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Ebony C. Jackson et al
Figure 1. Process-control chart: Monthly average of urine cultures processed. Discussion
Education coupled with an EHR intervention significantly decreased the number of urine cultures processed and moderately decreased antibiotic prescriptions without impacting rates of PJI in asymptomatic patients undergoing elective joint arthroplasty. Lamb et al7 demonstrated a relative risk ratio of 99% in the number of urine cultures processed after removal from order sets and a laboratory intervention. Although we showed improvement with education, other studies have demonstrated that education alone does not sustain the benefit.8 Education coupled with changes in the EHR is likely to have a more lasting impact. Our interventions resulted in $2,128 of cost savings in laboratory materials due to averted urine testing costs. We did not evaluate additional savings related to a reduction in personnel time, antibiotic prescriptions, and adverse event avoidance. The limita- tions of this study include lack of randomization, potential effect of unknown confounders, and lack of power to draw conclusions related to clinical outcomes, including no difference in PJI. In summary, we have demonstrated that education coupled
with EHR order set revision can have a significant impact on reducing inappropriate urine cultures in preoperative orthopedic patients. With an international focus on antibiotic stewardship, this is a quick, effective intervention that could be easily imple- mented in other institutions.
Acknowledgments. We would like to thank Anne Burgess, MT (ASCP) for her contributions to this project.
Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
Supplementary materials. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.278
References
1. Sousa R, Munoz-Mahamud E, Quayle J, et al. Is asymptomatic bacteriuria a risk factor for prosthetic joint infection? Clin Infect Dis 2014;59: 41–47.
2. Duncan RA. Prosthetic joint replacement: should orthopedists check urine because it’s there? Clin Infect Dis 2014;59:48–50.
3. Codero-Ampuero J, González-Fernández E, Martínez-Vélez D, et al. Are antibiotics necessary in hip arthroplasty with asymptomatic bacteriuria? Seeding risk with/without treatment. Clin Orthop Relat Res 2013;471: 3822–3829.
4. CDC/NHSN. Surveillance definitions for specific types of infections. Page 7.
https://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current. pdf. Updated January 2018. Accessed September 10, 2018.
5. Nicolle L, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.
6. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997;11:551–581.
7. Lamb M, Baillie L, Pajak D, et al. Elimination of screening urine cultures prior to elective joint arthroplasty. Clin Infect Dis 2017;64: 806–809.
8. Hamishehkar H, Vahidinezhad M, Mashayekhi SO, et al. Education alone is not enough in ventilator-associated pneumonia care bundle compliance. J Res Pharm Pract 2014;3:51–55.
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