Infection Control & Hospital Epidemiology (2019), 40,72–78 doi:10.1017/ice.2018.276
Original Article
The clinical impact of a urinary tract infection management bundle in a tertiary-care teaching hospital
Timothy D. MacLaggan BScPharm, PharmD, ACPR, BCPS1, Christopher P. Le BSc, MD, CCFP2, Kristen A. Iverson MB ChB, CCFP3, Chelsey L. Ellis MD, FRCPC4, Jacques Allard PhD5,a, Tammie J. Wilcox-Carrier HBSc RT4 and
Daniel J. Smyth BSc, MD, FRCPC, DTMH6 1Department of Pharmacy Services, Horizon Health Network, Moncton, New Brunswick, Canada, 2Family Practice, Fraser Health, New Westminster, British Columbia, Canada, 3Dalhousie University Department of Medicine, Halifax, Nova Scotia, Canada, 4Department of Laboratory Medicine, Horizon Health Network,
Moncton, New Brunswick, Canada, 5Département de mathématiques et statistique, Université de Moncton, Moncton, New Brunswick, Canada (retired) and 6Department of Internal Medicine, Horizon Health Network, Moncton, New Brunswick, Canada
Abstract
Objective: The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs. Design: Before-and-after intervention study. Settings: Tertiary-care hospital. Patients: Consecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital. Methods: The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists’ prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle. Results: Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment. Conclusions: A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.
(Received 29 May 2018; accepted 20 September 2018)
Asymptomatic bacteriuria (AB) is defined as the presence of a positive urine culture in the absence of clinical symptoms of urinary tract infection (UTI) including fever, increased urinary frequency, dysuria, or suprapubic tenderness.1 Treatment of AB offers no benefit in the majority of patients and is only indicated in select clinical circumstances, including patients who are pregnant and those undergoing urological intervention in which
Author for correspondence: Dr Timothy MacLaggan, Clinical Resource Pharmacist,
Infectious Disease, Horizon Health Network, 135 MacBeath Ave., Suite 6400, Moncton, NB, E1C 6Z8. E-mail:
Timothy.MacLaggan@
HorizonNB.ca Or Dr Daniel Smyth, Infectious Diseases/Internal Medicine, Horizon Health Network, 135 MacBeath Ave, Suite 6400, Moncton, NB, E1C 6Z8. E-mail:
dr.daniel.smyth@
horizonnb.ca PREVIOUS PRESENTATION: Preliminary abstract was presented as a poster for the
2016 AMMI Canada Annual conference and was published as Smyth D, Iverson K, Le C, Hussain Z, MacLaggin T, Wilcox T, Ellis C. The clinical impact of a UTI management
bundle in a tertiary-care teaching hospital. JAMMI 2016;1.1:73 (IP13). aRetired.
Cite this article: MacLaggan TD, et al. (2019). The clinical impact of a urinary tract
infection management bundle in a tertiary-care teaching hospital. Infection Control & Hospital Epidemiology 2019, 40, 72–78. doi: 10.1017/ice.2018.276
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
disruption of the mucosa is anticipated.2,3 Despite having no clinical benefit, antimicrobial therapy is frequently provided to patients with AB in an inpatient setting.4,5 Inappropriate provi- sion of antimicrobial therapy for AB increases the risk of adverse events, including infection with Clostridium difficile.6 Antimicrobial stewardship programs guide the rational use
of antimicrobials to optimize patient outcomes and minimize adverse events.7,8 The efficacy of interventions within the microbiology laboratory to promote antimicrobial stewardship has previously been demonstrated.9 Recognizing that urine cul- tures are frequently submitted in patients with AB, the role of modifying urine culture results in noncatheterized patients has previously been shown to be an effective means by which the treatment of AB can be reduced.9 Laboratory-based interventions provide an opportunity to reduce treatment initiation in response to a positive culture and force clinicians to reflect upon a patient’s clinical status prior to antimicrobial prescription.9 Our study further evaluated the use of this intervention within the context of
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