Urinary Tract Infection Guidelines Research Articles

Urinary Tract Infection Guideline Adherence in Dutch Nursing Home Network

Urinary Tract Infection Guideline Adherence in Dutch Nursing Home Network

Multidrug resistance in pathogenic Escherichia coli isolates from urinary tract infections in dogs, Spain.

Escherichia coli (E. coli) is a pathogen frequently isolated in cases of urinary tract infections (UTIs) in both humans and dogs and evidence exists that dogs are reservoirs for human infections. In addition, E. coli is associated to increasing antimicrobial resistance rates. This study focuses on the analysis of antimicrobial resistance and the presence of selected virulence genes in E. coli isolates from a Spanish dog population suffering from UTI. This collection of isolates showed an extremely high level of phenotypic resistance to 1st-3rd generation cephalosporins, followed by penicillins, fluoroquinolones and amphenicols. Apart from that, 13.46% of them were considered extended-spectrum beta-lactamase producers. An alarmingly high percentage (71.15%) of multidrug resistant isolates were also detected. There was a good correlation between the antimicrobial resistance genes found and the phenotypic resistance expressed. Most of the isolates were classified as extraintestinal pathogenic E. coli, and two others harbored virulence factors related to diarrheagenic pathotypes. A significant relationship between low antibiotic resistance and high virulence factor carriage was found, but the mechanisms behind it are still poorly understood. The detection of high antimicrobial resistance rates to first-choice treatments highlights the need of constant antimicrobial resistance surveillance, as well as continuous revision of therapeutic guidelines for canine UTI to adapt them to changes in antimicrobial resistance patterns.

1236. Implementation and Impact of a Pharmacist-driven Outpatient Antimicrobial Stewardship Program in a Costa Rican Private Hospital

Abstract Background Antimicrobial stewardship programs (AMS) have been shown to be beneficial in both inpatient (IP) and outpatient (OP) settings. The CDC set the core elements for OP AMS initiation. In Latin America, progress has been made about AMS, but mainly in the IP. This hospital has an IP AMS that lacks activities dedicated to OP prescriptions. After conducting a baseline characterization of the OP antibiotics (ABs) prescriptions received in the hospital pharmacies, it was identified that ABs were prescribed mostly for urinary tract infections (UTIs). Methods A retrospective observational analysis of the implementation of an OP AMS (Apr.-June 2022) and the impact of this program on the prescribing patterns for the management of OP UTIs. The level of adherence to CDC's core elements was assessed before and after the implementation. The impact in OP UTIs was estimated by comparing prescribing patterns according to the hospital clinical guideline in the emergency ward (ER) preAMS (July 2021-Mar. 2022) and postAMS (July 2022-Dec. 2022). Results Compliance with CDC only met 28.6% of the core elements in the preAMS period, a percentage that improved to 85.7% after the implementation (Fig.1). For the impact on UTIs, 269 patient cases were analyzed (53.2% preAMS and 46.8% postAMS). The optimal selection of ABs in the preAMS period was 53.8% (n=77) and 95.2% (n=120) in the postAMS with an improvement of 41.4% (p< 0.001). Ciprofloxacin optimal selection had a 31.3% (p=0.028) increase, while levofloxacin exhibited a 60.0% (p=0,027) increment. Additionally, in the postAMS, the overall use of nitrofurantoin increased 3.6 times and the use of TMP-SMX and fluoroquinolones was reduced by 92.9% and 48.3%, respectively (Table 1). By diagnosis, there was a 56.0% (p< 0.001) improvement in the optimal treatment of uncomplicated cystitis and 9.6% (p=0.05) for complicated cystitis (Table 1). The ER physicians were evaluated according to compliance with the clinical guidelines for UTIs. The mean score in the preAMS period was 46.2% and 90.0% in the postAMS (Fig.2).Figure 1.Compliance and activities related to the CDC Core Elements of outpatient AMS.Table 1.Comparison of optimal therapy selection in the emergency ward pre-AMS intervention and post-AMS by antibiotic prescription and UTI classification.Figure 2.Distribution of scores of ER physicians according to adherence to clinical guidelines for UTI by period. Conclusion The implementation of an OP-AMS according to CDC standards led to an improvement in complying with the OP UTI clinical guidelines. This suggests that this strategy could be applied to optimize the use of ABs in other infections in this population and region. Disclosures José P. Díaz-Madriz, PharmD, Eli Lilly: Stocks/Bonds|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial.

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

The Burden of Urinary Tract Infections on Quality of Life and Healthcare in Patients with Interstitial Cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) patients are more susceptible to urinary tract infections (UTIs), likely worsening pre-existing symptoms. However, this receives limited attention in guidelines. This study aimed to explore the burden of UTIs on IC/BPS patients' quality of life and their healthcare. Two quantitative retrospective database studies were conducted in cystoscopically proven IC/BPS patients: one compiled existing patient survey data (n = 217) from July 2021 to examine physical and emotional UTI burden, and the other used a patient file database (n = 100) from January 2020 to May 2022, focusing on UTI prevalence, healthcare use, urine cultures and antibiotic resistance. A delay in diagnosis was seen in 70% of patients, due to doctors confusing IC/BPS symptoms with UTIs. The UTI prevalence was over 50%; these patients also report anxiety for new UTIs (70%) and worsening of IC/BPS symptoms (60%). Additionally, for UTI+ patients, healthcare consumption was significantly increased in both studies. Antibiotic resistance (80% of cultures) and prophylactic antibiotic use were common. These findings highlight the burden of UTIs on quality of life in IC/BPS patients and the healthcare system. These results emphasize the need for improved UTI guidelines concerning diagnosis, management and prevention for IC/BPS patients to improve quality of life and care.

Appropriateness of antibiotic use for patients with asymptomatic bacteriuria or urinary tract infection with positive urine culture: a retrospective observational multi-centre study in Korea

Antibiotic resistance threatens public health worldwide, and inappropriate use of antibiotics is one of the main causes. To evaluate qualitative use of antibiotics in asymptomatic bacteriuria (ABU) and urinary tract infection (UTI). Cases of positive urine culture (≥105 colony-forning units/mL) performed in inpatient, outpatient and emergency departments in April 2021 were screened in 26 hospitals in the Republic of Korea. The cases were classified as ABU, lower UTI and upper UTI. The appropriateness of antibiotic use was evaluated retrospectively by infectious disease specialists using quality indicators based on clinical guidelines for ABU and UTI. This study included a total of 2697 patients with ABU or UTI. The appropriateness of antibiotic use was assessed in 1157 patients with ABU, and in 677 and 863 patients with lower and upper UTI, respectively. Among the 1157 patients with ABU, 251 (22%) were prescribed antibiotics without appropriate indications. In 66 patients with ABU in which antibiotics were prescribed with appropriate indications, the duration was adequate in only 23 (34.8%) patients. The appropriateness of empirical and definite antibiotics was noted in 527 (77.8%) and 353 (68.0%) patients with lower UTI, and 745 (86.3%) and 583 (78.2%) patients with upper UTI, respectively. The duration of antibiotics was adequate in 321 (61.8%) patients with lower UTI and 576 (78.7%) patients with upper UTI. This nationwide qualitative assessment of antibiotic use in ABU and UTI revealed that antibiotics were often prescribed inappropriately, and the duration of antibiotics was unnecessarily prolonged.

MP34-01 UTI KNOWLEDGE ASSESSMENT AND ACQUISITION FOR URINARY TRACT INFECTIONS AMONG ADULT WOMEN

You have accessJournal of UrologyCME1 Apr 2023MP34-01 UTI KNOWLEDGE ASSESSMENT AND ACQUISITION FOR URINARY TRACT INFECTIONS AMONG ADULT WOMEN Stephanie Gleicher, Elisabeth Sebesta, Melissa Kaufman, Roger Dmochowski, and W. Stuart Reynolds Stephanie GleicherStephanie Gleicher More articles by this author , Elisabeth SebestaElisabeth Sebesta More articles by this author , Melissa KaufmanMelissa Kaufman More articles by this author , Roger DmochowskiRoger Dmochowski More articles by this author , and W. Stuart ReynoldsW. Stuart Reynolds More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003268.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Substantial information and misinformation exists about urinary tract infection (UTI) management, and there is significant variability in provider expertise. While evidence-based UTI guidelines exist for providers, many women are not able to access this information. The aim of this study was to assess current UTI knowledge and preferences for information dissemination in a population-based cohort of adult women. METHODS: Subjects were recruited from Researchmatch database to participate in a web-based study. Inclusion criteria included non-pregnant females aged 18 or older who had a UTI in the last 12 months. Subjects were provided various statements to assess UTI knowledge/perceptions, and asked about preferences for health-information communication. SPSS was used for the statistical analysis. RESULTS: Among the 755 subjects, >50% believe most women suffer from UTI, women get more UTIs as they get older, and supplements are available to prevent UTI (Table 1). 46.2% of women believe UTIs are caused by tight fitting clothing and 44.6% believe UTIs are caused by lack of cleanliness. Among subjects, 89.8% have looked up information regarding UTI, and 81.2% endorsed that health information is more meaningful from their health care provider (HCP). 88.5% of women normally obtain health information from their HCP, and 79.7% obtain information from online websites. When asked about educational preferences, 53.8% strongly preferred office-based HCP visits, followed by virtual HCP visits (25.3%) and online websites (25.2%). More than 30% of subjects would be willing to spend 15+ minutes reviewing information about UTIs, and 33.5% would like to receive UTI information weekly or monthly. Barriers to obtaining information included that information is too complex (26.6%), they did not know where to find information (26.%) and having too much written information (24.6%). CONCLUSIONS: Women have misperceptions about UTIs. Despite most subjects looking up UTI health information, it is often too complex, hard to find, or cumbersome. Most women find health information more meaningful from their HCP and prefer office-based HCP educational platforms. Almost half of participants are interested in frequent UTI information updates. Future research is needed to better design educational campaigns regarding UTI. Source of Funding: VICTR Award ID VR63981 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e459 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stephanie Gleicher More articles by this author Elisabeth Sebesta More articles by this author Melissa Kaufman More articles by this author Roger Dmochowski More articles by this author W. Stuart Reynolds More articles by this author Expand All Advertisement PDF downloadLoading ...

Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments.

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

Guideline commentary on updated NICE guidelines for urinary tract infections

... Urinary tract infection (UTI) accounts for 1–3% of primary care consultations and 13.7% of community antibiotic prescriptions in the UK; worldwide, UTI affects around 92 million people annually [1]. The incidence of UTI increases with age and it is the most commonly diagnosed infection in long-term care facilities [2, 3], where 1-year recurrence rates are as high as 50% [4]. Although updated NICE guidance is timely [5], they do not seem to have fully taken account of older people for whom UTI is a common presentation. Ruling UTI in or out can be especially difficult in older people who often present with ‘atypical’ or non-specific presentations. Non-specific presentations include immobility, confusion, falls, incontinence (the ‘geriatric giants’ [6]) and reduced functional abilities [7–13]. It can be difficult to assess lower urinary tract symptoms (LUTS) in older patients due to cognitive impairment and the high prevalence of chronic LUTS that are seen in conditions such as overactive bladder and genitourinary syndrome of menopause [14].

890. Bundled Antimicrobial Stewardship Intervention Reduces Inpatient Third Generation Cephalosporin Use without Restriction

Abstract Background The use of third generation cephalosporins (3GC) has been linked to collateral damage such as increased risk of infection with C. difficile, ESBL-producing organisms, VRE, and MRSA. Reduction in use of 3GC has been shown to reduce prevalence of these infections, particularly with C. difficile and ESBLs. An increase in 3GC use was observed at our facility in 2019 and 2020, likely due to targeted fluoroquinolone reduction initiatives in 2019 and COVID-19 surges in 2020. A multifaceted intervention targeting 3GC reduction without restriction was implemented starting in December 2020. Figure 1Monthly third generation cephalosporin use (Days of Therapy per 1000 patient days) from January 2019 to December 2021. Methods We conducted a retrospective quasi-experimental study evaluating the impact of a combination of interventions intended to reduce 3GC use. The intervention included modification of local clinical guidelines for urinary tract infection (UTI) and community acquired pneumonia (CAP), provider education, and daily review of active 3GC orders in 2021. Local guideline changes include preferred use of ampicillin/sulbactam and amoxicillin/clavulanate for CAP and cefazolin and cephalexin for UTI over 3GCs. Use of first generation cephalosporins for UTI was supported by local antibiogram susceptibilities for common UTI pathogens. Days of therapy (DOT) per 1000 patient days were collected monthly and yearly for ceftriaxone, ceftazidime, cefpodoxime, and cefdinir for pre-intervention (January 2019 to December 2019 and January to December 2020) and post-intervention (January 2021 to December 2021) periods. Results 3GC use significantly decreased from 89.52 DOT per 1000 patient days in 2020 to 53.06 in 2021, a 40.73% reduction. To account for increases in antibiotic use during COVID-19 surges in 2020 as a potential confounding variable, 2019 3GC use was also compared to 2021 use. A 31.40% decrease was seen, with 77.35 DOT per 1000 patient days in 2019. This effect was sustained through COVID-19 surges in January and August 2021 (Figure 1). Conclusion A combination of interventions without restriction of 3GC was successful in reducing inpatient use of this class of antibiotics, including through two COVID-19 surges in 2021. Further study is required to determine impact on clinical outcomes, such as C. difficile and antimicrobial resistance rates. Disclosures All Authors: No reported disclosures.

1756. Prescriber Adherence to System-Wide Urinary Tract Infection Guidelines in Ambulatory Care Clinics

Abstract Background Antimicrobial stewardship (AMS) practices are well established in acute care, only recently expanding into ambulatory care settings. It has been estimated that 80-90% of antibiotic use occurs in the ambulatory setting with up to 52% of that use being unnecessary. Urinary tract infections (UTIs) are commonly treated in ambulatory settings, and drug selection and duration of therapy vary among different practices. Our study evaluated the impact of a system-wide guideline and prescriber education, two recommended AMS strategies, on antibiotic utilization for UTIs in the ambulatory setting. Methods This retrospective study evaluated female adult patients prescribed an antibiotic for acute uncomplicated cystitis by a primary care provider at a clinic within our organization between January and March 2021. System-wide UTI treatment guidelines were implemented in November 2020, with live education delivered to primary care prescribers in December 2020. The primary objective of this study was to assess prescriber adherence to system-wide guidelines. The secondary objective was to evaluate utilization of antibiotic regimens for treatment of acute uncomplicated cystitis. Results A total of 100 patients were evaluated. Guideline adherence was met in 49% of patients. The primary reason for guideline non-adherence was duration of therapy, which was inappropriate (too long) in 42% of patients. Nitrofurantoin, the first-line antibiotic recommendation on the system-wide guideline, was the antibiotic prescribed most frequently (48%), but was the antibiotic of choice in 90% of patients. Sulfamethoxazole/trimethoprim was prescribed in 35% of patients and was most often prescribed correctly with respect to appropriate dose and duration of therapy (60%), followed by nitrofurantoin (54%). Recurrent cystitis within 30 days occurred in 11% of patients. Conclusion Implementation of a system-wide guideline and prescriber education for treatment of UTIs in the ambulatory setting identified areas for future optimization of antibiotic use, namely first line antibiotic selection and duration of therapy. This data will be shared with our prescribers to continue to encourage guideline-adherent antibiotic use. Disclosures All Authors: No reported disclosures.

Defining effective durations of antibiotic therapy for community-acquired pneumonia and urinary tract infections in hospitalized children.

Community-acquired pneumonia (CAP) and urinary tract infections (UTI) are two common childhood infections often leading to hospital admission. National guidelines for CAP and UTI in children recommend durations of antibiotic therapy of 10 days and 7-14 days, respectively. Due to concerns of rising antimicrobial resistance and an increased awareness of harms associated with prolonged courses of antibiotics, there is a renewed emphasis on reevaluating commonly prescribed durations of antibiotic therapy across bacterial infections. We describe recent clinical trials and observational studies evaluating durations of therapy for CAP and UTI in adults and children and translate the findings to our suggested approach for selecting durations of antibiotic therapy in hospitalized children. There is a growing body of evidence, primarily in adults, that shorter durations of therapy than are commonly prescribed are just as effective as longer durations for CAP and UTIs. Combining clinical trial data from adults with available data in children, we believe it is reasonable to consider 5 days of therapy for CAP, 3-5 days of therapy for cystitis, and 7 days of therapy for pyelonephritis for most hospitalized children with uncomplicated infections.

The Influence of Non-E. Coli or Extended-Spectrum β-Lactamase-Producing Bacterial Growth on the Follow-Up Procedure of Infants with the First Febrile Urinary Tract Infection.

To evaluate the effects of non-E. coli or extended-spectrum β-lactamase-positive (ESBL-positive) microorganism growth in the first febrile urinary tract infection (UTI) of infants on laboratory findings or renal parenchymal damage presenting the severity of inflammation, anatomic abnormalities defined by imaging studies, and recurrent UTIs in the follow-up period. The data of patients aged between 2 and 24 mo and followed up for at least 6 mo with febrile UTI guideline of the authors' pediatric-nephrology clinic, were retrospectively analyzed. Ultrasonography was performed in all the cases at the time of UTI and dimercaptosuccinic-acid(DMSA) at least 4mo after the infection. Voiding cystourethrography (VCUG) was performed only if ultrasonography findings were abnormal, the uptake deformity was detected in DMSA scan, or the patients experienced recurrent UTIs. The patients were grouped concerning E. coli or non-E. coli and ESBL-PB or non-ESBL-BP growth in the urine cultures. There were 277 infants followed up for 28.55 ± 15.24(6-86) mo. The causative microorganisms were non-E. coli in 73 (26.4%) and ESBL-PB in 58 (20.9%) cases. CRP values, pyuria, and leukocyte-esterase positivity were significantly higher in UTIs causedby E. coli compared to non-E. coli bacteria. All clinical and laboratory findings were similar between the ESBL-PB and non-ESBL groups, but abnormal ultrasonography findings were more common in non-E. coli group. E. coli causes more severe inflammation, but non-E. coli infections are more frequently associated with ultrasound abnormalities. However, ESBL production did not affect either laboratory or radiological findings in the present cohort.

Clinical guidelines of UTIs in children: quality appraisal with AGREE II and recommendations analysis

ObjectiveTo explore the current Chinese and English guidelines of urinary tract infection (UTI) in children and provide a summary of the recommendations of the guidelines.MethodsAn electronic search was conducted on...

Guideline Adherence of Asymptomatic Bacteriuria Could Be Improved among General Practitioners in The Netherlands: A Survey Study.

Asymptomatic bacteriuria (ASB) is a common finding in certain populations. This study assessed general practitioners’ (GPs’) knowledge about ASB and their current clinical practice regarding urine testing. Methods: An online survey was used for GPs in the Netherlands from October to December 2020. Results: In total, 99 surveys were included in the analyses. All GPs strongly agreed with the statements about their knowledge and self-confidence regarding urine diagnostics and treatment of ASB. The median knowledge score was 4 out of 6 (IQR 2 to 6). Most GPs (64 of 92; 70%) followed the guideline for the choice of urine diagnostics and reported appropriate indications for urine testing. However, 71/94 (75.5%) GPs would treat patients for ASB if they have diabetes mellitus. Further, 34 (37%) of 92 participants would inappropriately repeat a urine test after a patient was treated for a urinary tract infection (UTI). One-third of the GPs responded that ASB was insufficiently addressed within the guidelines for UTI. Conclusion: These results indicate that knowledge about ASB could be improved in primary care in the Netherlands, mainly in diabetic patients that have ASB, as well as for follow-up tests after treatment for UTI.

Clinical Characteristics of Febrile Urinary Tract Infection and Application of Thai Guideline Imaging Recommendations Compared between Children Aged 2 Months to 2 Years and Children Aged 2 to 5 Years

Background: In 2014, the Thai Pediatric Nephrology Association (TPNA) launched a guideline for febrile urinary tract infection (UTI) in children aged two months to five years. Renal and bladder ultrasound (RBUS) is recommended for first febrile UTI, and voiding cystourethrography (VCUG) is recommended in patients with at least one of eight proposed risk factors. Objective: To compare characteristics of febrile urinary tract infection (UTI), compliance with the imaging study recommendation regarding to the TPNA guide, and kidney, ureter, and bladder (KUB) abnormality detections between children aged two months to two years and older than two years to five years. Materials and Methods: The present study was a retrospective study, reviewed children aged two months to five years presenting with first or recurrent episode of febrile UTI between 2014 and 2019 at Siriraj Hospital. Clinical parameters during febrile UTI, indications to perform VCUG, and kidney, ureter, and bladder (KUB) abnormality detections were compared between the younger group and the older group. RBUS and VCUG undergone according to the recommendation were accounted for the compliance. Results: The mean age of 259 younger and of 51 older age children was 8.2±5.6 and 40.0±10.9 months, respectively. Female gender (p=0.01), complaint of constipation (p=0.03), abnormal bladder emptying (p&lt;0.01), and renal impairment (p=0.03) were more frequent in the older than the younger. Overall imaging study compliance was 73.9% and the KUB abnormality detection was 16.5%. High-grade vesicoureteral reflux (VUR) was more common than low-grade VUR. The rates of compliance (p=0.45) and KUB abnormality detections (p=0.54) between the younger and older children were not different. Conclusion: Female gender, and bladder and bowel dysfunction were associated to febrile UTI in older children. The TPNA febrile UTI guideline imaging recommendation was shown to be applicable in both younger and older children. Keywords: Clinical characteristics; Febrile urinary tract infection; Thai guideline imaging recommendations; Renal and bladder ultrasound; Voiding cystourethrography

197. Healthcare Resource Utilization and Costs Associated with Inappropriate and Suboptimal Prescribing of Antibiotics for Uncomplicated Urinary Tract Infection in the United States

BackgroundDespite well-established guidelines for urinary tract infection (UTI) treatment, prescribing practices vary. We examined the association between inappropriate (IA) or suboptimal (SO) antibiotic (AB) prescribing (RX) and hospitalization, healthcare resource use (HRU), and costs among patients with uncomplicated UTI (uUTI) in the US.MethodsThis retrospective cohort study used linked Premier Healthcare/Optum claims data from female outpatients (≥ 12 years old) with a uUTI diagnosis (January 1, 2013 to December 31, 2018). Patients with complicated UTIs (eg, urological abnormalities, medications/procedures associated with complicated UTI, or intravenous AB receipt at index) were excluded. HRU and costs between patients with IA/SO and appropriate and optimal (AP&OP) AB RX (defined in Table 1) were assessed from Optum claims data during index episode (within 28 days of index) and 12-month follow-up.Table 1. Definitions of appropriateness of AB RX ResultsOf 5870 patients, 1856 (31.6%) had IA and 1255 (21.4%) had SO AB RX. Patients with IA/SO AB RX (47.1%) were older and more likely to have a Charlson Comorbidity Index score > 0 than those with AP&OP AB RX (52.9%; Table 2). During index episode, mean ambulatory care and pharmacy claims were significantly higher for IA/SO versus AP&OP AB RX (8.0 vs 6.3, 3.3 vs 2.6, respectively; p < 0.01), and total HRU cost per patient was higher for IA/SO (&2616) versus AP&OP AB RX (&649; p < 0.01). During follow-up, 267 (9.7%) patients with IA/SO AB RX had a UTI-related emergency department (ED) visit versus 202 (6.5%) patients with AP&OP AB RX (p < 0.001). Mean UTI-related HRU costs were significantly higher for IA/SO (&5048) versus AP&OP AB RX (&3633; p = 0.01). After adjusting for patient characteristics, patients with IA/SO AB RX were 40% more likely than those with AP&OP AB RX to have a UTI-related ED visit (odds ratio 1.40; 95% confidence interval 1.15–1.71) during follow-up (Table 3). Adjusted HRU costs for IA/SO AB RX (vs AP&OP) were numerically higher for index uUTI episode (by &1772), and UTI-related (by &1102) and all-cause (by &1528) charges during follow-up (Figure).Table 2. Baseline characteristics of patients stratified by appropriateness of AB RX Table 3. Associations of AP&OP AB RX and HRU charges for index episode and 12-month follow-up Figure. Total 12-month UTI-related and all-cause visit charges (adjusted), stratified by appropriateness of AB RX at index and during follow-up ConclusionIA/SO AB RX was associated with higher overall and UTI-related HRU and costs during index episode and 12-month follow-up, highlighting a need for education on applying prescription guidelines and the use of culture-based RX.Disclosures Rena Moon, MD, Premier Applied Sciences, Premier Inc. (Employee) Alen Marijam, MSc, GlaxoSmithKline plc. (Employee, Shareholder) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder) Daniel C. Gibbons, PhD, GlaxoSmithKline plc. (Employee, Shareholder) Alex Kartashov, PhD, Premier Applied Sciences, Premier Inc. (Employee) Ning Rosenthal, MD, Premier Applied Sciences, Premier Inc. (Employee, Shareholder) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder)

100. Assessment of Emergency Department Prescribing Practices for Outpatient Treatment of Urinary Tract Infection, Community-Acquired Pneumonia, and Skin and Soft Tissue Infections

BackgroundStudies have found a need for improved antimicrobial stewardship in the outpatient setting. The literature is limited by the populations and disease states studied as many focus on viral infections. This study focuses on the adult emergency departments (EDs) in a large healthcare system and quantifies the proportion of antibiotic prescriptions deemed inappropriate for common outpatient infections.MethodsA retrospective study was conducted in patients with selected common infections treated as an outpatient from the ED. Patients were reviewed for eligibility based on the inclusion and exclusion criteria in Table 1. Appropriateness was analyzed based on: need for antimicrobial therapy; agent choice, dose, duration, and directions in concordance with national guidelines and local resistance patterns; and no clinically relevant drug interactions, unnecessary dual coverage, or a better or safer alternative available. The entire prescription was marked inappropriate if any factor was deemed inappropriate. Table 1. Inclusion and Exclusion Criteria Based on the Epic report generated, a random sample of patients were selected for manual review. Only patients who met the following criteria were eligible for inclusion in the final analysis.ResultsOf the 318 patients reviewed, 274 were included. Treatment was deemed inappropriate 64% (174/274) of the time, significantly above the estimated 30% (p < 0.001). The agent selection, duration, and dose were the most the frequent factors deeming a prescription inappropriate. The most inappropriately used agents were fluoroquinolones and azithromycin. A positive culture required modification of therapy 31% (22/70) of the time and more so when the drug was guideline recommended. For example, when empiric antibiotic selection was per urinary tract infection guidelines, 31% (14/53) required modification compared to 19% (3/16) when the agent was not. This was most apparent when cephalexin was used. ConclusionThe use of antibiotics at the studied EDs was not in concordance with guidelines in the study period. However, the cultures were sensitive less often to agents deemed appropriate per guidelines for empiric therapy. It is possible that the ideal treatments of bacterial infections in this community are not representative of national resistance patterns. Using ED-specific antibiograms to create order panels for common infections, as well as prospective pharmacist review at ED discharge, could increase appropriate utilization of preferred agents. Disclosures All Authors: No reported disclosures

Egyptian pediatric clinical practice guidelines for urinary tract infections in infants and children (evidence based)

BackgroundNational evidence-based recommendations for diagnosis, treatment, imaging, and follow-up in urinary tract infection are crucial being a major health problem in pediatrics. Every region should follow international recommendations with respect to the disease local profile and available facilities for that area.MethodsBased on AGREE II (the assessment tool of practice guidelines), Egyptian CGLs used *American Academy Pediatrics, *European Association Urology, European Society Pediatric Urology, and *Asian Association Urinary tract infections as its evidence-based references. Health questions were listed for evidence base answers adopted from selected CGLs after their permission. Key statements were approved by all members and further approved by the Egyptian Pediatric Guidelines Committee after local and international external peer reviewing.Results(1) Diagnosis recommendations: Urine culture with diagnostic colony counts is essential for diagnosis. Catheter samples are important for critical cases and non-toilet-trained cases especially when they show significant bacteriuria and pyuria. (2) Treatment plan included areas of debate as choice of antibiotic, oral versus intravenous, duration, antibiotic prophylaxis considering age, disease severity, recurrence, + risk factors, and imaging reports. (3) Imaging recommendations were tailored to suit our community. Renal bladder ultrasound is important for children with febrile UTI, due to the high prevalence of congenital anomalies of the kidney and urinary tract, paucity of prenatal ultrasound, and lack of medical documentation to reflect previously diagnosed UTI or US reports. We recommend renal isotopic scan and voiding cystography for serious presentation, high-risk factors, recurrence, and abnormal US. (4) Urological consultation is recommended: in urosepsis or obstruction, male infants < 6 months. Acute basal DMSA is recommended in congenital renal hypodysplasia. Six months post-infection, US and DMSA are recommended in severe pyelonephritis and vesico-ureteric reflux, where those with abnormal US or DMSA or both should have voiding cystography. (5) Follow-up recommendations include family orientation with hazards of noncompliance and monitoring at pregnancy.ConclusionDiagnosis and treatment show strong recommendations. Imaging depends on patient assessment. Referral to a pediatric nephrologist and urologist in complicated cases is crucial. Follow-up after the age of 16 years in adult clinics is important.

Asian guidelines for UTIs & STIs UTI section: Complicated UTIs with neurogenic bladder

Urinary tract infection (UTI) in patients with neurogenic bladder causes significant morbidity and mortality. UTI in neurogenic bladder causes atypical symptomatology. Urine tests are pivotal in confirming or excluding UTI, and in guiding appropriate antibiotic treatment. 1. Symptomatic UTI warrants appropriate antibiotic treatment with reference to culture results and local antibiotic resistance patterns. Asymptomatic bacteriuria should not be treated, and antibiotic prophylaxis is generally not recommended.2. Adequate bladder drainage is essential in reducing the occurrence of urinary tract infections.3. Recurrent UTI in neurogenic bladder may necessitate the treatment of neurogenic detrusor overactivity and the restoration of low bladder pressure during bladder storage and voiding by drugs or surgery.