Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting.

Michelle T Hecker,Ajay K Sethi,Christine P Muganda,Rita K Cydulka,Jonathan E Siff,Charles L Emerman,Andrea H Son,Clinton J Fox,Curtis J Donskey,Praveen Thumbikat

doi:10.1371/journal.pone.0087899

Abstract

ObjectiveTo evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.MethodsThe intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).ResultsAdherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.ConclusionsA stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

Highlights

Acute uncomplicated cystitis and pyelonephritis are common indications for prescription of antimicrobials in healthy, nonpregnant women [1]
Ecological effects merit particular consideration in treatment of cystitis because there is minimal risk of progression to severe illness and infection may resolve in 25% to 42% of women who are not treated or who are treated with a drug without in vitro activity against the uropathogen [14,15,16]
66% to 74% of visits were classified as cystitis

Summary

Introduction

Acute uncomplicated cystitis and pyelonephritis are common indications for prescription of antimicrobials in healthy, nonpregnant women [1]. Guidelines for the treatment of these conditions were first published by the Infectious Diseases Society of America (IDSA) in 1999[2]. The updated IDSA and European Society for Microbiology and Infectious Diseases guidelines published in 2011 emphasize the importance of local susceptibility data and the ecological adverse effects of antimicrobial therapy, including antimicrobial resistance and Clostridium difficile infection [14]. Fluoroquinolones for 3 days are recommended as a second line option for treatment of cystitis due to their adverse ecological effects [17]. The updated guidelines are more specific in recommending that nitrofurantoin for 5 days or a single dose of fosfomycin should be considered as first line options for treatment of cystitis. Fluoroquinolones remain a first line option for pyelonephritis; the updated guidelines recommend a 7 day fluoroquinolone regimen as opposed to a 7–14 day regimen

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Results

Conclusion