Infection Control & Hospital Epidemiology
Table 3. Pharmacist Prospective Audit and Feedback Recommendation Initiate therapy Change therapy
Discontinue therapy Optimize dose
IV-to-PO conversion Modify duration
Recommend not to treat, asymptomatic
No recommendation made, therapy appropriate Total
Note. IV, intravenous; PO, per oral.
patient developed a complicating bacteremia at 72 hours that was promptly identified and managed by the bloodstream infection surveillance program without significant clinical sequelae.
Discussion
When faced with a positive urine culture, prescribers often inappropriately provide antimicrobial therapy in the absence of UTI symptoms and without detailed clinical assessment. Our study has shown that the laboratory-based intervention, in both noncatheterized and catheterized patients as part of a UTI management bundle, is effective in reducing the inappropriate treatment of AB and improving overall adherence to best practice. Improvements were observed in all 3 domains assessed as part of the overall adherence to best practice assessment with respect to appropriateness to culture, appropriate antimicrobial use, and appropriate duration of therapy. In addition, no significant safety signal was noted during the study, with similar rates of untreated UTI and sepsis at 72 hours between the groups. The durability of the intervention was assessed by the local antimicrobial stewardship committee in a small repeat audit (n=47) completed 2 years after the initial implementation of the UTI management bundle. The rate of adherence to best practice continued to show evidence of improvement (43%), and treat- ment of AB remained low at 10·6%. The impact of the UTI bundle on the laboratory workload was
published as a separate analysis. Our results showed that the number of urine specimens submitted for culture from study units decreased from 863 to 581, a decrease of 33% for the same calendar period before and after implementation of the UTI bundle, with a 50% savings in material costs.14 This study has several limitations. Although the current study
included all positive urine cultures with the exception of high-risk patient groups, the lack of a controlled design resulted in a dif- ference between the study populations with respect to the types of UTI observed. We believe the difference in types of UTI, with more complex and catheter-associated UTIs observed in the postintervention analysis, is a result of the impact of the educa- tional component of the UTI bundle. After the implementation of the bundle, there was a significant improvement in the appropriateness to culture, and the proportion of patients with AB decreased. Second, a lack of physician documentation of
symptoms may have led to misclassification of patients as having AB; however, this impact would likely have been similar in the pre- and postintervention groups and, therefore, would only minimally affect the final results. Third, interventions were not staggered with regard to data collection, so we were unable to determine the individual effect of each component of theUTI bundle. Although it would be beneficial to know the weighted impact of each or whether their synergy is the key to success, this was not possible with our study design. Finally, the pharmacist intervention was limitedto28% of patients,largely duetostaffingissueson inter- vention wards. Considering the high number of appropriate recom- mendations from the pharmacy team, the impact of the bundle may have been even greater with improved pharmacy access. In conclusion, implementation of an UTI management bundle
resulted in a dramatic improvement in the rate of adherence to best practice and a 75·5% decrease in the inappropriate treatment of AB. Based on these results, 1 case of inappropriate treatment of AB will be prevented for every 2 patients with a positive urine culture reported under the UTI management bundle.
Acknowledgments. We acknowledge the help and support of Dr. Gordon Dow and the infectious diseases service as well as the pharmacy department and microbiology laboratory at The Moncton Hospital during the develop- ment and implementation of 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 material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.276
References
1. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309–332.
2. Nicolle LE, 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.
3. Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: To treat or not to treat? Clin Infect Dis 2012;55:771–777.
77
All, No. (%) 5 (6·1)
22 (26·8) 2 (2·4) 1 (1·2)
10 (12·2) 2 (2·4)
18 (22·0) 22 (26·8) 82 (100·0)
Appropriate, No. (%) 5 (100·0) 19 (86·4) 2 (100·0) 0 (0·0)
9 (90·0) 2 (100·0) 17 (94·4) 15 (68·2) 69 (84·1)
Inappropriate, No. (%) 0 (0·0)
3 (13·6) 0 (0·0)
1 (100·0) 1 (10·0) 0 (0·0) 1 (5·6)
7 (31·8) 13 (15·9)
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