Abstract
A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
Highlights
Antibiotics have been arguably the most significant advancement in medicine within the past century with an impact spanning all aspects of medicine allowing for major advances in both surgical and intensive care
The literature search was performed 9/26/21 and restricted to articles in the English language. These results were reviewed for relevance with specific attention to articles focusing on the implementation of diagnostic stewardship methods as they applied to a urinary infection
Sults were reviewed for relevance with specific attention to articles focusing on the implementation of diagnostic stewardship methods as they applied to a urinary infection
Summary
Antibiotics have been arguably the most significant advancement in medicine within the past century with an impact spanning all aspects of medicine allowing for major advances in both surgical and intensive care. Highlighting this finding, due to the high incidence of ASB in elderly residents of long-term care facilities, one study found that routine submission of urinary cultures was almost arbitrary and urine culture and treatment did not have any appreciable functional improvement in resident activities of daily living (ADL) score [34] Despite these recommendations, frequent overtreatment of catheter- and non-catheter-associated ASB continue to occur with increases notable in the ambulatory and telemedicine setting [35,36,37]. Unnecessarily prolonged duration of antibiotics are often prescribed, occurring in over 60% of cases in some series [37] This ambiguity of symptoms, the commonality of positive urine cultures, and prolonged duration of antibiotic prescriptions all combine to make a UTI a prime target for DS intervention with a high potential impact in patient care and cumulative antibiotic reduction
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