Prescribing For Urinary Tract Infections Research Articles

Risk Factors for Trimethoprim and Sulfamethoxazole-Resistant Escherichia Coli in ED Patients with Urinary Tract Infections

BackgroundWhile trimethoprim-sulfamethoxazole (TMP-SMX) is recommended as one of the first-line empiric therapies for treatment of acute uncomplicated cystitis, institutions that observe resistance rates exceeding 20% for Escherichia coli (E. coli) should utilize alternative empiric antibiotic therapy per the Infectious Diseases Society of America (IDSA). Identifying risk factors associated with TMP-SMX resistance in E. coli may help guide empiric antibiotic prescribing for urinary tract infections (UTIs). MethodsThis multicenter, retrospective study included adult patients who were discharged from 12 emergency departments (EDs) with a urine culture positive for E. coli between January 1, 2019 and December 31, 2019. Logistic regression was used to assess the relationship between potential risk factors and TMP-SMX resistance. The overall institutional antimicrobial resistance rates for E. coli were compared to the rates seen in the study population of ED urinary isolates. ResultsAmong 427 patients included from a randomized sample of 500 with a urine culture positive for E. coli, 107 (25.1%) were resistant to TMP-SMX. Three predictors of TMP-SMX resistance were identified: recurrent UTI (OR 2.27 [95% CI 1.27–3.99]), genitourinary abnormalities (OR 2.31 [95% CI 1.17–4.49]), and TMP-SMX use within 90 days (OR 8.77 [95% CI 3.19–28.12]). When the antibiotic susceptibilities for this ED cohort were compared to the institutional antibiogram, the TMP-SMX resistance rate was found to be higher in the ED population (25.1% vs 20%). ConclusionsTMP-SMX should likely be avoided as first-line therapy for UTI in patients who have recurrent UTIs, genitourinary abnormalities, or have previously received TMP-SMX within the past 90 days. The use of an ED-specific antibiogram should be considered for assessing local resistance rates in this population.

Clinical Decision Support Systems for Antibiotic Prescribing: An Inventory of Current French Language Tools.

Clinical decision support systems (CDSSs) are increasingly being used by clinicians to support antibiotic decision making in infection management. However, coexisting CDSSs often target different types of physicians, infectious situations, and patient profiles. The objective of this study was to perform an up-to-date inventory of French language CDSSs currently used in community and hospital settings for antimicrobial prescribing and to describe their main characteristics. A literature search, a search among smartphone application stores, and an open discussion with antimicrobial stewardship (AMS) experts were conducted in order to identify available French language CDSSs. Any clinical decision support tool that provides a personalized recommendation based on a clinical situation and/or a patient was included. Eleven CDSSs were identified through the search strategy. Of the 11 CDSSs, only 2 had been the subject of published studies, while 9 CDSSs were identified through smartphone application stores and expert knowledge. The majority of CDSSs were available free of charge (n = 8/11, 73%). Most CDSSs were accessible via smartphone applications (n = 9/11, 82%) and online websites (n = 8/11, 73%). Recommendations for antibiotic prescribing in urinary tract infections, upper and lower respiratory tract infections, and digestive tract infections were provided by over 90% of the CDSSs. More than 90% of the CDSSs displayed recommendations for antibiotic selection, prioritization, dosage, duration, route of administration, and alternative antibiotics in case of allergy. Information about antibiotic side effects, prescription recommendations for specific patient profiles and adaptation to local epidemiology were often missing or incomplete. There is a significant but heterogeneous offer for antibiotic prescribing decision support in French language. Standardized evaluation of these systems is needed to assess their impact on antimicrobial prescribing and antimicrobial resistance.

An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial.

To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents. Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual. 212 residents with suspected UTI, from 16 NHs in the Netherlands. Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level. 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was-0.95 in the intervention group NHs and-0.05 in the control group NHs (P= .02). Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.

Impact of Education and Data Feedback on Antibiotic Prescribing for Urinary Tract Infections in the Emergency Department: An Interrupted Time-Series Analysis.

Urinary tract infections (UTIs) are often misdiagnosed or treated with exceedingly broad-spectrum antibiotics, leading to negative downstream effects. We aimed to implement antimicrobial stewardship (AS) strategies targeting UTI prescribing in the emergency department (ED). We conducted a quasi-experimental prospective AS intervention outlining appropriate UTI diagnosis and management across 3 EDs, within an academic and 2 community hospitals, in North Carolina, United States. The study was divided into 3 phases: a baseline period and 2 intervention phases. Phase 1 included introduction of an ED-specific urine antibiogram and UTI guideline, education, and department-specific feedback on UTI diagnosis and antibiotic prescribing. Phase 2 included re-education and provider-specific feedback. Eligible patients included adults with an antibiotic prescription for UTI diagnosed in the ED from 13 November 2018 to 1 March 2021. Admitted patients were excluded. The primary outcome was guideline-concordant antibiotic use, assessed using an interrupted time-series regression analysis with 2-week intervals. Overall, 8742 distinct patients with 10426 patient encounters were included. Ninety-two percent of all encounters (n = 9583) were diagnosed with cystitis and 8.1% with pyelonephritis (n = 843). There was an initial 15% increase in guideline-concordant antibiotic prescribing in phase 1 compared with the preintervention period (incidence rate ratio [IRR], 1.15; 95% confidence interval [CI], 1.03-1.29). A significant increase in guideline-concordant prescriptions was seen with every 2-week interval during phase 2 (IRR, 1.03; 95% CI, 1.01-1.04). This multifaceted AS intervention involving a guideline, education, and provider-specific feedback increased guideline-concordant antibiotic choices for treat-and-release patients in the ED.

Impact of order sentence implementation on outpatient antibiotic prescribing for urinary tract infection and skin and soft tissue infection

AbstractIntroductionDue to the high volume of outpatient antibiotic prescribing, the Joint Commission now requires antimicrobial stewardship program (ASP) expansion to ambulatory practice settings. Unfortunately, ASP resources in these settings are scarce. The purpose of this study was to determine whether the implementation of antibiotic order sentences alongside education would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infections (SSTI).ObjectivesThe primary objective was to compare the proportion of total guideline‐concordant antibiotic prescribing before (pre‐ASP) vs after (post‐ASP) implementing order sentences. Guideline concordance was defined as antibiotic selection, dosing, and duration in accordance with the health system's empiric guidelines. Secondary objectives included comparing patient‐centered outcomes, such as infection‐related revisits and Clostridiodes difficile infections between groups.MethodsThis retrospective, quasi‐experimental study evaluated adult patients treated for uncomplicated UTI or SSTI at an outpatient Family Medicine office between 1 February 2020 and 1 January 2021. The institution's stewardship team provided in‐person education and set prescribing order sentence “favorites” for providers. Patients were excluded who were diagnosed with a complicated UTI, treated only with topical antibiotics, were pregnant, or received care via telephone encounter.ResultsTwo hundred sixty patients were included in this study (pre‐ASP n = 139, post‐ASP n = 121). Total antibiotic appropriateness improved significantly from 24.5% to 39.7% after implementation of order sentences and education (P = .008). Significant improvement was seen for appropriate drug selection (52.5% vs 66.9%, P = .018) and duration (47.5% vs 68.6%, P = .001). There were no differences observed in patient‐centered outcomes between groups.ConclusionImplementing stewardship‐focused order sentences significantly improved outpatient antibiotic prescribing for UTI and SSTI. Tailoring antibiotic order sentences may be a useful tool for ASP expansion into the outpatient setting with limited resources to allocate to stewardship efforts.

146. Predictors of Long Duration Antibiotic Therapy for Urinary Tract Infections and Community-Acquired Pneumonia in Pediatric Ambulatory Care Settings

BackgroundSignificant variation exists in the duration of antibiotic therapy for children in ambulatory care settings. Understanding drivers of variation for common conditions such as community-acquired pneumonia (CAP) and urinary tract infection (UTI) is important to informing antimicrobial stewardship interventions. MethodsA retrospective observational study was conducted of patients with CAP and UTI seen in outpatient clinics or discharged from the emergency room (ER) of a tertiary care children’s hospital network from 2016 – 2019. Diagnoses CAP and UTI were identified via ICD-10 coding. Only oral medications ordered for ≥ 3 and < 28 days were included. Multivariable logistic regression was performed to identify predictors of long antibiotic duration (defined as ≥ 10 days). Potential non-clinical drivers of longer duration included race, ethnicity, sex, primary language, and insurance status. ResultsA total of 2,104 prescriptions for CAP from 442 prescribers and 1,070 prescriptions for UTI from 314 prescribers were included. Antibiotic durations were ≥ 10 days in 59.9% and 47.6% of prescriptions for CAP and UTI, respectively. Long duration of therapy was more common in children discharged from the ER when compared to clinics for both CAP (OR 1.795, 95% CI: 1.107 - 2.929), and UTI (OR 5.149, 95% CI: 1.933 - 16.373). The proportion of patients with long duration of therapy increased with younger age for both diagnoses and decreased overall in the final year of the study. Race, gender, ethnicity, and primary language were not associated with prolonged duration of therapy. However, patients with Medicaid insurance were more likely to receive long duration of therapy for CAP (OR 1.337, 95% CI: 1.062 - 1.682) and UTI (1.654, 95%, CI: 1.181 - 2.325). ConclusionIn pediatric patients in ambulatory care settings, younger age, care in the ER, and being insured through Medicaid were independently associated with prolonged duration of therapy for both UTI and CAP.Disclosures All Authors: No reported disclosures

1426. Empiric Antimicrobial Prescribing for Urinary Tract Infections in Patients Discharged from the Emergency Department

BackgroundUrinary tract infections (UTIs) are commonly treated infections in the emergency department (ED), accounting for 3 million visits annually and 15% of outpatient antibiotic prescriptions. The purpose of this study was to characterize empiric and definitive antimicrobial therapy for treatment of UTIs in a nationally representative sample of ED patients.MethodsThis was a multicenter, retrospective cohort study utilizing the Emergency Medicine PHARMacy Research NETwork (EMPHARM-NET), a network of 15 geographically diverse EDs. Patients ≥18 years presenting to and discharged home from the ED with primary diagnosis code of cystitis, pyelonephritis, or UTI from 2018-2020 were included. We describe empiric intravenous (IV) and oral antibiotics used for the treatment of UTI in patients seen and discharged from the ED.ResultsOf the 3779 ED patients treated for UTI, most were discharged from the ED (n=2483, 66%). Most patients were female (76.3%) and common comorbidities were hypertension (47.8%) and diabetes (26.5%). Most patients had uncomplicated (39.4%) or complicated (40.9%) cystitis. 1134 (45.6%) had a positive urine culture, most commonly E. coli (63%) and K. pneumoniae (13%). The most common antibiotics administered in the ED were ceftriaxone (19.7%), nitrofurantoin (6.2%), cephalexin (5.8%), and sulfamethoxazole/trimethoprim (SMX/TMP, 4.8%). The most common antibiotics prescribed at discharge where cephalexin (33.9%), nitrofurantoin (20.6%), SMX/TMP (12%), ciprofloxacin (8.2%), and cefdinir (8%). The mean length of treatment was 7.1 days (standard deviation 2.5 days). Overall, 454 patients returned to the ED within 30 days. The odds of returning to the ED within 30 days was higher in those that did not have appropriate empiric antibiotics based on susceptibilities (OR 1.37, 95% confidence interval 1.06, 1.78).ConclusionThis multicenter, retrospective cohort study describes ED patients discharged from the ED after UTI diagnosis. Patients presented most commonly for cystitis. Nearly half of discharged patients were culture positive. Antimicrobial selection varied; IV ceftriaxone and oral cephalexin were most commonly empirically utilized to treated patients with UTI. Inappropriate antimicrobial selection increased odds of a return ED visit within 30 days. Disclosures Megan A. Rech, PharmD, MS, BCCCP, FCCM, Spero (Research Grant or Support) Brett Faine, PharmD, Spero Therapeutics (Research Grant or Support) David A. Talan, MD, AbbVie (Consultant)GSK (Consultant)SPERO Therapeutics (Grant/Research Support)

Antibiotics in nursing homes: a tailored intervention

Difficulties in the management of infections in patients aged 65 years or older are certainly familiar to many doctors, including infectious diseases specialists. In an open-label, cluster randomised controlled trial, Sif Helene Arnold and colleagues1 were able to reduce the number of antibiotic prescriptions for urinary tract infections (UTI) by 58% in Danish nursing home residents without substantially increasing the risk of all-cause hospitalisation or death.

Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting.

BackgroundUrinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed.MethodsWe conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach.ResultsData were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use.ConclusionsClinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.

Impact of pharmacist-led selective audit and feedback on outpatient antibiotic prescribing for UTIs and SSTIs.

An estimated 30% of all outpatient antibiotic prescriptions in the United States are unnecessary. The Joint Commission, in 2016, implemented core elements of performance requiring antimicrobial stewardship programs (ASPs) to expand to outpatient practice settings. A study was conducted to determine whether pharmacist-led audit and feedback would improve antibiotic prescribing for urinary tract infections (UTIs) and skin and soft tissue infection (SSTIs) at 2 primary care practices. A retrospective, quasi-experimental study was conducted to evaluate antibiotic prescribing for patients treated for a UTI or SSTI at 2 primary care offices (a family medicine office and an internal medicine office). The primary objective was to compare the rate of appropriate antibiotic prescribing to patients treated before implementation of a pharmacist-led audit-and-feedback process for reviewing antibiotics prescribed for UTIs and SSTIs (the pre-ASP group) and patients treated after process implementation (the post-ASP group). Total regimen appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy guidelines. Secondary objectives included comparing rates of infection-related revisits and Clostridioides difficile infection between groups. A total of 400 patients were included in the study (pre-ASP group, n = 200; post-ASP group, n = 200). The rate of total antibiotic prescribing appropriateness improved significantly, from 27.5% to 50.5% (P < 0.0001), after implementation of the audit-and-feedback process. There were also significant improvements in the post-ASP group vs the pre-ASP period in the individual components of regimen appropriateness: appropriate drug (70% vs 53%, P < 0.001), appropriate duration (83.5% vs 57.5%, P < 0.001), and appropriate therapy indication (98% vs 94%, P = 0.041). There were no significant between-group differences in other outcomes such as rates of adverse events, treatment failure, C. difficile infection, and infection-related revisits or hospitalizations within 30 days. A pharmacist-led audit-and-feedback outpatient stewardship strategy was demonstrated to achieve significant improvement in outpatient antibiotic prescribing for UTI and SSTI.

1335. Accuracy of Outpatient Antibiotic Prescriptions for Urinary Tract Infection in Pediatric Ambulatory Care

BackgroundAntimicrobial stewardship programs have typically focused on inpatient care, but antibiotics are frequently prescribed at pediatric ambulatory care centers. Ensuring accurate pediatric antibiotic dosing is important to optimize outcomes while minimizing adverse drug effects. Outpatient pharmacists often lack the resources to recommend optimal antibiotic dosing for pediatric infections. The primary objective was to evaluate the accuracy of antibiotic dose, frequency and formulation prescribed. The secondary objective was to describe the most commonly prescribed treatment durations.MethodsA retrospective review of electronic medical records was conducted at two suburban pediatric practices. Patients diagnosed with uncomplicated UTI over a two year period were identified using ICD-10 codes N39, R30 and R35. Patients 2 months-18 years were included if prescribed an oral antibiotic for the treatment of UTI. Data collected included baseline demographics, antibiotic, dose (mg and mg/kg), frequency, formulation, and duration. Antibiotic dose, frequency and formulation were considered accurate if they were consistent with clinical guidelines and tertiary dosing references, allowing for 10% rounding in weight-based doses.ResultsA total of 472 outpatient prescriptions met inclusion criteria. Overall, 24% of dosing regimens were found to be inaccurate. Patients were most commonly prescribed doses that were too low (54/118, 45%) or too high (41/118, 35%). Less frequently, doses exceeded the maximum total dose (9/118, 8%), were given at the wrong frequency (8/118, 7%), or the wrong dosage form was selected (6/118, 5%). Of the commonly prescribed antibiotics, dosing errors were most likely to occur with ciprofloxacin (24/27, 89%) and amoxicillin (33/64; 55%). The majority of patients completed a 10 day course of antibiotics (381, 80%), followed by 7 days (66, 13.9%). Durations of 3 days (20, 4.2%), 5 days (7, 1.5%) and 14 days (2, 0.4%) occurred less frequently.ConclusionErrors in antibiotic dosing occurred with nearly one in four prescriptions written for outpatient UTI from pediatric primary care centers. Durations were most commonly 10 days. Education and resources should be provided to outpatient pediatric providers to optimize antibiotic dosing.Disclosures All Authors: No reported disclosures

140. Impact of Pharmacist-led Audit &amp; Feedback on Outpatient Antibiotic Prescribing for UTIs and SSTIs

BackgroundAn estimated 30% of all outpatient antibiotic prescriptions in the U.S. are unnecessary. Effective January 2020, The Joint Commission has implemented new core elements of performance requiring antimicrobial stewardship programs (ASP) to expand to outpatient practice settings. The purpose of this study was to determine whether pharmacist-led audit-and-feedback would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infection (SSTI) at two primary care practices.MethodsThis retrospective, quasi-experimental study was conducted evaluating patients treated for UTI and SSTI at two outpatient primary care offices, one Family Medicine and the other Internal Medicine. The primary objective was to compare rates of total appropriateness of antibiotic prescribing before (Pre-ASP) versus after (Post-ASP) implementing a pharmacist-led audit-and-feedback process reviewing antibiotics prescribed for UTIs and SSTIs. Total appropriateness was defined by appropriate antibiotic selection, dose, duration, and therapy indication in accordance with institutional outpatient empiric therapy antimicrobial guidelines. Secondary objectives included comparing patient outcomes, including infection-related re-visits and Clostridioides difficile infections between groups.ResultsA total of 400 patients were included in this study (Pre-ASP n=200, Post-ASP n=200) Total antibiotic appropriateness improved significantly from 27.5% to 50.5% after implementation of the audit-and-feedback process (p< 0.0001). Significant improvement was also seen for individual prescribing components including appropriate drug selection (94% vs. 98%, p=0.041), duration (57.5% vs.83.5%, p< 0.0001), and therapy indication (94% vs. 98%, p=0.041). There were no differences in patient outcomes between groups including adverse drug events, treatment failure, C.difficile infections, and infection-related re-visits or hospitalizations within 30 days.ConclusionA pharmacist-led audit-and-feedback outpatient stewardship strategy demonstrated significant improvement in outpatient antibiotic prescribing for UTI and SSTI.Disclosures All Authors: No reported disclosures

Using implementation science to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty.

Introduction: Guidelines and consensus statements do not support routine preoperative testing for asymptomatic bacteriuria (ASB) prior to elective arthroplasty. Despite this, urine testing remains commonplace in orthopaedic practice. This mixed methods stepwise quality improvement project aimed to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty within a single centre. Methods: Step 1 – description of current practice in preoperative urine testing prior to arthroplasty within a single centre; Step 2 – examination of the association between preoperative urine culture and pathogens causing prosthetic joint infection (PJI); Step 3 – co-design of a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty; Step 4 – implementation of a sustainable guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty. Results: Retrospective chart review showed inconsistency in mid-stream urine (MSU) testing prior to elective arthroplasty (49 % preoperative MSU sent) and in antimicrobial prescribing for urinary tract infection (UTI) and ASB. No association was observed between organisms isolated from urine and joint aspirate in confirmed cases of PJI. Co-design of a guideline and decision support tool supported through an implementation strategy resulted in rapid uptake and adherence. Sustainability was demonstrated at 6 months. Conclusion: In this stepwise study, implementation science methodology was used to challenge outdated clinical practice, achieving a sustained reduction in unnecessary preoperative urine testing for ASB prior to elective arthroplasty.

Antibiotic prescribing for adult bacteriuria and pyuria in community hospital emergency departments.

To describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities. Patients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7days for cystitis or>14days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated. Of 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18-22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14days, 20 (5%) were prescribed <7days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29-33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits. Among reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis.

A descriptive analysis of outpatient antibiotic use for urinary tract infections in Virginia.

Background: Data regarding outpatient antibiotic prescribing for urinary tract infections (UTIs) are limited, and they have never been formally summarized in Virginia. Objective: We describe outpatient antibiotic prescribing trends for UTIs based on gender, age, geographic region, insurance payer and International Classification of Disease, Tenth Revision (ICD-10) codes in Virginia. Methods: We used the Virginia All-Payer Claims Database (APCD), administered by Virginia Health Information (VHI), which holds data for Medicare, Medicaid, and private insurance. The study cohort included Virginia residents who had a primary diagnosis of UTI, had an antibiotic claim 0–3 days after the date of the diagnosis and who were seen in an outpatient facility in Virginia between January 1, 2016, and December 31, 2016. A diagnosis of UTI was categorized as cystitis, urethritis or pyelonephritis and was defined using the following ICD-10 codes: N30.0, N30.00, N30.01, N30.9, N30.90, N30.91, N39.0, N34.1, N34.2, and N10. The following antibiotics were prescribed: aminoglycosides, sulfamethoxazole/trimethoprim (TMP-SMX), cephalosporins, fluoroquinolones, macrolides, penicillins, tetracyclines, or nitrofurantoin. Patients were categorized based on gender, age, location, insurance payer and UTI type. We used χ2 and Cochran-Mantel-Haenszel testing. Analyses were performed in SAS version 9.4 software (SAS Institute, Cary, NC). Results: In total, 15,580 patients were included in this study. Prescriptions for antibiotics by drug class differed significantly by gender (P < .0001), age (P < .0001), geographic region (P < .0001), insurance payer (P < .0001), and UTI type (P < .0001). Cephalosporins were prescribed more often to women (32.48%, 4,173 of 12,846) than to men (26.26%, 718 of 2,734), and fluoroquinolones were prescribed more often to men (53.88%, 1,473 of 2,734) than to women (47.91%, 6,155 of 12,846). Although cephalosporins were prescribed most frequently (42.58%, 557 of 1,308) in northern Virginia, fluoroquinolones were prescribed the most in eastern Virginia (50.76%, 1677 of 3,304). Patients with commercial health insurance, Medicaid, and Medicare were prescribed fluoroquinolones (39.31%, 1,149 of 2,923), cephalosporins (56.33%, 1,326 of 2,354), and fluoroquinolones (57.36%, 5,910 of 10,303) most frequently, respectively. Conclusions: Antibiotic prescribing trends for UTIs varied by gender, age, geographic region, payer status and UTI type in the state of Virginia. These data will inform future statewide antimicrobial stewardship efforts. Funding: None Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.

A Descriptive Analysis of Outpatient Antimicrobial Use for Urinary Tract Infections in Virginia

Background: Data regarding outpatient antibiotic prescribing for urinary tract infections (UTIs) are limited, and they have never been formally summarized in Virginia. Objective: We describe outpatient antibiotic prescribing trends for UTIs based on gender, age, geographic region, insurance payer and International Classification of Disease, Tenth Revision (ICD-10) codes in Virginia. Methods: We used the Virginia All-Payer Claims Database (APCD), administered by Virginia Health Information (VHI), which holds data for Medicare, Medicaid, and private insurance. The study cohort included Virginia residents who had a primary diagnosis of UTI, had an antibiotic claim 0–3 days after the date of the diagnosis and who were seen in an outpatient facility in Virginia between January 1, 2016, and December 31, 2016. A diagnosis of UTI was categorized as cystitis, urethritis or pyelonephritis and was defined using the following ICD-10 codes: N30.0, N30.00, N30.01, N30.9, N30.90, N30.91, N39.0, N34.1, N34.2, and N10. The following antibiotics were prescribed: aminoglycosides, sulfamethoxazole/trimethoprim (TMP-SMX), cephalosporins, fluoroquinolones, macrolides, penicillins, tetracyclines, or nitrofurantoin. Patients were categorized based on gender, age, location, insurance payer and UTI type. We used χ2 and Cochran-Mantel-Haenszel testing. Analyses were performed in SAS version 9.4 software (SAS Institute, Cary, NC). Results: In total, 15,580 patients were included in this study. Prescriptions for antibiotics by drug class differed significantly by gender (P &lt; .0001), age (P &lt; .0001), geographic region (P &lt; .0001), insurance payer (P &lt; .0001), and UTI type (P &lt; .0001). Cephalosporins were prescribed more often to women (32.48%, 4,173 of 12,846) than to men (26.26%, 718 of 2,734), and fluoroquinolones were prescribed more often to men (53.88%, 1,473 of 2,734) than to women (47.91%, 6,155 of 12,846). Although cephalosporins were prescribed most frequently (42.58%, 557 of 1,308) in northern Virginia, fluoroquinolones were prescribed the most in eastern Virginia (50.76%, 1677 of 3,304). Patients with commercial health insurance, Medicaid, and Medicare were prescribed fluoroquinolones (39.31%, 1,149 of 2,923), cephalosporins (56.33%, 1,326 of 2,354), and fluoroquinolones (57.36%, 5,910 of 10,303) most frequently, respectively. Conclusions: Antibiotic prescribing trends for UTIs varied by gender, age, geographic region, payer status and UTI type in the state of Virginia. These data will inform future statewide antimicrobial stewardship efforts.Funding: NoneDisclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.

Microbiology testing and antibiotic treatment for urinary tract infections in general practice: a nationwide observational study.

Routine urine testing is recommended prior to antibiotic treatment for urinary tract infections (UTIs) among high-risk groups for complicated UTIs. This study aims to examine whether the proportion of UTI encounters where antibiotics are prescribed that have accompanying urine testing differs by patient groups. A retrospective analysis was conducted using records of general practice encounters for UTIs occurring between January 2013 and July 2018 in an Australian national database. We calculated the proportion of UTI encounters with antibiotics prescribed that had accompanying urine microbiology testing and the odds ratios for the likelihood of testing by patient groups using generalised estimating equations. Of 132,688 UTI encounters with antibiotics prescribed, 95,800 (72.2%) were accompanied by urine testing. Among high-risk groups for complicated UTIs and expected to have a high likelihood of testing, we found pregnant women [82.6% vs. non-pregnant 72.3%, adjusted odds ratio (aOR) 1.82, 95% confidence intervals (CI) 1.55-2.12] and children aged 5-9years (77.6% vs. 20-44years 72.0%, aOR 1.33, 95% CI 1.22-1.45) had relatively high odds of testing. However, children aged < 5years (68.7% vs. 20-44years 72.0%, aOR 0.83, 95% CI 0.76-0.90), patients with recurrent UTIs (69.0% compared to first-onset UTIs 73.6%, aOR 0.81, 95% CI 0.79-0.83), and patients in residential aged care facilities (67.3% vs. not 72.3%, aOR 0.80, 95% CI 0.72-0.90) had relatively low odds of testing. Our results suggest inconsistencies and potential underuse of urine testing when antibiotics were prescribed for high-risk groups in UTI management. Further antibiotic stewardship is needed to improve guideline-based antibiotic prescribing for UTIs.

Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial.

BackgroundUrinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis.ObjectiveThe objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality.MethodsThe study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period.ResultsThe trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020.ConclusionsThe greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI.Trial RegistrationClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062International Registered Report Identifier (IRRID)DERR1-10.2196/17710

Appropriateness of Antibiotic Prescriptions for Urinary Tract Infections.

IntroductionUrinary tract infections (UTI) are a common indication for antibiotic use in the emergency department (ED). With antibiotic resistance on the rise, it is essential that antibiotics be prescribed appropriately for UTIs. Our objective was to evaluate the appropriateness of antibiotic prescriptions by ED providers for uncomplicated cystitis and pyelonephritis.MethodsWe conducted a retrospective study of females ages 2–50 years seen in an academic ED from January 2017 to April 2018 diagnosed with UTI. We assessed the appropriateness of discharge antibiotic prescriptions, as determined by adherence to clinical practice guidelines, best evidence for the particular indication (cystitis vs pyelonephritis for children and adults), and the local antibiogram.ResultsA total of 421 patients were included in this study. Of these, 60 children and 198 adults were diagnosed with cystitis, and 47 children and 116 adults were diagnosed with pyelonephritis. Treatment in the absence of true infection was common, with culture-confirmed UTI occurring in only 17/50 (34%) of children and 60/129 (47%) of adults diagnosed with cystitis, and 23/40 (58%) of children and 58/87 (67%) of adults diagnosed with pyelonephritis, among patients who had urine cultures. The type of antibiotic prescribed was appropriate in 53/60 (88%) of children and 135/198 (68%) of adults with cystitis, and 38/47 (81%) of children and 53/116 (46%) of adults with pyelonephritis. The most common inappropriate antibiotic types were beta-lactams in adults (n = 92), nitrofurantoin for pyelonephritis (n = 16), and amoxicillin (n = 15). Dosing and duration errors were also common, occurring in 122/279 (44%) of prescriptions of an appropriate antibiotic type. The frequency of errors in the type of antibiotic prescribed was similar among provider types (attending physician, resident physician, and advanced practice clinician; p = 0.926).ConclusionThis study reveals room for improvement in antibiotic prescription practices across provider cohorts in the ED for the management of uncomplicated cystitis and pyelonephritis in females.

Impact of the Scottish Reduction in Antimicrobial Prescribing (ScRAP) Programme on primary care prescribing for urinary tract infection (UTI)

Introduction The ScRAP programme was developed as a national initiative to support improvements in managing patients presenting with symptoms of UTI. The programme comprises educational content plus improvement ideas. It was implemented in one large, mainly urban, NHS board region covering 21% of the Scottish population via Prescribing Support Pharmacists working with individual GP Practices. A key aim was to reduce unnecessary antibiotic use. Method A facilitated learning session was delivered and all clinical and non-clinical GP Practice staff, were invited to attend. Evidence supporting best practice in managing UTI, local prescribing data and local practice was considered and discussed. The session concluded with action planning to reflect on current practice and identify areas for improvement. National data held by NHS National Services Scotland was used to evaluate prescribing across all NHS board regions in Scotland focusing on total use of antibiotics and use of trimethoprim and nitrofurantoin which are used solely for UTI. Results Analysis of national prescribing data comparing the implementation region with the rest of Scotland suggests the intervention has been successful. Comparing data from prior to and for one year after the intervention period reductions for the intervention board versus the rest of Scotland were as follows: all antibiotics 7.29% vs 6.11%; trimethoprim 6.14% vs 3.73%; nitrofurantoin 3.92% vs 0.56%. Conclusion Quantitative evaluation provides evidence of the impact of ScRAP on prescribing rates. This suggests that improved practice has led to reduction in unnecessary use of antibiotics for acute and recurrent UTI.