818 infection control & hospital epidemiology july 2018, vol. 39, no. 7 table 2. Treatment Decision ITT Population Treatment at 72 h Intervention


Standard, no. (%) Modified, no. (%)


UTI treated 12/14 (85.7)


18/20 (90.0)


UTI untreated 2/14 (14.3)


2/20 (10.0)


appeared successful; however, we found nonsignificantly more UTIs in the modified reporting arm compared to the standard reporting arm (P = .219). Because our primary outcome included both appropriate treatment of UTI and appropriate treatment of ASB, this difference between groups at baseline did not bias our conclusion. Our diagnosis was based on prospective review of medical


Our study has several limitations. Our randomization


records and discussion with nursing staff, not on taking the history from the patient. Thus, where data may have been unavailable, our diagnosis may have been biased toward ASB. Furthermore, investigators were not blinded to reporting assignment, so assessment of appropriate treatment may have been biased toward a favorable effect of the intervention. Although we actively surveilled harms and observed equal


adverse events in both arms, our trial was not powered to adequately assess the safety of modified reporting. Safety should be further assessed in a large effectiveness trial, before implementation. We observed a very large and statistically significant reduc-


tion in length of stay when appropriate antibiotics were pre- scribed; however, this observation may have been confounded by many alternative explanations. Most positive urine cultures in our study represented ASB


(69.1%), not UTI. This proportion may not be generalizable to other hospitals, depending on local practice in urine culture ordering. This proportion suggests that our laboratory is cur- rently testing many inpatient urine specimens which should not have been collected.Weare not aware of other laboratories using restricted reporting. Other limitations to generalizability include exclusion of


tional verification trials before implementation. It would be impractical for laboratories to manually screen all inpatient urine specimens using our inclusion criteria, although auto- mated eligibility screening may be possible. Antibiotic stewardship guidelines9 suggest that laboratories take a more active role in stewardship. Modified reporting


urines collected from many patients. Future research could expand the application of our intervention to include catheter-collected urines, long-term care, children, intensive care units, or outpatients. Because treatment for ASB may be appropriate among pregnant women or prior to urologic surgery, these groups should not be included in modified reporting. Our design is a proof-of-concept study that requires addi-


ASB treated 24/41 (58.5)


10/35 (37.1)


ASB untreated 17/41 (41.5)


25/35 (71.4)


represents a simple, low-cost, sustainable intervention. Future possible laboratory interventions could include physician order entry or rejection of urine collected for inappropriate reasons. Whether physician urine ordering would be more appropriate compared to nurse ordering remains a question for further study.


acknowledgments


The authors thank Dr Brendan Barrett and Dr Jerome Leis for critical review of the manuscript. Financial support: No financial support was provided relevant to this article. Potential conflicts of interest: All authors report no conflicts of interest rele-


vant to this article. Address correspondence to Peter Daley, Associate Professor of Medicine,


Memorial University of Newfoundland, Room 1J421, 300 Prince Phillip Dr, St John’s, Newfoundland,


supplementary material


To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2018.100.


references 1. Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler MT, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev 2015;4:CD009534.


2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asympto- matic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.


3. Leis JA, Rebick GW, Daneman N, et al. Reducing antimicrobial therapy for asymptomatic bacteriuria among noncatheterized inpatients: a proof-of-concept study. Clin Infect Dis 2014;58: 980–983.


4. Stagg A, Lutz H, Kirpalaney S, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2017:1–8; doi: 10.1136/bmjqs-2016- 006250.


5. Centers for Disease Control and Prevention. Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other urinary system infection [USI]) events In: Network NHS, ed. Atlanta: CDC; 2017.


6. Urbaniuk GC, Plous S. Research Randomizer (version 4.0) soft- ware website. http://www.randomizer.org/. Published 2015. Accessed December 15, 2016.


7. Irfan N,Brooks A, MithoowaniS,Celetti SJ,MainC, Mertz D. A controlled quasi-experimental study of an educational intervention


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