infection control & hospital epidemiology july 2018, vol. 39, no. 7 original article
Modified Reporting of Positive Urine Cultures to Reduce Inappropriate Treatment of Asymptomatic Bacteriuria Among Nonpregnant, Noncatheterized Inpatients: A Randomized Controlled Trial
Peter Daley, MD, MSc, FRCPC, DTM&H;1,2 David Garcia, MD;1 Raheel Inayatullah, MD;2 Carla Penney, BSc, MSc;1 Sarah Boyd, BSc, MSc1
design. We conducted a randomized, parallel, unblinded, superiority trial of a laboratory reporting intervention designed to reduce anti- biotic treatment of asymptomatic bacteriuria (ASB).
methods. Results of positive urine cultures from 110 consecutive inpatients at 2 urban acute-care hospitals were randomized to standard report (control) or modified report (intervention). The standard report included bacterial count, bacterial identification, and antibiotic sus- ceptibility information including drug dosage and cost. The modified report stated: “This POSITIVE urine culture may represent asymptomatic bacteriuria or urinary tract infection. If urinary tract infection is suspected clinically, please call the microbiology laboratory…for identification and susceptibility results.” We used the following exclusion criteria: age <18 years, pregnancy, presence of an indwelling urinary catheter, samples from patients already on antibiotics, neutropenia, or admission to an intensive care unit. The primary efficacy outcome was the proportion of appropriate antibiotic therapy prescribed.
results. According to our intention-to-treat (ITT) analysis, the proportion of appropriate treatment (urinary tract infection treated plus ASB not treated) was higher in the modified arm than in the standard arm: 44 of 55 (80.0%) versus 29 of 55 (52.7%), respectively (absolute difference, −27.3%; RR, 0.42; P = .002; number needed to report for benefit, 3.7).
conclusions. Modified reporting resulted in a significant reduction in inappropriate antibiotic treatment without an increase in adverse events. Safety should be further assessed in a large effectiveness trial before implementation. TRIAL REGISTRATION.
clinicaltrials.gov#NCT02797613
Infect Control Hosp Epidemiol 2018;39:814–819
Asymptomatic bacteriuria (ASB), defined as the presence of significant bacterial count in the urine without the associated symptoms of a urinary tract infection, is common among women, diabetics, and the elderly.1 Screening for, and treat- ment of, ASB with antibiotics has not been shown to prevent symptomatic urinary tract infection (UTI), complications, or death. Treatment is associated with an increased rate of adverse events.1,2 Treatment for UTI is generally empirical, based on urinary
symptoms. In contrast, treatment for ASB occurs in response to a positive urine culture result. Confronted with positive urine-culture results, physicians often treat without consider- ing the symptom history, especially among inpatients, because urine culture may be submitted by nurses without a physician’s order. A novel approach to laboratory reporting would
partially withhold positive culture results, unless the physician specifically contacts the laboratory, based on symptoms. In a nonrandomized study using historical controls, this interven- tion reduced treatment of ASB among noncatheterized inpa- tients from 48% to 12% (absolute risk reduction, 36%; 95% CI, 15%–57%).3 It is established practice for the microbiology laboratory to withhold certain results, unless requested, such as second-line antimicrobial susceptibility, to encourage physicians to use narrow-spectrum antibiotics when appropriate. A related laboratory intervention (ie, delayed ordering of urine culture) has been shown to reduce inappropriate treatment of ASB.4 We hypothesized that modified reporting of positive urine cultures among inpatients would reduce treatment of ASB without increasing untreated UTI, pyelonephritis, bacteremia, or death.
Affiliations: 1. Memorial University of Newfoundland Department of Clinical Epidemiology, St John’s, Newfoundland, Canada; 2. Memorial University of Newfoundland Department of Medicine, St John’s, Newfoundland, Canada; Canada A1B3V6 (
Pkd336@mun.ca).
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0007. DOI: 10.1017/ice.2018.100 Received December 19, 2017; accepted April 5, 2018; electronically published May 28, 2018
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144
