1592. SHEA Featured Oral Abstract: Reducing Unnecessary Antibiotic Treatment for Asymptomatic Bacteriuria: A Statewide Collaborative Quality Initiative

Abstract

Background Up to one-third of hospitalized patients treated for urinary tract infection (UTI) have asymptomatic bacteriuria (ASB). Both diagnostic (avoiding inappropriate urine cultures) and antibiotic stewardship (reducing unnecessary antibiotic use in asymptomatic patients) have been proposed to reduce unnecessary antibiotic use for ASB. However, it's unclear which method is most effective. Methods The Michigan Hospital Medicine Safety Consortium aimed to improve antibiotic use and outcomes of hospitalized patients with a positive urine culture between 7/1/2017—3/31/2020 (see Table 1 for patient characteristics) by benchmarking performance across 46 Michigan hospitals, sharing best practices, and implementing pay-for-performance metrics related to unnecessary treatment of ASB (see Figure 1). Using logistic regression models controlling for hospital clustering, we assessed change over time in percentage of hospitalized patients treated for UTI who had ASB (i.e., had no documented signs or symptoms of UTI) and hospital characteristics associated with baseline or change in unnecessary antibiotic prescribing. We then estimated the percentage of avoided ASB treatment attributable to diagnostic (decrease in urine cultures ordered on asymptomatic patients) vs. antibiotic stewardship (decrease duration or avoidance of antibiotic treatment). Results Across 46 hospitals, there were 15,493 patients with a positive urine culture. Of 13,805 patients treated for a UTI, 23.2% (3,197) had ASB. The percentage of patients treated for UTI who had ASB declined over time from 29.0% (95% CI: 26.1%, 32.0%) to 16.9% (95% CI: 14.2%, 20.1%; aOR 0.94 per quarter, 95% CI: 0.92-0.96; Figure 1) with hospitals not belonging to a larger healthcare system having the largest decrease over time (Table 2). Neither the proportion of patients with ASB who were treated with antibiotics (P=0.07) nor the duration of therapy for ASB changed over time (P=0.09); thus, nearly all avoided antibiotic therapy for ASB appeared due to diagnostic stewardship. Conclusions Across 46 hospitals, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement. Disclosures Payal K. Patel, MD, MPH, Qiagen: Honoraria.

Increasing Evidence That Diagnostic Stewardship May Improve Antibiotic Use

“…2,3 Exposure to these unnecessary antibiotics can lead to patient adverse drug events and promotes antibiotic resistance.As reported in this issue of JAMA Internal Medicine, Vaughn and colleagues conducted a quality improvement initiative across 46 hospitals in the state of Michigan from 2017 to 2020 to address the problem of inappropriate antibiotic use for ASB. 4 They prospectively collected data on the prevalence of ASB at each hospital, shared data for benchmarking, shared best practices in antimicrobial and diagnostic stewardship, and, in 2018, selected treatment of ASB as a pay-forperformance metric. Hospitals then made individual decisions on how to best improve their practice.…”

“…5 It is notable that laboratorybased metrics are some of the few drivers to reduce overtesting and medical overuse. The study by Vaughn et al 4 focused on ASB, which was recently endorsed by the National Quality Forum as a metric of inappropriate diagnosis of UTI in hospitalized patients. 8 This metric will be one of the first to explicitly focus on limiting wrong diagnoses to limit unnecessary treatment with potential for greater improvement in testing.…”

“…This study provocatively frames findings in terms of favoring diagnostic over antimicrobial stewardship. 4 A Related article page 933 common goal of both forms of stewardship is improved antibiotic use and patient outcomes, and often staff from antimicrobial stewardship programs are those enacting diagnostic stewardship interventions. Diagnostic stewardship tends to make hardwired changes to testing and diagnosis, while antimicrobial stewardship tends to focus on communication with clinicians around treatment choices after a diagnosis.…”

“…In summary, Vaughn and colleagues 4 have completed a large, prospective evaluation of real-life quality improvement changes to address ASB, one of the primary drivers of unnecessary antibiotic use. They identified diagnostic stewardship changes to urine culturing as the most effective interventions to reduce antibiotic use for ASB.…”

“…The best interventions include requiring appropriate indications for urine culture ordering and only performing urine cultures if the urine sample has pyuria, indicating inflammation. It is notable that in the study by Vaughn et al, relatively few defined approaches were used by hospitals, indicating the possibility of reducing antibiotic use for ASB far beyond the 34% relative reduction they noted.…”