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documented or systemic symptoms were documented to be out of proportion or duration to that expected from the primary diagnosis. When broader antimicrobial therapy was prescribed for other concurrent infections, treatment was considered appropriate if prescribed antimicrobial therapy covered the implicated urinary pathogen. Empiric therapy was defined as antimicrobial therapy administered after urine-sample culture was obtained but prior to reporting any preliminary results. Directed therapy was defined as a new antimicrobial agent or change in antimicrobial therapy after preliminary urine culture results were reported. The pooled data were compiled and coded by at least 2 study investigators. Each case was assessed jointly by 2 investigators for appropriateness to collect culture, antibiotic selection, dose, and duration of therapy. Treatment of AB was noted for each sample. The final data entry and assessment were verified by an additional study investigator for consistency and accuracy. Disagreements in assignment of appropriateness were reached by consensus. Primary outcome measures were overall adherence to the institutional UTI management guideline with respect to appro- priateness of obtaining a urine sample for culture; appropriate antibiotic use and duration of therapy; and the rates of inap- propriate therapy for AB. Secondary outcome measures included appropriateness of pharmacist intervention, acceptance of phar- macist intervention, number of urine cultures ordered without a prescriber order, total and average days of avoidable antimicrobial therapy, incidence of untreated symptomatic UTI or AB requiring therapy, untreated patients with sepsis at 72 hours of positive urine culture, and C. difficile infection within 30 days of positive urine culture. For continuous response variables, the mean and standard
deviation for each group are reported. For nominal variables, the frequency table and proportions by group are reported. The Student-Welch t test was applied for continuous response vari- ables. The Fisher exact test was applied for 2×2 tables dichotomic response variables. The Fisher exact test for 2×r tables was used for nominal response variables with r > 2 values, using 5,000 simulations; therefore, in these cases, the smallest P value reported is .0002. Computations were carried out using R statis- tical software version 3.3.3 (R Foundation for Statistical Com- puting, Vienna, Austria). The study was reviewed and approved
Timothy D. MacLaggan et al
by the Research Ethics Board of Horizon Health Network, New Brunswick, Canada.
Results
In total, 359 samples were screened for inclusion in the pre- intervention analysis; among these, 65 were excluded and 18 had incomplete data (Fig. 1). For the postintervention analysis, a total of 314 samples were screened, and 46 of these were excluded. The pre- and postintervention study populations were similar
with respect to age, sex, and uropathogens, but they showed variability in terms of service group, UTI diagnosis, and culture source (Table 1). The clear majority of both study populations (74·6% and 86·6%, respectively) were treated by medical as opposed to surgical services. The most frequently identified uropathogens in both groups were Escherichia coli, Klebsiella spp, and Enterococcus spp. Asymptomatic bacteriuria was the most frequently assigned UTI diagnosis, accounting for 59·8% and 49·6% of the pre- and postintervention study populations, respectively. Complicated and catheter-associated UTIs were more commonly identified in the postintervention study population. As a result of the UTI management bundle, 156 of the 268
urine samples analyzed (58·2%) had their cultures report mod- ified within the postintervention study population, and 69 (44·2%) of these were requested for release. Significantly fewer patients in the postintervention study population received any antimicrobial therapy: 217 of 276 patients (78·6%) preinterven- tion versus 154 of 268 patients (57·5%) postintervention (Table 2). Overall adherence to best practice was observed for 103 of 268
patients (38·4%) in the postintervention study population com- pared to only 32 of 276 patients (11·7%) in the preintervention study population. Within the preintervention study population, 165 patients
were identified to have AB, of whom 111 (67·3%) inappropriately received antimicrobial therapy. After implementation of the UTI management bundle, 133 patients in the postintervention study population were identified as having AB, and only 22 (16·5%) inappropriately received antimicrobial therapy, representing a 75·5% reduction in the rate of AB treated. The absolute risk
Fig. 1. Cases with positive urine culture eligible for assessment.
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