Reviewed by Cynthia T. Nguyen, PharmD, University of Chicago Medicine
In the first issue of SHEA’s new open-access journal, Antimicrobial Stewardship and Healthcare Epidemiology, several articles discuss opportunities for diagnostic and antibiotic stewardship for urinary tract infections (UTIs).
Advani and colleagues call for improved use of the urinalysis (UA) in the diagnosis of UTIs. The review breaks down the various laboratory components of a complete UA. For example, the authors describe how the color, clarity, and red blood cells provide little value for the diagnosis of a UTI; while leukocyte esterase and the white blood cells are the most useful for detecting inflammation. In addition to misinterpretation of the UA, the review discusses how routine use of the UA for screening in settings such as the ED, pre-operatively, and within nursing homes contributes to misuse and can lead to inappropriate antibiotic prescribing. The UA is also used in many hospitals to guide reflex urine cultures. Although UAs can reduce the amount of urine cultures, UAs with reflex to culture should be reserved for the appropriate patient populations. Ultimately, the authors call for diagnostic stewardship and recommend (1) reducing routine UA screening, (2) only using reflex UA in certain patient populations (e.g., symptomatic non-catheterized patients), (3) creating panels based on the indication for a UA (i.e., UA inflammation versus UA renal versus UA metabolic), and (4) piloting interventions to determine their sustainability and long-term impact.
Laguio-Vila and colleagues evaluated the impact of a urine culture antibiogram and EHR alert on antibiotic use for UTIs. At their institution, susceptibility rates for common urinary pathogens to cefazolin is high (92-95%). Consequently, they sought to reduce broad-spectrum cephalosporin use (ceftriaxone) and increase narrow-spectrum cephalosporin use (cefazolin and cephalexin). There were 2 intervention phases: (1) development of a urine culture antibiogram, educational lectures with distribution of a pocket card, and prospective audit of ceftriaxone orders; and (2) interruptive EHR alert BPA to providers ordering ceftriaxone for UTI to suggest using a narrow-spectrum agent based on the antibiogram. During Phase 1, they observed significant decreases in ceftriaxone UTI orders and increases cefazolin and cephalexin UTI orders, but there was no difference in total days of therapy (any indication) for any of the antibiotics. With Phase 2 interventions, there were even greater decreases in ceftriaxone UTI orders and increases cefazolin and cephalexin use (UTI orders and total days of therapy). The authors conclude that this multimodal intervention significantly reduced ceftriaxone and successfully increased narrow-spectrum cephalosporin use for UTI treatments in hospitalized patients. Considerations prior to pursuing similar interventions at your institution include: urine susceptibility rates, the pros and cons of using an interruptive alert, and resource consumption (e.g., for prospective audit with feedback).
Antibiotics are commonly prescribed for possible or confirmed UTI and many targets exist to optimize antimicrobial use for this indication. Diagnostic stewardship can help reduce inappropriate use of UAs, urine cultures, and antibiotics for asymptomatic bacteriuria; while the encouraging use of urine antibiograms through various interventions can reduce broad-spectrum antibiotic use.
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