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

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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1083. Risk Factors Associated with Treatment of Asymptomatic Bacteriuria in the Emergency Department: A Multi-Hospital Cohort Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.947 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S384-S385

Author(s):

Lindsay A Petty ◽

Valerie M Vaughn ◽

Twisha S Patel ◽

Anurag N Malani ◽

Jason M Pogue ◽

...

Keyword(s):

Emergency Department ◽

Asymptomatic Bacteriuria ◽

Altered Mental Status ◽

Estimating Equation ◽

Generalized Estimating Equation ◽

Medical Patients ◽

Positive Urine Culture ◽

Factors Associated ◽

Patient Variables ◽

Antibiotic Dose

Abstract Background Antimicrobial stewardship interventions to decrease testing and treatment of asymptomatic bacteriuria (ASB) have primarily focused on inpatient clinicians, however emergency medicine (EM) clinicians also test and treat ASB. We identified testing attributable to EM clinicians and patient-level factors associated with EM treatment of ASB. Methods Between November 2017 and March 2019, data were abstracted from medical records of adult non-ICU medical patients at 43 Michigan hospitals admitted through the Emergency Department (ED) with a positive urine culture (Ucx) collected on day 1 or 2 of hospitalization. Exclusions included pregnancy, urologic surgery or abnormality, immune-compromise, severe sepsis, or concomitant infection. ASB was defined as a positive Ucx without signs or symptoms of a urinary tract infection (UTI). The treatment group included patients receiving ≥1 antibiotic dose ordered by an EM clinician. Patient factors associated with ASB treatment by EM clinicians vs. no treatment were evaluated using logistic generalized estimating equation models. Results Of 1,778 patients with ASB, 74.7% (N = 1328) had a Ucx ordered by an EM clinician (Figure 1), and 74.4% (N = 1323) were treated with antibiotics (Figure 2). Of those treated for ASB, 64.3% (851/1328) had the first dose ordered by an EM clinician (Figure 2). Patient variables associated with EM treatment included nonambulatory status, incontinence, presence of a urinary catheter, acutely altered mental status (AMS), leukocytosis, and positive urinalysis (Table 1). When EM initiated treatment, most patients (80%) remained on antibiotics for ≥3 days (Figure 3), with a median treatment duration of 6 days [IQR 4–9]. Conclusion Among patients with ASB admitted through the ED with a Ucx collected on day 1 or 2 of hospitalization, most were treated with antibiotics. The majority of testing and initial treatment for ASB was by EM clinicians. The strongest predictors of EM treatment of ASB were positive urinalysis and AMS. Once started by EM, patients often received a full course for UTI. Given the burden of ASB testing and treatment, expanding stewardship into the ED is critical and should start with addressing interpretation of urinalyses in patients without specific urinary symptoms. Disclosures All authors: No reported disclosures.

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803. Risk factors associated with Clostridioides difficile infection in hospitalized patients with community-acquired pneumonia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.993 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S445-S445

Author(s):

William Justin Moore ◽

Caroline C Jozefczyk ◽

Paul R Yarnold ◽

Karolina Harkabuz ◽

Valerie Widmaier ◽

...

Keyword(s):

Risk Factors ◽

Decomposition Analysis ◽

Antibiotic Use ◽

Community Acquired Pneumonia ◽

Hospitalized Patients ◽

Structural Decomposition Analysis ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Pre Treatment ◽

Healthcare Associated

Abstract Background Patients with community-acquired pneumonia (CAP) who are hospitalized and treated with antibiotics may carry an increased risk for developing Clostridioides difficile infection (CDI). Accurate risk estimation tools are needed to guide monitoring and CDI mitigation efforts. We aimed to identify patient-specific risk factors associated with CDI among hospitalized patients with CAP. Methods Design: retrospective case-control study of hospitalized patients who received CAP-directed antibiotic therapy between 1/1/2014 and 5/29/2018. Cases were hospitalized CAP patients who developed CDI post-admission. Control patients did not develop CDI and were selected at random from CAP patients hospitalized during this period. Variables: comorbidities, laboratory results, vital signs, severity of illness, prior hospitalization, and past antibiotic use. Propensity-score weights: identified via structural decomposition analysis of pre-treatment variables. Analysis: weighted classification tree models that predicted any CDI, hospital-onset CDI, and any healthcare-associated CDI according to CAP antibiotic treatment. Performance: percent accuracy in classification (PAC) and weighted positive (PPV) and negative predictive values (NPV). Modeling: completed using the ODA package (v1.0.1.3) for R (v3.5.1). Results A total of 32 cases and 232 controls were identified. Sixty pre-treatment variables were screened. Structural decomposition analysis, completed in two stages, identified prior hospitalization (OR 6.56, 95% CI: 3.01-14.31; PAC: 80.3%) and BUN greater than 29 mg/dL (OR 11.67, 95% CI: 2.41-56.5; PAC: 80.8%) as propensity-score weights. With respect to CDI, receipt of broad-spectrum anti-pseudomonal antibiotics was significantly (all P’s< 0.05) associated with any CDI (NPV: 90.29%, PPV: 27.94%), hospital-onset CDI (NPV: 97.53%, PPV: 26.86%), and healthcare-associated CDI (NPV: 92.89%, PPV: 27.94%). Conclusion We identified risk factors available at hospital admission and empiric use of broad-spectrum Gram-negative antibiotics as being associated with the development of CDI. Model PPVs were over two-fold greater than our sample base rate. Increased monitoring and avoidance of overly broad antibiotic use in high-risk patients appears warranted. Disclosures All Authors: No reported disclosures

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219. Characteristics Associated with Inappropriate Antibiotic Prescribing in Patients with Asymptomatic Bacteriuria (ASB)

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.263 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S111-S111

Author(s):

Morgan L Bixby ◽

Brian R Raux ◽

Aakansha Bhalla ◽

Christopher McCoy ◽

Elizabeth B Hirsch

Keyword(s):

Antibiotic Treatment ◽

Inappropriate Prescribing ◽

White Blood Cells ◽

Asymptomatic Bacteriuria ◽

Panel Member ◽

Culture Collection ◽

Antibiotic Prescribing ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection ◽

Klebsiella Spp

Abstract Background Antibiotic treatment of asymptomatic bacteriuria (ASB) is considered inappropriate, does not improve patient outcomes, and may lead to adverse events such as antibiotic resistance and Clostridioides difficile infection. Previous stewardship interventions have focused on reducing unnecessary urine culture collection in individuals without urinary symptoms; however, further interventions to reduce inappropriate prescribing in ASB are warranted. This study sought to identify characteristics associated with treatment of ASB in order to implement future stewardship interventions. Methods This two-center, retrospective cohort study included unique emergency department or inpatient adults with consecutive non-duplicate monomicrobial urine isolates of Enterobacterales or Pseudomonas aeruginosa collected between 8/2013 and 1/2014 from two academic hospitals in Boston, Massachusetts. Patients with ASB (without chart-documented urinary-specific symptoms) were identified through chart review and stratified into two groups: those treated with empiric urinary tract infection (UTI) antibiotics and those untreated. Logistic regression analyses were performed to identify variables independently associated with antibiotic treatment of ASB. Results During the study, 255 patients were determined to have ASB and a majority (80.8%) were treated with empiric UTI antibiotics. Most patients were female (71.4%) and elderly (mean age 70 years). The most common organisms isolated were Escherichia coli (59.2%), Klebsiella spp. (23.1%), and P. aeruginosa (9.8%). The presence of isolated fever (OR, 7.83 [95% confidence interval, 1.51, 144.20]); p = 0.05), urinalysis positive for pyuria (>10 white blood cells) (OR, 2.52 [95% CI, 1.15, 5.54]; p = 0.02), and Klebsiella spp. urine isolate (OR, 2.99 [95% CI, 1.19, 8.60]; p = 0.02) were independently associated with treatment. Conclusion A large proportion of ASB patients were treated with antibiotics despite clinical practice guidelines recommending against this practice. Isolated fever, pyuria, and Klebsiella spp. culture were all significantly associated with the treatment of ASB; targeted review of these patients by stewardship programs may help to reduce inappropriate ASB treatment within these institutions. Disclosures Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support) Nabriva Therapeutics (Advisor or Review Panel member)

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10-Year Trends in Urine Testing and Treatment in Patients with Spinal Cord Injury: An Opportunity for Targeted Stewardship

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.586 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s90-s90

Author(s):

Alison Nelson ◽

Kalpana Gupta ◽

Judith Strymish ◽

Maura Nee ◽

Katherine Linsenmeyer

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Antibiotic Treatment ◽

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Routine Screening ◽

Organizational Level ◽

Cord Injury ◽

Urine Testing ◽

Over Time

Background: Guidelines regarding asymptomatic bacteriuria (ASB) have consistently recommended against screening and treatment in most circumstances. However, screening of patients with spinal cord injury (SCI) is common practice and in some cases is a formal protocol at the organizational level. A previous study found that more than one-third of patients with ASB detected on routine screening cultures performed at annual visits in 2012 received antibiotics. However, the role of antibiotic stewardship has become more prominent over the last decade. We hypothesized that diagnostic and therapeutic stewardship efforts may be impacting the practice of annual urine-culture screening for SCI patients. We evaluated urine culture screening and treatment rates over a 10-year period. Methods: Patients with SCI seen in the VA Boston HCS for an annual exam in 2018 were eligible for inclusion and formed the baseline cohort for this study. Annual visits for the cohort over a 10-year period (January 1, 2009–December 31, 2018) were included in the analysis. Electronic data collection and manual chart review were utilized to capture outcomes of interest including urine culture, antibiotic prescriptions and indication within 15 days, and documentation of urinary or infectious symptoms. The main outcomes were (1) rate of urine cultures performed ±3 days of the visit, (2) rate of antibiotic treatment in asymptomatic patients, and (3) trend over time of urine culturing and treating. The χ2 test for trend was used to compare rates over time. Results: In total, 1,962 annual visits were made by the 344 unique patients over the 10-year period and were available for analysis. Among these, 639 (32.6%) visits had a urine culture performed within 3 days. The proportion of visits with a collected culture decreased from (109 of 127) 85.8% of visits in 2009 to (65 of 338) 19.2% of visits in 2018, P ≤ .001 (Fig. 1). In the treatment analysis, 39 visits were excluded for active symptoms, concern for uncontrolled infection, or prophylaxis as antibiotic indication. Among 600 remaining screening cultures, 328 had a bacterial pathogen or >100,000 mixed colonies consistent with ASB. Overall, 51 patients (17%) received antimicrobials. The rate of antibiotic treatment for ASB did not significantly decrease over time pP = 0.79 (Fig. 2). Conclusions: Over a 10-year period of annual SCI visits, the proportion of visits with a urine culture performed as routine screening significantly and consistently decreased. However, the rate of treatment for positive urine cultures remained consistent. These data support targeted diagnostic stewardship in this population to reduce unnecessary antibiotic use.Funding: NoneDisclosures: None

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785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.975 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S437-S437

Author(s):

Kerui Xu ◽

Andrea L Benin ◽

Hsiu Wu ◽

Jonathan R Edwards ◽

Qunna Li ◽

...

Keyword(s):

Acute Care ◽

Acute Care Hospitals ◽

Antibiotic Use ◽

Prevalence Rates ◽

Hospital Level ◽

First Line ◽

Oral Vancomycin ◽

Patient Admissions ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection

Abstract Background Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Methods We matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs. Results Among the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63). Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018 Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs Conclusion The moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs. Disclosures All Authors: No reported disclosures

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Burden and risk factors for inappropriate Clostridioides Difficile infection testing among hospitalized patients

Diagnostic Microbiology and Infectious Disease ◽

10.1016/j.diagmicrobio.2020.115283 ◽

2021 ◽

Vol 99 (4) ◽

pp. 115283

Author(s):

Ellen Axenfeld ◽

William G. Greendyke ◽

Jianhua Li ◽

Daniel A. Green ◽

Susan Whittier ◽

...

Keyword(s):

Risk Factors ◽

Hospitalized Patients ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection

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Clostridioides difficile infection evaluation and management in the emergency department

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2020.06.083 ◽

2020 ◽

Vol 38 (10) ◽

pp. 2203-2208

Author(s):

Brandon M. Carius ◽

Stephen Y. Liang ◽

Alex Koyfman ◽

Brit Long

Keyword(s):

Emergency Department ◽

Clostridioides Difficile ◽

Clostridioides Difficile Infection

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

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.975 ◽

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.

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