Infection Control & Hospital Epidemiology
a broader UTI management bundle in catheterized and non- catheterized patients. The aims of the intervention were to decrease inappropriate treatment of AB, to ensure that urine cultures are collected for an appropriate indication, to improve antimicrobial selection and duration of therapy for the treatment of symptomatic UTI, and to decrease unintended consequences of unnecessary antimicrobial therapy.
Methods
This study was a retrospective before-and-after intervention study of the implementation of UTI management bundle for inpatients. Aspects of the study and UTI management bundle design were based on studies completed by Leis et al9 and Landry et al.10 The Moncton Hospital is a 381-bed tertiary-care hospital in New Brunswick, Canada. The preintervention study analysis was completed in January 2014; it consisted of a chart review for ~300 consecutive inpatients with positive single or mixed-predominant urine cultures reported while admitted to the hospital in late 2013. The results of the preintervention audit were used to assist in finalizing the main components of the UTI management bundle. The postintervention analysis commenced in February 2015 and consisted of a review of ~300 consecutive inpatient positive single and mixed-predominant urine cultures for subjects meeting inclusion criteria on hospital wards where the UTI management bundle had been implemented. Patients excluded from the study analysis included those with duplicated urine-culture results within the same clinical encounter, age <18 years old, renal transplant recipients, those admitted to an intensive care unit, those who were neutropenic at the time of the positive urine report, those who died prior to report of urine culture results or who were palliative and not treated, and those who were dis- charged from hospital or study ward prior to healthcare team assessment and intervention. We excluded several nursing units from the UTI management bundle and postintervention analysis: emergency medicine, obstetrics/gynecology/maternal health, oncology, pediatrics, and intensive care units. The intervention, a UTI management bundle, consisted of 4 components: nursing education, prescriber education, laboratory intervention, and pharmacy prospective audit and feedback. Nurses and prescribers were observed to be initiating urine cul- tures for symptoms not specific for UTI; therefore, targeted education was provided and concentrated on appropriate indi- cations for urine culture, UTI diagnosis, and appropriate treat- ment according to an institutional guideline. Nursing education also highlighted that urine cultures were not to be obtained without a prescriber order. The laboratory and pharmacy com- ponents were present in the bundle to sustain the changes. The laboratory intervention consisted of a modification in culture reporting. Single or mixed-predominant urine cultures for both noncatheterized and catheterized patients meeting inclusion cri- teria from study wards were no longer routinely reported according to the usual process. Urine samples were processed according to usual procedures; however, the following message appeared on the microbiology report unless documentation of suspected UTI, pyelonephritis, or urosepsis was available to the laboratory technologist at the time of processing:
“The majority of positive urine cultures in inpatients represent asymp- tomatic bacteriuria. Please call Microbiology laboratory at XXX-XXXX if your patient is symptomatic and you require microbial identification and susceptibility results.”
73 Any healthcare professional contacting the microbiology
laboratory during normal working hours would immediately obtain the results. During nonworking hours, a messaging service was available for healthcare professionals to leave a request for urine results to be released immediately the following work day. Pharmacists provided prospective audit and feedback of positive urine cultures for inpatients admitted to study wards according to the institutional UTI management guideline. All pharmacists were provided education sessions prior to the implementation of the UTI management bundle. The institutional UTI management guideline classifications
and therapy options were based on standard definitions and followed the Treatment of Adult Urinary Tract Infections guideline from the New Brunswick Provincial Health Authorities Anti-Infective Stewardship Committee (NB-ASC) (see supple- mentary material).2,11–13 The guideline provides both preferred and alternative treatment options for empiric therapy as well as recommended durations of treatment for both uncomplicated cystitis and complicated UTI. Considering high rates of resistance in uropathogens, the guideline discouraged the use of fluoroquinolone therapy. Education sessions for physicians, pharmacists, and nurses began in January 2015, and the mod- ification to routine laboratory reporting and pharmacists’ pro- spective audit and feedback started in February 2015. Data were collected using a standardized data collection form
and included the following data: patient demographics; medical comorbidities; allergies; immunocompromised status; source of urinary culture and date; urinalysis results; white blood count (WBC) on day of urine collection (or most recent prior to col- lection); urinary culture isolate and antibiogram; previous urinary tract microbiology within the previous 1 year of the current UTI; blood culture isolate and date; C. difficile diagnosis within 30 days of current UTI; documented symptoms; documented urine cul- ture order; prescribed antibiotic, dose, and duration, including any subsequent changes in antibiotics; and attending service. In the postintervention analysis, pharmacist interventions, and the following data were recorded: any recommended changes to antibiotic, dose, route, or duration of therapy, and the acceptance of the pharmacist’s recommendation. UTIs were classified according to the institutional UTI management guideline. Management of the positive urine culture was assessed
according to the adherence to the institutional UTI manage- ment guideline. UTI diagnosis was established based on docu- mented symptoms or prescriber documentation of a UTI. Indication to culture was considered appropriate if the patient had symptoms referable to the urinary tract, if the patient was pregnant, or if a urologic intervention with mucosal bleeding was anticipated in an asymptomatic patient. Antimicrobial therapy was considered appropriate if either a preferred or alternative antimicrobial option was chosen. Fluoroquinolones were considered appropriate only when all preferred or alter- natives options were not appropriate due to allergy, intolerance, or known resistance. Appropriateness of duration of therapy was assessed based on recommendations as per the institutional UTI management guideline and deemed appropriate if within 24, 48, and 72 hours for indications for which 3, 7, and 14 days, respectively, are recommended. In the event of multiple urine cultures performed in close proximity, the culture on which empiric antimicrobial selection was based was used for study purposes. In the presence of a competing infectious disease diagnosis, treatment of urinary tract infection was deemed appropriate if localized urinary tract symptoms were
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