1830. Avoiding Routine Urinalysis (UA) and Improving Urine Culture (UC) Utilization: An Antibiotic Stewardship Imperative in Geriatric Psychiatry and Emergency Medicine (EM)

Abstract

BackgroundA prior investigation alerted us to a common practice of obtaining UAs and UCs for admission to our geriatric psychiatry unit (GPU). These findings compelled us to assess antibiotic use (AU) on our 22-bed unit at Cambridge Health Alliance, Everett, a community-based teaching hospital, from February 1, 2016 to January 31, 2017. Among 427 patients, 115 (27%) received an antibiotic. Urinary tract infection (UTI) was the most common diagnosis (53%); however, only 12 patients (20%) met diagnostic criteria. Contaminated (CT) specimens and asymptomatic bacteriuria (ASB) were more prevalent (26% and 22%, respectively). UC orders were not triggered by symptoms.MethodsWe evaluated the impact of education to the GPU (August 14, 2017), removing a requirement for UA (September 6, 2017) which was communicated to EM leadership, and clinical decision support (CDS) during computerized order entry for UC (October 1, 2017) on UA and UC utilization. AU appropriateness was determined for patients who received at least four doses of an antibiotic for UTI. Pre-(discharge June 3, 2017–August 14, 2017) and post-intervention (admitted after October 1, 2017 and discharged prior to January 17, 2018) periods were compared.ResultsThere were nonsignificant (NS) decreases in UAs and UCs and an NS increase in UAs among asymptomatic patients, largely ordered by EM providers. There was a 23% decrease in unjustified AU for UTI (NS). CT specimens and ASB were far more common than UTIs.Pre-Intervention PeriodPost-Intervention Period P-valueNumber of patients48109UAs ordered38 (79.2%)79 (72.5%)0.74UAs in asymptomatic patients19 (50%)50 (63.3%)0.49Urine cultures15 (31.3%)25 (22.9%)0.41Unjustified antibiotic Rx UTI4 (8.3%)7 (6.4%)0.68Contaminated6 (40%)12 (48%)0.78ASB4 (26.7%)6 (24%)0.88UTI1 (6.7%)2 (8%)0.93ConclusionEducation, removal of the UA requirement for medical clearance, and CDS were minimally effective in improving UA and UC utilization and reducing inappropriate antibiotic therapy. Efforts are undermined by a requirement for UA by other psychiatric units in our referral network. We intend to collaborate with medical directors in our psychiatry network to expand this improvement work, provide more robust education to our EM providers and implement a UA with reflex to UC for > 10 WBC/hpf.Disclosures All authors: No reported disclosures.