85. Evaluation of Urinalysis and Urine Culture Use at a Community Health-system

Abstract Background The Infectious Diseases Society of America asymptomatic bacteriuria (ASB) guidelines recommend against screening for or treating ASB in most patients without symptoms of a urinary tract infection (UTI). The purpose of this study was to characterize current urine testing practices and their potential impact on identification and treatment of asymptomatic bacteriuria on hospitalized adults. Methods This retrospective, point prevalence study conducted at a 4 hospital community health-system that included all inpatients ≥ 18 years old present on November 13th, 2019. Patients were excluded if they were admitted or transferred to either a labor & delivery or mother-baby unit. A chart review was performed for a sub-group of patients with abnormal urine testing, with a target sample size of 200 (n=50 from each hospital). The primary outcome was the prevalence of patients with a urinalysis, urine culture, or both performed during their admission. Secondary outcomes included abnormal urine testing in the overall cohort and symptomatology and antibiotic use in the sub-group (Figure 1). Results 947 patients met inclusion criteria. Of those patients, 516 (54%) had urine testing performed during their admission. 322 (34%) patients had abnormal urine testing results (Table 1). In the sub-group, 192 patients with abnormal urine tests were included. Antibiotics with a documented indication of UTI were administered to 66 (34%) patients. Of those given antibiotics with a UTI indication, 49/66 (74%) did not have documented signs or symptoms of a UTI (Figure 2). Conclusion Urine testing was performed on the majority of admitted adult patients. Unnecessary testing likely contributes to guideline discordant screening and treatment of ASB. Future studies are needed to identify effective diagnostic stewardship interventions to decrease screening and treatment of ASB. Disclosures Ashley Wilde, PharmD, BCPS-AQ ID, Nothing to disclose

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15. Leveraging Data to Explore the Consequences of Urine Testing and Antibiotic Use During the Spinal Cord Injury Annual Evaluation

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa417.014 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S8-S9

Author(s):

Sarah B May ◽

Annette Walder ◽

S Ann Holmes ◽

Ivy Poon ◽

Charlesnika T Evans ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Positive Culture ◽

Antibiotic Use ◽

Health Administration ◽

Comorbidity Score ◽

Cord Injury ◽

Urine Testing

Abstract Background The Veterans’ Health Administration (VHA), currently mandates that every spinal cord injury and disorder (SCI/D) patient receives a screening urinalysis and urine culture (UC) during the annual evaluation (AE). Our pilot study at a single VHA center showed that 87% of the UCs obtained during the AE represented asymptomatic bacteriuria (ASB), and that 35% of those UC were treated with antibiotics unnecessarily. The objective of the current study is to determine the association between UC and antibiotic use using a national VHA sample of SCI/D patients. Methods Retrospective cohort of Veterans who presented to a VHA SCI/D clinic for their AE in FY18 or FY19. Demographic and clinical characteristics as well as information on primary outcomes (receipt of urine culture and antibiotics) were extracted from the VHA Corporate Data Warehouse. Associations between covariates and outcomes were assessed using logistic regression. P values < 0.05 were considered significant. Results 9447 veterans with SCI/D were included, of whom 5088 (54%) had a UC obtained. Of those with a UC, 2910 (57%) were classified as positive (Figure 1). 1054 (11%) veterans were prescribed antibiotics within 7 days of their AE. Of these, 515 had a positive UC, 202 had a negative UC, and 2878 did not have a UC obtained during the AE. Age, ethnicity, neurologic level of injury (NLI), comorbidity score, frequently identified organism on positive culture, and receipt of antibiotics within 7 days of AE were significantly associated with obtaining a UC during the AE. Race, NLI, bladder management strategy, comorbidity score, frequently identified organism on positive culture, and having a UC obtained during the AE were significantly associated with receipt of antibiotics within 7 days of AE. Flowchart of SCI/D Veterans who had a urine culture and/or received antibiotics during their FY18/19 AE Conclusion Over half of Veterans with SCI/D presenting for their AE receive a screening UC, contrary to other national guidelines recommending against this practice. Age and type or organism identified on UC drive antibiotic use, which was similar to our previous findings and reflect themes identified during our qualitative interviews with SCI/D providers. The knowledge gained from this national VA study will assist the development of interventions to reduce unnecessary urine testing and antibiotic use in the SCI/D population. Disclosures All Authors: No reported disclosures

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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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238. Novel Way to Evaluate Antibiotic Use Appropriateness: Moving Towards the “Never Event” Classification by Electronic Algorithm

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.282 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S119-S120

Author(s):

Twisha S Patel ◽

Lindsay A Petty ◽

Jiajun Liu ◽

Marc H Scheetz ◽

Nicholas Mercuro ◽

...

Keyword(s):

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

Data Capture ◽

Electronic Data Capture ◽

Electronic Data ◽

False Positivity ◽

Never Event ◽

Manual Review

Abstract Background Antibiotic use is commonly tracked electronically by antimicrobial stewardship programs (ASPs). Traditionally, evaluating the appropriateness of antibiotic use requires time- and labor-intensive manual review of each drug order. A drug-specific “appropriateness” algorithm applied electronically would improve the efficiency of ASPs. We thus created an antibiotic “never event” (NE) algorithm to evaluate vancomycin use, and sought to determine the performance characteristics of the electronic data capture strategy. Methods An antibiotic NE algorithm was developed to characterize vancomycin use (Figure) at a large academic institution (1/2016–8/2019). Patients were electronically classified according to the NE algorithm using data abstracted from their electronic health record. Type 1 NEs, defined as continued use of vancomycin after a vancomycin non-susceptible pathogen was identified, were the focus of this analysis. Type 1 NEs identified by automated data capture were reviewed manually for accuracy by either an infectious diseases (ID) physician or an ID pharmacist. The positive predictive value (PPV) of the electronic data capture was determined. Antibiotic Never Event (NE) Algorithm to Characterize Vancomycin Use Results A total of 38,774 unique cases of vancomycin use were available for screening. Of these, 0.6% (n=225) had a vancomycin non-susceptible pathogen identified, and 12.4% (28/225) were classified as a Type 1 NE by automated data capture. All 28 cases included vancomycin-resistant Enterococcus spp (VRE). Upon manual review, 11 cases were determined to be true positives resulting in a PPV of 39.3%. Reasons for the 17 false positives are given in Table 1. Asymptomatic bacteriuria (ASB) due to VRE in scenarios where vancomycin was being appropriately used to treat a concomitant vancomycin-susceptible infection was the most common reason for false positivity, accounting for 64.7% of false positive cases. After removing urine culture source (n=15) from the algorithm, PPV improved to 53.8%. Conclusion An automated vancomycin NE algorithm identified 28 Type 1 NEs with a PPV of 39%. ASB was the most common cause of false positivity and removing urine culture as a source from the algorithm improved PPV. Future directions include evaluating Type 2 NEs (Figure) and prospective, real-time application of the algorithm. Disclosures Marc H. Scheetz, PharmD, MSc, Merck and Co. (Grant/Research Support)

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Importance of Urinary Tract Infection to Antibiotic Use Among Hospitalized Patients

Infection Control and Hospital Epidemiology ◽

10.1086/593951 ◽

2009 ◽

Vol 30 (2) ◽

pp. 193-195 ◽

Cited By ~ 30

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.

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1986. Impact of Two-Step Testing on the Diagnosis and Management of Clostridium difficile in a Multi-Hospital Healthcare System

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1666 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S665-S666

Author(s):

Angelina Davis ◽

Todd Parker ◽

Julia Coluccio ◽

Kimberly Mann ◽

Elizabeth Dodds Ashley ◽

...

Keyword(s):

Health System ◽

Community Health ◽

Negative Binomial ◽

Cohort Analysis ◽

Antibiotic Use ◽

Baseline Period ◽

Post Intervention ◽

Care Community ◽

Days Of Therapy ◽

The Impact

Abstract Background Distinguishing active C. difficile infection (CDI) from asymptomatic colonization remains a significant challenge. A multi-step testing algorithm can improve the diagnostic accuracy of CDI and associated antibacterial prescribing. This study evaluated the impact of two-step testing on CDI rates and management in a multi-hospital community health system. Methods Two-step C. difficile testing (PCR for initial screening followed by EIA for toxin detection) was implemented in 6 acute care community hospitals in April 2018. EIA testing was automatically performed on all stool samples with a positive C. difficile PCR result. Prior to implementation, PCR alone was used to identify CDI. Messaging attached to the PCR laboratory report alerted prescribers of discrepant results (PCR +/EIA -). Anti-C. difficile therapy was at the discretion of the prescriber. We performed a retrospective cohort analysis over a 2-year period to evaluate the effect of two-step testing on system-wide hospital-onset CDI (HO-CDI) per 10,000 patient-days (PD) and anti-CDI antimicrobial use (AU) in days of therapy (DOT) per 1,000 PD. Segmented negative binomial regression with hospital clustering was used to estimate predicted HO-CDI rate for the baseline period between April 1, 2017 through March 31, 2018 and the post-intervention between May 1, 2018 through March 31, 2019. The implementation date at all sites in April 2018 was unknown; therefore, this month was removed from the analysis. Anti-CDI agents included fidaxomicin, metronidazole, and oral vancomycin, but may have included non-CDI indications for metronidazole. Results A total of 115 HO-CDI cases were identified; 91 (79%) before and 24 (21%) after. Prior to implementation of two-step testing, CDI rates declined at 4% per month (P = NS). The rate immediately dropped by 36% (P = 0.004) after two-step testing was implemented, but the trend did not significantly change (P = 0.52, Figure 1). Community-onset CDI rates also decreased during this time period. Combined facility-wide anti-CDI agent use was 824.87 before and 838.21 DOT/1,000 PD after and did not significantly change. Conclusion Use of a two-step approach for CDI testing reduced HO-CDI rates, but did not have a significant impact on anti-CDI antibiotic use in a multi-hospital community health system. Disclosures All authors: No reported disclosures.

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Urine Culture Testing in Community Nursing Homes: Gateway to Antibiotic Overprescribing

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2016.326 ◽

2017 ◽

Vol 38 (5) ◽

pp. 524-531 ◽

Cited By ~ 20

Author(s):

Philip D. Sloane ◽

Christine E. Kistler ◽

David Reed ◽

David J. Weber ◽

Kimberly Ward ◽

...

Keyword(s):

North Carolina ◽

Nursing Homes ◽

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Signs And Symptoms ◽

High Rate ◽

Community Nursing ◽

Initiation Factors ◽

Urine Color ◽

Urine Testing

OBJECTIVETo describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs)DESIGNObservational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study periodSETTING31 NHs in North CarolinaPARTICIPANTS254 NH residents who had a urine culture ordered within the 1-month study periodMETHODSWe conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs.RESULTSEmpirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000–99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%).CONCLUSIONSUrine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available.Infect Control Hosp Epidemiol 2017;38:524–531

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Impact of Urine Testing on Unnecessary Antibiotic Use for Asymptomatic Bacteriuria

Open Forum Infectious Diseases ◽

10.1093/ofid/ofv133.1052 ◽

2015 ◽

Vol 2 (suppl_1) ◽

Author(s):

Corinne Klein ◽

Miriam R. Elman ◽

Adam Brady ◽

James Lewis ◽

Erin Bonura ◽

...

Keyword(s):

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

Urine Testing

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1112. Improving Urine Culturing Practices in a Neurocritical Care Unit through a Multidisciplinary Algorithm-Based Approach

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.976 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S396-S396

Author(s):

Dana Hazen ◽

William Snyderman ◽

Josh Sadowski ◽

Kristen Kelley ◽

Cole Beeler ◽

...

Keyword(s):

Neurocritical Care ◽

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

P Value ◽

Improvement Project ◽

Increased Risk ◽

High Prevalence ◽

Implementation Time ◽

Culture Algorithm

Abstract Background Asymptomatic bacteriuria is common in hospitalized patients with urinary catheters. Inappropriate urine culturing as part of reflexive response to fever contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridium difficile infections, and false elevation in catheter-associated urinary tract infection (CAUTI) rates. This project aimed to implement an evidence-based urine culture algorithm in a 33-bed neurocritical care unit, a unit with a historically elevated CAUTI rate due to a high prevalence of noninfectious fever. Methods A multidisciplinary quality improvement project was initiated in August 2018 by the Infection Prevention, Quality and Safety, Neurocritical Care, Trauma, and Neurosurgery teams of an urban academic health center. The group implemented a urine culture algorithm that was adapted from the Infectious Diseases Society of America (IDSA) guidelines that clearly highlighted appropriate indications for sending urine cultures. The team agreed to utilize a urinalysis with reflex to culture as the preferred method to evaluate for CAUTI. The algorithm was implemented in September 2018. Outcomes were compared for pre-implementation (March-August 2018) and post-implementation (September 2018–February 2019). Results The NHSN CAUTI rate decreased from 4.52/1,000 Foley days to 1.27/1,000 Foley days (P-value 0.037) as a result of the intervention. The number of urine cultures ordered decreased by 82% after implementation. No cases of bacteremia or mortality secondary to a urinary source were identified during the project. Total days of antibiotic therapy for the unit was similar between the pre- and post-implementation time periods (P = 0.631). Conclusion Implementation of a urine culture algorithm in a neurocritical care unit resulted in reduced CAUTI rate with less financial and operational waste in unnecessary orders and treatment, without resulting in adverse events to patients as a result of missed diagnosis. Disclosures All authors: No reported disclosures.

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Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study (Preprint)

10.2196/preprints.12272 ◽

2018 ◽

Author(s):

Felicia Skelton ◽

Lindsey Ann Martin ◽

Charlesnika T Evans ◽

Jennifer Kramer ◽

Larissa Grigoryan ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Mixed Methods ◽

Research And Development ◽

Clinical Outcomes ◽

Urine Culture ◽

Antibiotic Use ◽

Health Administration ◽

Cord Injury ◽

Urine Testing

BACKGROUND Bacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use. OBJECTIVE Through a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices. METHODS Aim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site. RESULTS This protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019. CONCLUSIONS The negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/12272

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Urinary tract infections (UTIs); a leaflet for older adults, and carers: the development of a UTI leaflet for older adults and their carers

British Journal of General Practice ◽

10.3399/bjgp18x696833 ◽

2018 ◽

Vol 68 (suppl 1) ◽

pp. bjgp18X696833 ◽

Cited By ~ 1

Author(s):

Leah Ffion Jones ◽

Emily Cooper ◽

Cliodna McNulty

Keyword(s):

Older Adults ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Care Home ◽

Asymptomatic Bacteriuria ◽

Theoretical Domains Framework ◽

Antibiotic Use ◽

Primary Care Providers ◽

Care Providers ◽

Tract Infections

BackgroundEscherichia coli bacteraemia rates are rising with highest rates in older adults. Mandatory surveillance identifies previous Urinary Tract Infections (UTI) and catheterisation as risk factors.AimTo help control bacteraemias in older frail patients by developing a patient leaflet around the prevention and self-care of UTIs informed by the Theoretical Domains Framework.MethodFocus groups or interviews were held with care home staff, residents and relatives, GP staff and an out of hours service, public panels and stakeholders. Questions explored diagnosis, management, prevention of UTIs and antibiotic use in older adults. The leaflet was modified iteratively. Discussions were transcribed and analysed using Nvivo.ResultsCarers of older adults reported their important role in identifying when older adults might have a UTI, as they usually flag symptoms to nurses or primary care providers. Information on UTIs needs to be presented so residents can follow; larger text and coloured sections were suggested. Carers were optimistic that the leaflet could impact on the way UTIs are managed. Older adults and relatives liked that it provided new information to them. Staff welcomed that diagnostic guidance for UTIs was being developed in parallel; promoting consistent messages. Participants welcomed and helped to word sections on describing asymptomatic bacteriuria simply, preventing UTIs, causes of confusion and when to contact a doctor or nurseConclusionA final UTI leaflet for older adults has been developed informed by the TDF. See the TARGET website www.RCGP.org.uk/targetantibiotics/

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