Treatment of asymptomatic pyuria in psychiatric patients discharged from the emergency department following antimicrobial stewardship implementation

Abstract

Introduction Abnormal urinalysis (UA) results, such as pyuria or bacteriuria, increase the risk for antibiotic treatment even in the absence of urinary symptoms. In the emergency department (ED), patients presenting with psychiatric emergencies commonly undergo a medical assessment which includes a UA. We hypothesized that the rate of inappropriate antibiotic treatment for asymptomatic pyuria in the psychiatric medical population would decrease following implementation of an antimicrobial stewardship program (ASP) in the ED. Methods This retrospective cohort study compared the treatment of adult patients presenting to the ED for medical assessment during a psychiatric emergency with noted pyuria between three time periods following implementation of an ASP: early ASP (2014), established ASP (2016), and mature ASP (2018). The ASP provided education and routine audit‐and‐feedback focused on reducing urine testing and eliminating treatment of asymptomatic pyuria. The primary end point was to compare rates of inappropriate treatment of asymptomatic pyuria between groups. Secondary end points included comparing appropriate agent selection and duration for patients who were prescribed antibiotics, prescriber documentation, and patient outcomes between groups. Results A total of 180 patients with pyuria were included; 60 within each study group with 88.3% being asymptomatic. Inappropriate prescribing of antibiotics for asymptomatic patients at ED discharge decreased over time following ASP implementation (2014 = 40.4%, 2016 = 31.4%, 2018 = 17.6%; P = .036). Additionally, documentation noting a positive UA requiring antibiotic treatment decreased (2014 = 46.7%, 2016 = 40%, 2018 = 26.7%). Of the 62 patients treated with antibiotics, selection of a first‐line agent increased with ASP maturity (2014 = 15.4%, 2016 = 26.1%, 2018 = 69.9%; P = .002). Conclusion Inappropriate treatment of asymptomatic pyuria in patients presenting to the ED with psychiatric emergencies decreased significantly over time following implementation of an ASP. EDs may benefit from ASP interventions aimed at decreasing reliance on UA interpretation in this patient population.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

“…Effectiveness of interventions was similar across study sizes (smaller24 153–156 vs larger106 135 138 157 158), locations (single-site73 159–162 vs multisite85 124 163–165), quality (lower72 74 75 83 166 vs higher127 128 139–141) and designs (uncontrolled79 104 105 107 133 vs controlled86 125 126 167 168). Multifaceted interventions were more likely to be effective than single-faceted interventions.…”

“…Education,73–77 audit and feedback,78–82 stakeholder engagement,24 83–86 clinical decision support,87–91 nudge,92–96 clinical champions,97–101 training102–106 and incentives79 107 were the component facets of interventions. Interventions were multifaceted in 79% (113/143) of studies and single faceted in 21% (30/143) of studies.…”

“…Clinical decision support and nudge have complementary features94 95 which can be leveraged in resource-limited settings where electronic clinical decision support might not be an option and nudge might suffice. Feedback worked best when it was immediate,178 specific,73 detailed,179 case-based,180 181 individualised with peer group comparison159 182 and accompanied by deep engagement with clinicians 136. Engagement of multidisciplinary stakeholders in development of priorities, identification of barriers and design of interventions led to effective deimplementation 81 183 184.…”

Evaluating the impact of emergency department clinical pharmacist integration within a discharge urine culture follow‐up program

“…A recent study evaluating ASB treatment in ED psychiatric patients before and after establishing an ID pharmacist-led culture review also found no difference in 72-h ED revisit, despite significantly decreased ASB treatment rates after program initiation. 15 This study is not without limitations, including that it is a retrospective analysis, potentially resulting in incomplete data collection and confounders. Limited documentation describing UTI symptoms potentially identified during patient outreach by the UCRP team could also factor into whether treatment is truly appropriate.…”

“…The large number of ASB‐treated patients in the before pharmacist integration arm who, by definition, have no active infection, have a lower likelihood of ED revisit and may play a role in why no difference was seen. A recent study evaluating ASB treatment in ED psychiatric patients before and after establishing an ID pharmacist‐led culture review also found no difference in 72‐h ED revisit, despite significantly decreased ASB treatment rates after program initiation 15 …”