient has altered mental status without a urinary catheter) are highlighted as areas of use outside of current guidelines.

scholarly journals 1110. Outcomes Following Implementation of a Urine Culture

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S395-S395
Author(s):  
Timothy Simpson ◽  
Janet Wu ◽  
Chirag Choudhary ◽  
Sneha Shah
Keyword(s):  
Antimicrobial Therapy ◽  
Urine Culture ◽  
Foley Catheter ◽  
Asymptomatic Bacteriuria ◽  
Primary Objective ◽  
Implementation Phase ◽  
Medical Intensive Care ◽  
Baseline Characteristics ◽  
Algorithm Implementation ◽  
The Impact

Abstract Background Antimicrobials are often inappropriately initiated for asymptomatic bacteriuria (ASB). At our institution, urinalysis (U/A) and urine culture (UCx) are ordered simultaneously, leading to an increased rate of catheter-associated UTI (CAUTI) diagnosis and antimicrobial initiation. A UCx algorithm was implemented in the medical intensive care unit (MICU) to guide the appropriate ordering of UCx in patients with foley catheters. The purpose of this study was to assess the impact of this UCx algorithm paired with nursing and prescriber education on overall patient outcomes. Methods This was a single-center, pre- and post-analysis of patients admitted to the MICU with an order for a U/A and/or UCx for suspected UTI. Patients were excluded if they had a suspected co-infection from another source, absence of foley catheter or UCx drawn prior to MICU admission. The pre-implementation phase was November 1, 2017 to April 31, 2018, and the post-phase was May 1, 2018 to October 31, 2018. The primary objective was to compare the incidence of CAUTI between pre- and post-implementation phases. Secondary objectives included rate of adherence to the algorithm, number of UCx ordered, rate and days of antimicrobial therapy for ASB, duration of catheterization and 30-day mortality between pre- and post-implementation phase. Results There were 94 patients in the pre-phase and 77 patients in the post-phase. Baseline characteristics were similar between groups, except a greater proportion of patients in the pre-phase had a catheter prior to admission (12.8% vs. 2.6%; P = 0.02). Incidence of CAUTI decreased following algorithm implementation (16% vs. 6.5%; P = 0.05). Complete algorithm adherence was 2.6%, whereas partial adherence was 49.4%. Number of UCx ordered were 126 (comprising 100% of patients) and 76 (comprising 86% of patients) in the pre- and post-phase, respectively. Antimicrobial therapy for ASB was initiated in 55.3% of patients in the pre-phase vs. 37.7% in the post-phase; P = 0.02. There were no differences in duration of ASB treatment, catheterization or 30-day mortality. Conclusion Implementation of UCx algorithm paired with educational intervention resulted in a significant decrease in CAUTI and ASB treatment. Additional interventions may be necessary to optimize adherence to the algorithm. Disclosures All authors: No reported disclosures.

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