Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments

Abstract

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

SWOT and Root Cause Analyses of Antimicrobial Resistance to Oral Antimicrobial Treatment of Cystitis

“…A multimodal AMS initiative decreased outpatient usage of fluoroquinolones for cystitis by 39% [40] in a large health system of Texas from 2016 to 2018, and a similar effort in Colorado, US, was more successful in encouraging the use of nitrofurantoin as a first-line therapy for acute uncomplicated cystitis [139]. The overuse of OAT was also noted in a retrospective study of Medicare Part B enrollees in the New York State between 2016 and 2017, which found that, although AMS efforts slightly reduced the use of oral fluoroquinolones for uncomplicated cystitis, there was still a need for additional outpatient AMS efforts to curtail the use of oral fluoroquinolones in American hospitals [41,49].…”

“…Furthermore, cystitis can dilate the tight junctions of the inflamed urothelium [12,65,82] to reportedly cause a four-fold rise in creatinine reabsorption [55,67] via passive paracellular diffusion, and the resulting decline in the urine creatinine levels can potentially introduce errors in the estimation of the renal function status of cystitis patients, leading to their under-and overdosing of OAT [25,113]. Given that every dose of an OAT regimen produces an initial subtherapeutic concentration in urine [122] during the intended build-up to the MIC, which is itself indeterminable, there is an inevitable period of potential AMR risk with the initiation of OAT, even with AMS [40,41,[137][138][139]. Thus, our root cause analysis (studies listed in Table 1) identifies the initial delay in the MIC as the root cause of AMR, which is a risk with every treatment course of OAT for cystitis.…”

Outcomes of patients with bacteriuria/pyuria of clinically undetermined significance (BPCUS) treated with antibiotics in 23 community hospital emergency departments

“…We performed two cross-sectional evaluations 6 , 7 of antibiotic prescribing for UTI in 23 EDs in Utah and Idaho (14 to 503-bed hospitals; 9 rural, 14 urban) in the Intermountain Healthcare system, an integrated not-for-profit network of hospitals and clinics. Briefly, these studies included adult patients with an ED visit in 2017 or 2021 who had a urinalysis (UA) ordered, were diagnosed with “UTI” (identified via ICD10 code), and were discharged with an antibiotic prescription.…”