Antibiotic Treatment Of Asymptomatic Bacteriuria Research Articles

Fewer Unnecessary Urine Cultures Is Key to Reducing Antibiotic Treatment for Asymptomatic Bacteriuria.

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Treatment of Asymptomatic Bacteriuria after Kidney Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background and Objectives: Asymptomatic bacteriuria (ASB) is prevalent in kidney transplant recipients (KTRs) and is hypothesized to heighten the risk of subsequent urinary tract infections (UTIs). Whether antibiotic treatment of ASB in KTRs is beneficial has not been elucidated. Materials and Methods: We carried out a systematic review and meta-analysis of all randomized controlled trials (RCTs) and quasi-RCTs that examined the merits of managing asymptomatic bacteriuria in KTRs. The primary outcomes were rates of symptomatic urinary tract infections (UTIs) and antimicrobial resistance. Results: Five studies encompassing 566 patients were included. No significant difference in symptomatic UTI rates was found between antibiotics and no treatment groups (relative risk (RR) 1.05, 95% confidence interval (CI) = 0.78-1.41), with moderate heterogeneity (I2 = 36%). Antibiotic treatment was found to present an uncertain risk for the development of drug-resistant strains (RR = 1.51, 95% CI = 0.95-2.40, I2 = 0%). In all trials, no significant difference between study arms was demonstrated regarding patient and graft outcomes, such as graft function, graft loss, hospitalization due to UTI, all-cause mortality, or acute rejection. Conclusions: The practice of screening and treating kidney transplant patients for asymptomatic bacteriuria does not curtail the incidence of future symptomatic UTIs, increase antimicrobial resistance, or affect graft outcomes. Whether early treatment of ASB after kidney transplantation (<2 months) is beneficial requires more RCTs.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria

Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

1796. Evaluation of Asymptomatic Bacteriuria in Critical Access Hospitals

Abstract Background The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) provides antimicrobial stewardship education and training to rural and critical access hospitals (CAHs) in the United States through collaborative tele-mentoring. In 2021, UW-TASP implemented a pilot stewardship cohort to reduce antibiotic treatment of asymptomatic bacteriuria (ASB). We sought to quantify the overall prevalence of ASB and proportion treated in participating hospitals. Methods Patients undergoing urine testing were identified through local electronic medical records and microbiology data. CAHs adjudicated their own cases and reported demographics, symptoms of urinary tract infection, systemic inflammatory response symptoms (SIRS), location at the time of culture, laboratory results, and antibiotic treatment through a RedCap collection tool. The data form was created and analyzed by UW-TASP faculty. This study was waived by the University of Washington institutional review board. Results Nineteen CAHs in 5 states participated in this pilot. Eight submitted urine analysis and culture data for 417 patients. Seventy-seven percent of patients were female and the median age was 70. The emergency department was the most common culture collection location (274/417, 66%), followed by ambulatory care clinics (111/417, 27%), and nursing facilities (13/417, 3%). SIRS criteria and/or organ dysfunction were present in 149/417 patients (36%). Two hundred sixty patients (62%) had a positive culture with Escherichia coli being the most common implicated organism (167/260, 64%). ASB was identified in 69/260 patients (27%), and antibiotics were prescribed for 53/69 (77%) of those with ASB. Oral antibiotics were prescribed for 311 (75%) patients. Of those, 22% were prescribed a fluoroquinolone. Median treatment duration was 7 days (range, 1-14). Conclusion Although the prevalence of ASB was only 27% among 417 patients, treatment of ASB was high at 77%. High numbers of culture collections from the emergency department and ambulatory care settings identify these locations as future foci for stewardship interventions in CAHs. Low hanging fruit for intervention include reducing unnecessary fluoroquinolone use and reducing duration of antibiotic therapy. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.

1592. SHEA Featured Oral Abstract: Reducing Unnecessary Antibiotic Treatment for Asymptomatic Bacteriuria: A Statewide Collaborative Quality Initiative

Abstract Background Up to one-third of hospitalized patients treated for urinary tract infection (UTI) have asymptomatic bacteriuria (ASB). Both diagnostic (avoiding inappropriate urine cultures) and antibiotic stewardship (reducing unnecessary antibiotic use in asymptomatic patients) have been proposed to reduce unnecessary antibiotic use for ASB. However, it's unclear which method is most effective. Methods The Michigan Hospital Medicine Safety Consortium aimed to improve antibiotic use and outcomes of hospitalized patients with a positive urine culture between 7/1/2017—3/31/2020 (see Table 1 for patient characteristics) by benchmarking performance across 46 Michigan hospitals, sharing best practices, and implementing pay-for-performance metrics related to unnecessary treatment of ASB (see Figure 1). Using logistic regression models controlling for hospital clustering, we assessed change over time in percentage of hospitalized patients treated for UTI who had ASB (i.e., had no documented signs or symptoms of UTI) and hospital characteristics associated with baseline or change in unnecessary antibiotic prescribing. We then estimated the percentage of avoided ASB treatment attributable to diagnostic (decrease in urine cultures ordered on asymptomatic patients) vs. antibiotic stewardship (decrease duration or avoidance of antibiotic treatment). Results Across 46 hospitals, there were 15,493 patients with a positive urine culture. Of 13,805 patients treated for a UTI, 23.2% (3,197) had ASB. The percentage of patients treated for UTI who had ASB declined over time from 29.0% (95% CI: 26.1%, 32.0%) to 16.9% (95% CI: 14.2%, 20.1%; aOR 0.94 per quarter, 95% CI: 0.92-0.96; Figure 1) with hospitals not belonging to a larger healthcare system having the largest decrease over time (Table 2). Neither the proportion of patients with ASB who were treated with antibiotics (P=0.07) nor the duration of therapy for ASB changed over time (P=0.09); thus, nearly all avoided antibiotic therapy for ASB appeared due to diagnostic stewardship. Conclusions Across 46 hospitals, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement. Disclosures Payal K. Patel, MD, MPH, Qiagen: Honoraria.

Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria

Antibiotic treatment for asymptomatic bacteriuria is not recommended in guidelines but is a major driver of inappropriate antibiotic use. To evaluate whether clinician culture and personality traits are associated with a predisposition toward inappropriate prescribing. This survey study involved secondary analysis of a previously completed survey. A total of 723 primary care clinicians in active practice in Texas, the Mid-Atlantic, and the Pacific Northwest, including physicians and advanced practice clinicians, were surveyed from June 1, 2018, to November 26, 2019, regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Clinician culture was represented by training background and region of practice. Attitudes and cognitive characteristics were represented using validated instruments to assess numeracy, risk-taking preferences, burnout, and tendency to maximize care. Data were analyzed from November 8, 2021, to March 29, 2022. The survey described a male patient with asymptomatic bacteriuria and changes in urine character. Clinicians were asked to indicate whether they would prescribe antibiotics. The main outcome was self-reported willingness to prescribe antibiotics for asymptomatic bacteriuria. Willingness to prescribe antibiotics was hypothesized to be associated with clinician characteristics, background, and attitudes, including orientation on the Medical Maximizer-Minimizer Scale. Individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous. Of the 723 enrolled clinicians, 551 (median age, 32 years [IQR, 29-44 years]; 292 [53%] female; 296 [54%] White) completed the survey (76% response rate), including 288 resident physicians, 202 attending physicians, and 61 advanced practice clinicians. A total of 303 respondents (55%) were from the Mid-Atlantic, 136 (25%) were from Texas, and 112 (20%) were from the Pacific Northwest. A total of 392 clinicians (71% of respondents) indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. In multivariable analyses, clinicians with a background in family medicine (odds ratio [OR], 2.93; 95% CI, 1.53-5.62) or a high score on the Medical Maximizer-Minimizer Scale (indicating stronger medical maximizing orientation; OR, 2.06; 95% CI, 1.38-3.09) were more likely to prescribe antibiotic treatment for asymptomatic bacteriuria. Resident physicians (OR, 0.57; 95% CI, 0.38-0.85) and clinicians in the Pacific Northwest (OR, 0.49; 95% CI, 0.33-0.72) were less likely to prescribe antibiotics for asymptomatic bacteriuria. The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the US Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions.

Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term care

BackgroundChart reviews often fall short of determining what drove antibiotic treatment of asymptomatic bacteriuria (ASB). To overcome this shortcoming, we searched providers’ free-text for documentation of their decision-making and for misleading signs and symptoms that may trigger unnecessary treatment of ASB. MethodsWe reviewed a random sample of 10 positive urine cultures per month, per facility, from patients in acute or long-term care wards at 8 Veterans Affairs facilities. Cultures were classified as urinary tract infection (UTI) or ASB, and as treated or untreated. Charts were searched for 13 potentially misleading symptoms, and free-text documentation of providers’ decision-making was classified into 5 categories. We used generalized estimating equations logistic regression to identify factors associated with ASB treatment. ResultsOne hundred fifty-eight (27.5%) of 575 ASB cases were inappropriately treated with antibiotics. Significant factors associated with inappropriate treatment included: abdominal pain, falls, decreased urine output, urine characteristics, abnormal vital signs, laboratory values, and voiding issues. Providers prescribed an average of 1.4 antimicrobials to patients with ASB, with cephalosporins (41%) and fluoroquinolones (21%) being the most common classes prescribed. ConclusionsChart reviews of providers’ decision-making highlighted new factors associated with inappropriate ASB treatment. These findings can help design antibiotic stewardship interventions for ASB.

87. Effectiveness of a Best Practice Advisory in Reducing Inappropriate Urine Cultures

Abstract Background Inappropriate urine cultures can contribute to overutilization of antibiotic treatment for asymptomatic bacteriuria. The objective of this study was to evaluate the appropriateness of urine cultures and the impact of a clinical decision support (CDS) intervention. Methods The CDS intervention involved embedding three questions in the urine culture order: whether the patient has fever, leukocytosis or urinary symptoms. When the answer to all three questions is no, a best practice advisory (BPA) alerts the provider that the patient may not meet criteria for a urine culture and suggests cancellation of the order. Cultures obtained in patients experiencing fever, leukocytosis, or urinary symptoms, and those who were pregnant, undergoing invasive urologic procedure, or &amp;lt; 3 years old were classified as appropriate. We performed a quasi-experimental study assessing appropriateness of urine cultures before and after implementation of the BPA. The pre-intervention period was 5/9/19 to 7/31/20 and the intervention period was 2/3/21 to 4/27/21. Random samples of 100 cases from pre- and post-intervention were reviewed to assess appropriateness. Results There were 12,679 and 8,270 urine cultures performed pre-intervention and post-intervention, respectively. In 100 cases reviewed pre-intervention, 74% of the cultures were appropriate. Of these, 54% were ordered due to fever or leukocytosis, 50% due to urinary symptoms, and 12% in pregnant women. Post-intervention, the BPA fired on 458 orders and 106 (23%) were subsequently discontinued. Of the 100 cases reviewed post-intervention, 5 orders were discontinued after the BPA fired. Of the remaining 95 cultures, 78% were appropriate. Of these, 41% were ordered for fever or leukocytosis, 69% for urinary symptoms, and 11% in pregnant women. The change in the proportion of appropriate cultures pre- and post-intervention was not statistically significant (74% vs 78%, respectively, p=0.906). Conclusion In nearly one quarter of urine cultures performed, there was not an appropriate indication. Our intervention led to cancellation of 23% urine culture orders and resulted in an absolute increase in 4% of the cultures being ordered appropriately. However, the change in appropriateness was not statistically significant. Disclosures All Authors: No reported disclosures

173. Antimicrobial Stewardship Education Changes Prescribing Behavior and Reduces Treatment of Asymptomatic Bacteriuria

BackgroundTreatment of asymptomatic bacteriuria (ASB) outside of pregnancy and urological procedures increases the risk of antibiotic resistance without improving outcomes. At Olive View-UCLA Medical Center (Sylmar, CA), the CDC U.S. Antibiotic Awareness Week (AAW) was utilized as a platform to promote antimicrobial stewardship (AS) for ASB. We evaluated the incidence of antibiotic treatment of ASB pre-AAW vs post-AAW, and the impact of AS education on future prescribing practices for ASB.MethodsIn this single-center retrospective observational study, AS education defining ASB vs urinary tract infection (UTI) was provided via visual aids distributed throughout the hospital during AAW from 11/18/2020 to 11/24/2020 (Figure 1). All positive urine cultures (Ucx) for adult inpatients were reviewed prior to AAW from 9/2020 to 11/2020 and after AAW from 12/2020 to 1/2021. Patients were excluded if they were unable to report UTI symptoms, pregnant, or undergoing urological procedure. The incidence of ASB treatment pre- and post-AAW was compared. A survey was sent to providers to compare the impact on antibiotic prescribing behavior for ASB pre- and post-AAW. Fisher’s exact and Chi-squared tests were used for statistical analysis.Figure 1. Antimicrobial Stewardship Education and Poster Distribution ResultsA total of 260 cases met study eligibility. In the pre-AAW group, 56 of 131 cases presented with ASB, of which 16 were treated with antibiotics (28.6%). In the post-AAW group, 55 of 129 cases presented with ASB, and 5 were treated with antibiotics (9.1%). Antibiotics were prescribed more often for patients with ASB in the pre-AAW group compared to those in the post-AAW group (p=0.014). Forty providers completed the survey, of which 97.5% had seen the visual aids, 70% had found the education "very” or “extremely" useful, and 43.6% reported they “always or sometimes” treated ASB pre-AAW vs 15% post-AAW (p< 0.01).ConclusionAS posters and education defining ASB significantly decreased the treatment of ASB. AAW education on ASB antimicrobial stewardship demonstrated a high value and shifted prescribing behavior to avoid antibiotic treatment of ASB. A similar approach to deliver provider education could serve as a valuable model to change provider AS practices for ASB.Disclosures All Authors: No reported disclosures

A Current Review of the Etiology, Clinical Features, and Diagnosis of Urinary Tract Infection in Renal Transplant Patients.

Urinary tract infection (UTI) represents the most common infection after kidney transplantation and remains a major cause of morbidity and mortality in kidney transplant (KT) recipients, with a potential impact on graft survival. UTIs after KT are usually caused by Gram-negative microorganisms. Other pathogens which are uncommon in the general population should be considered in KT patients, especially BK virus since an early diagnosis is necessary to improve the prognosis. UTIs following kidney transplantation are classified into acute simple cystitis, acute pyelonephritis/complicated UTI, and recurrent UTI, due to their different clinical presentation, prognosis, and management. Asymptomatic bacteriuria (ASB) represents a frequent finding after kidney transplantation, but ASB is considered to be a separate entity apart from UTI since it is not necessarily a disease state. In fact, current guidelines do not recommend routine screening and treatment of ASB in KT patients, since a beneficial effect has not been shown. Harmful effects such as the development of multidrug-resistant (MDR) bacteria and a higher incidence of Clostridium difficile diarrhea have been associated with the antibiotic treatment of ASB.

Treatment of Asymptomatic Bacteriuria after Implementation of an Inpatient Urine Culture Algorithm in the Electronic Medical Record.

Ordering urine cultures in patients without pyuria is associated with the inappropriate treatment of asymptomatic bacteriuria (ASB). In 2015, our institution implemented recommendations based on practice guidelines for the management of ASB and revised the urine culture ordering process to limit cultures in immunocompetent patients without pyuria. The purpose of this study was to determine how the treatment of ASB has changed over time since altering the urine culture ordering process to reduce unnecessary cultures at an academic medical center. A quasi-experimental study was conducted for inpatients with urine cultures from January to March of 2014, 2015, 2016 and 2020. The primary outcome was the antibiotic treatment of asymptomatic bacteriuria for over 24 h. The secondary outcomes were the total days of antibiotic therapy, type of antibiotic prescribed and overall urine culture rates at the hospital. A total of 200 inpatients with ASB were included, 50 at random from each year. In both 2014 and 2015, 70% of the patients with ASB received antibiotic treatment. Antibiotics were prescribed to 68% and 54% of patients with ASB in 2016 and 2020, respectively. The average duration of therapy decreased from 5.12 days in 2014 to 3.46 days in 2020. Although the urine cultures were reduced, there was no immediate impact in the prescribing rates for patients with ASB after implementing this institutional guidance and an altered urine culture ordering process. Over time, there was an observed improvement in prescribing and the total days of antibiotic therapy. This could be attributed to increased familiarity with the guidelines, culture ordering practices or improved documentation. Based on these findings, additional provider education is needed to reinforce the guideline recommendations on the management of ASB.

219. Characteristics Associated with Inappropriate Antibiotic Prescribing in Patients with Asymptomatic Bacteriuria (ASB)

BackgroundAntibiotic treatment of asymptomatic bacteriuria (ASB) is considered inappropriate, does not improve patient outcomes, and may lead to adverse events such as antibiotic resistance and Clostridioides difficile infection. Previous stewardship interventions have focused on reducing unnecessary urine culture collection in individuals without urinary symptoms; however, further interventions to reduce inappropriate prescribing in ASB are warranted. This study sought to identify characteristics associated with treatment of ASB in order to implement future stewardship interventions.MethodsThis two-center, retrospective cohort study included unique emergency department or inpatient adults with consecutive non-duplicate monomicrobial urine isolates of Enterobacterales or Pseudomonas aeruginosa collected between 8/2013 and 1/2014 from two academic hospitals in Boston, Massachusetts. Patients with ASB (without chart-documented urinary-specific symptoms) were identified through chart review and stratified into two groups: those treated with empiric urinary tract infection (UTI) antibiotics and those untreated. Logistic regression analyses were performed to identify variables independently associated with antibiotic treatment of ASB.ResultsDuring the study, 255 patients were determined to have ASB and a majority (80.8%) were treated with empiric UTI antibiotics. Most patients were female (71.4%) and elderly (mean age 70 years). The most common organisms isolated were Escherichia coli (59.2%), Klebsiella spp. (23.1%), and P. aeruginosa (9.8%). The presence of isolated fever (OR, 7.83 [95% confidence interval, 1.51, 144.20]); p = 0.05), urinalysis positive for pyuria (>10 white blood cells) (OR, 2.52 [95% CI, 1.15, 5.54]; p = 0.02), and Klebsiella spp. urine isolate (OR, 2.99 [95% CI, 1.19, 8.60]; p = 0.02) were independently associated with treatment.ConclusionA large proportion of ASB patients were treated with antibiotics despite clinical practice guidelines recommending against this practice. Isolated fever, pyuria, and Klebsiella spp. culture were all significantly associated with the treatment of ASB; targeted review of these patients by stewardship programs may help to reduce inappropriate ASB treatment within these institutions.Disclosures Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support) Nabriva Therapeutics (Advisor or Review Panel member)

Improving Value of Care: Cessation of Screening Urine Culture Prior to Orthopedic and Spinal Surgery.

ObjectiveTo assess the impact of cessation of screening urine cultures on surgical site infection (SSI) incidence in clinical practice.Patients and MethodsOur study included patients undergoing hip replacement, knee replacement, spinal fusion, and laminectomy 12 months before (preintervention) and after (postintervention) cessation of preoperative screening urine cultures on June 1, 2017, at our institution. Urine cultures and urinalyses performed within 30 days before surgery during the 12 months before and after cessation were reviewed. SSI surveillance was performed in accordance with the methods of the National Healthcare Safety Network.ResultsA total of 2754 patients were included (1286 preintervention and 1468 postintervention). In the preintervention period, 1141 urine cultures were performed, compared to 153 in the postintervention period; 35 and 6 episodes of asymptomatic bacteriuria were treated, respectively. The occurrence of SSI did not differ noticeably between time periods (1.2% vs 0.7%, P=.24), and quarterly incidences of SSI were unchanged. The rate of SSI was significantly lower in the postintervention period for laminectomy (3.0% vs 0.3%, P=.02).ConclusionAn 86.6% (153 vs 1141) reduction in screening urine cultures over a 12-month period was associated with a reduction of 988 unnecessary urine cultures, an 82.8% (6 vs 35) decline in inappropriate antibiotic treatment of asymptomatic bacteriuria, and no increase in SSI incidence after hip replacement, knee replacement, spinal fusion, or laminectomy procedures. No value of screening urine cultures before clean surgery was identified.

Antibiotics for asymptomatic bacteriuria in pregnancy.

Asymptomatic bacteriuria is a bacterial infection of the urine without any of the typical symptoms that are associated with a urinary infection, and occurs in 2% to 15% of pregnancies. If left untreated, up to 30% of mothers will develop acute pyelonephritis. Asymptomatic bacteriuria has been associated with low birthweight and preterm birth. This is an update of a review last published in 2015. To assess the effect of antibiotic treatment for asymptomatic bacteriuria on the development of pyelonephritis and the risk of low birthweight and preterm birth. For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 4 November 2018, and reference lists of retrieved studies. Randomised controlled trials (RCT) comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. Trials using a cluster-RCT design and quasi-RCTs were eligible for inclusion, as were trials published in abstract or letter form, but cross-over studies were not. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach. We included 15 studies, involving over 2000 women. Antibiotic treatment compared with placebo or no treatment may reduce the incidence of pyelonephritis (average risk ratio (RR) 0.24, 95% confidence interval (CI) 0.13 to 0.41; 12 studies, 2017 women; low-certainty evidence). Antibiotic treatment may be associated with a reduction in the incidence of preterm birth (RR 0.34, 95% CI 0.13 to 0.88; 3 studies, 327 women; low-certainty evidence), and low birthweight babies (average RR 0.64, 95% CI 0.45 to 0.93; 6 studies, 1437 babies; low-certainty evidence). There may be a reduction in persistent bacteriuria at the time of delivery (average RR 0.30, 95% CI 0.18 to 0.53; 4 studies; 596 women), but the results were inconclusive for serious adverse neonatal outcomes (average RR 0.64, 95% CI 0.23 to 1.79, 3 studies; 549 babies). There were very limited data on which to estimate the effect of antibiotics on other infant outcomes, and maternal adverse effects were rarely described. Overall, we judged only one trial at low risk of bias across all domains; the other 14 studies were assessed as high or unclear risk of bias. Many studies lacked an adequate description of methods, and we could only judge the risk of bias as unclear, but in most studies, we assessed at least one domain at high risk of bias. We assessed the quality of the evidence for the three primary outcomes with GRADE software, and found low-certainty evidence for pyelonephritis, preterm birth, and birthweight less than 2500 g. Antibiotic treatment may be effective in reducing the risk of pyelonephritis in pregnancy, but our confidence in the effect estimate is limited given the low certainty of the evidence. There may be a reduction in preterm birth and low birthweight with antibiotic treatment, consistent with theories about the role of infection in adverse pregnancy outcomes, but again, the confidence in the effect is limited given the low certainty of the evidence. Research implications identified in this review include the need for an up-to-date cost-effectiveness evaluation of diagnostic algorithms, and more evidence to learn whether there is a low-risk group of women who are unlikely to benefit from treatment of asymptomatic bacteriuria.

Antibiotic Treatment Versus No Treatment for Asymptomatic Bacteriuria in Kidney Transplant Recipients: A Multicenter Randomized Trial.

BackgroundWhether antibiotic treatment of asymptomatic bacteriuria (AB) can prevent acute graft pyelonephritis (AGP) in kidney transplant (KT) recipients has not been elucidated.MethodsIn this multicenter, open-label, nonblinded, prospective, noninferiority, randomized controlled trial, we compared antibiotic treatment with no treatment for AB in KT recipients in the first year after transplantation when urinary catheters had been removed. The primary endpoint was the occurrence of AGP. Secondary endpoints included bacteremic AGP, cystitis, susceptibility of urine isolates, graft rejection, graft function, graft loss, opportunistic infections, need for hospitalization, and mortality.ResultsWe enrolled 205 KT recipients between 2013 and 2015. AB occurred in 41 (42.3%) and 46 (50.5%) patients in the treatment and no treatment groups, respectively. There were no differences in the primary endpoint in the intention-to-treat population (12.2% [5 of 41] in the treatment group vs 8.7% [4 of 46] in the no treatment group; risk ratio, 1.40; 95% confidence interval, 0.40–4.87) or the per-protocol population (13.8% [4 of 29] in the treatment group vs 6.7% [3 of 45] in the no treatment group; risk ratio, 2.07, 95% confidence interval, 0.50–8.58). No differences were found in secondary endpoints, except for antibiotic susceptibility. Fosfomycin (P = .030), amoxicillin-clavulanic (P < .001) resistance, and extended-spectrum β-lactamase production (P = .044) were more common in KT recipients receiving antibiotic treatment for AB.ConclusionsAntibiotic treatment of AB was not useful to prevent AGP in KT recipients and may increase antibiotic resistance. However, our findings should be regarded with caution, due to the small sample size analyzed.

Risk of Surgical Site Infection in Patients with Asymptomatic Bacteriuria or Abnormal Urinalysis before Joint Arthroplasty: Systematic Review and Meta-Analysis.

Routine screening and treatment for pre-operative asymptomatic bacteriuria (ASB) before joint arthroplasty are controversial. This systematic review and meta-analysis aimed to evaluate the impact of ASB and other bacterial colonization markers (BCM) observed in abnormal urine analyses, such as positive nitrites, leukocyturia, or positive leukocyte esterase in the risk of surgical site infections (SSIs) of joint arthroplasty patients. Studies published between 1970 and 2017 that reported data on SSI and prosthetic joint infection (PJI) in patients after joint arthroplasty of the hip, knee, or shoulder with pre-operative ASB or BCM were included. A meta-analysis with random effect model was performed. Eleven studies were included (29,371 patients and 35,323 joints). The main procedures were total hip replacements (53.3%) and the mean follow-up period was 21.5 months, with 12 months being the minimum time of follow-up. A total of 2,400 cases (9.5%) reported pre-operative BCM (15%) or ASB (85%). The proportion of SSI was higher in patients with ASB (2.3% vs. 1.1%) (p < 0.001) and was related to a higher risk of SSI (odds ratio [OR] 2.89; 95% confidence interval [CI] 1.36-6.17), however, in only six cases (12.7%) was the SSI micro-organism correlated with the urine culture. Finally, antibiotic treatment for ASB did not reduce the SSI risk (OR = 0.82; 95% CI 0.34-1.97). Asymptomatic bacteriuria represent a relatively common finding among these patients and is related to a higher risk of SSI. However, the poor microbiologic correlation suggests that ASB could represent a surrogate marker for other conditions correlated with bacterial infection. Therefore, systematic urinalysis screening should be discouraged, whereas a complete risk assessment that considers comorbidities and past medical history should be promoted.

Prevention of recurrent urinary tract infections: bridging the gap between clinical practice and guidelines in Latin America.

The branches of the immune system work in concert to defend against pathogens and prevent tissue damage due to excessive inflammation. Uropathogens in general, and uropathogenic Escherichia coli (UPEC) in particular, have evolved a diverse range of virulence mechanisms to avoid detection and destruction by the mucosal immune system of the urinary tract. Research towards a vaccine active against UPEC continues but has yet to be successful. Orally administered immunomodulatory bacterial lysates both stimulate and modulate the immune response in the urinary tract via the integrated mucosal immune system. The 2018 European Association of Urology (EAU) guidelines on treating acute uncomplicated cystitis recommend aiming for rapid resolution of symptoms, reduction of morbidity, and prophylaxis against reinfection. Recommended short-term antibiotic therapy has the advantage of good compliance, low cost, few adverse events, and low impact on bacterial flora. Antibiotic treatment of asymptomatic bacteriuria is only indicated during pregnancy and before invasive interventions. For recurrent infection, prophylaxis using behavioral modification and counseling should be employed first, then nonantibiotic prophylaxis, and, finally, low-dose continuous or postcoital antibiotic prophylaxis. The 2018 EAU guidelines give a strong recommendation for the oral bacterial lysate immunomodulator OM-89. All other nonantibiotic prophylactic strategies require more data, except for topical estrogen for postmenopausal women. For last-resort antibiotic prophylaxis, nitrofurantoin or fosfomycin trometamol are recommended. Guidelines for Latin America are currently being drafted, taking into account the unique ethnicity, availability of medicines, prevalence of antibiotic resistance, and healthcare practices found throughout the region.

1892. Preparing for an Antibiotic Stewardship Intervention Through Nursing Surveys of Knowledge and Safety

BackgroundWe designed an intervention to reduce unnecessary antibiotic treatment of asymptomatic bacteriuria (ASB), by decreasing unnecessary urine cultures. Nurses and clinical nurse assistants (CNAs) play important roles in requesting urine cultures. As preparation for the intervention, we assessed knowledge of the appropriate indications for urine cultures among these personnel while measuring their safety climate.MethodsSurveys were administered to licensed nursing personnel (RN, LPN, and NP) as well as to CNAs on all acute medical and long-term care units of four VA facilities across the nation. Surveys combined two validated subcomponents: knowledge of ASB and safety attitudes. Knowledge questions, which differed in emphasis between the licensed personnel and the CNAs, focused on indications for urine cultures. Safety questions were the teamwork climate and safety climate domains from the Safety Attitudes Questionnaire. Surveys were administered on paper during January–April 2018.ResultsWe received 110 responses from licensed nursing personnel and 40 from CNAs. The response rate on distributed surveys was 110/140 (79%) for licensed personnel and 40/50 (80%) for CNAs. 94% of nurses and 73% of CNAs correctly recognized fever as an indication for urine culture. Many also endorsed incorrect triggers for urine cultures: cloudy urine (80% of nurses, 55% of CNAs), foul-smelling urine (87% of nurses, 85% of CNAs), and a change in color (44% of nurses, 73% of CNAs). 50% of nurses endorsed screening urine cultures on admission of catheterized patients. Scores on the teamwork climate (highest possible score 100) were 70 for nurses and 79 for CNAs; scores on the safety climate were 70 for nurses and 78 for CNAs.ConclusionThis multicenter survey identified actionable gaps in knowledge about when to send urine cultures among nursing personnel in acute medical and long-term care units. However, scores on teamwork and safety climate were high, suggesting that these personnel have an effective voice in patient safety. Together our survey results indicate that empowering the personnel at the bedside to discourage unnecessary urine culturing should be a key component of our stewardship intervention.Disclosures B. W. Trautner, Paratek: Consultant, Consulting fee. Zambon: Consultant, Consulting fee and Research grant.

Modified Reporting of Positive Urine Cultures to Reduce Inappropriate Treatment of Asymptomatic Bacteriuria Among Nonpregnant, Noncatheterized Inpatients: A Randomized Controlled Trial.

DESIGNWe conducted a randomized, parallel, unblinded, superiority trial of a laboratory reporting intervention designed to reduce antibiotic treatment of asymptomatic bacteriuria (ASB).METHODSResults of positive urine cultures from 110 consecutive inpatients at 2 urban acute-care hospitals were randomized to standard report (control) or modified report (intervention). The standard report included bacterial count, bacterial identification, and antibiotic susceptibility information including drug dosage and cost. The modified report stated: "This POSITIVE urine culture may represent asymptomatic bacteriuria or urinary tract infection. If urinary tract infection is suspected clinically, please call the microbiology laboratory … for identification and susceptibility results." We used the following exclusion criteria: age <18 years, pregnancy, presence of an indwelling urinary catheter, samples from patients already on antibiotics, neutropenia, or admission to an intensive care unit. The primary efficacy outcome was the proportion of appropriate antibiotic therapy prescribed.RESULTSAccording to our intention-to-treat (ITT) analysis, the proportion of appropriate treatment (urinary tract infection treated plus ASB not treated) was higher in the modified arm than in the standard arm: 44 of 55 (80.0%) versus 29 of 55 (52.7%), respectively (absolute difference, -27.3%; RR, 0.42; P = .002; number needed to report for benefit, 3.7).CONCLUSIONSModified reporting resulted in a significant reduction in inappropriate antibiotic treatment without an increase in adverse events. Safety should be further assessed in a large effectiveness trial before implementationTRIAL REGISTRATION. clinicaltrials.gov#NCT02797613Infect Control Hosp Epidemiol 2018;814-819.

Bacteriuria. Cochrane Database Syst Rev. 2015;4:CD009534.

Asymptomatic bacteriuria is frequently detected in women aged up to 60 years, patients with diabetes and elderly patients. The benefit of antibiotic treatment for this condition is controversial. The objective of this Cochrane systematic review was to assess the effectiveness and safety of antibiotic treatment for asymptomatic bacteriuria in adults. A systematic review of the literature up to 24 February 2015 was performed using the Cochrane Renal Group's Specialised Register. Randomised controlled trials (RCTs) and quasirandomised controlled trials comparing antibiotics to placebo or no treatment for asymptomatic bacteriuria in adults were included. The outcomes of interest were the development of symptomatic urinary tract infection, complications, death, adverse events, development of antibiotic resistance, bacteriological cure, and decline in kidney function. Nine studies (1614 participants) were included in this review. The incidence of symptomatic urinary tract infection, complications or death was similar between groups. Antibiotic use was significantly associated with bacteriological cure and an increase in minor adverse events. No decline in kidney function was observed with any one of the treatments. According to the results of the studies included in this revision, authors have concluded that there is no clinical benefit in treating asymptomatic bacteriuria in adults.