Unintended consequences of a reflex urine culture order set on appropriate antibiotic use

2020 ◽  
Vol 41 (9) ◽  
pp. 1090-1092
Author(s):  
Corinne N. Klein ◽  
Miriam R. Elman ◽  
John M. Townes ◽  
James S. Lewis ◽  
Jessina C. McGregor
Keyword(s):  
Urine Culture ◽  
Antibiotic Use ◽  
Unintended Consequences ◽  
Negative Culture ◽  
Positive Urine ◽  
The Impact ◽  
Urine Screen ◽  
Order Set

AbstractWe evaluated the impact of reflex urine culture screen results on antibiotic initiation. More patients with positive urine screen but negative culture received antibiotics than those with a negative screen (30.5 vs 7.1%). Urine screen results may inappropriately influence antibiotic initiation in patients with a low likelihood of infection.

scholarly journals 2057. Outpatient Antibiotic Stewardship “Bundles up” in Winter with Peer Comparison, URI Order Set and Education: Is It Enough to Weather the Storm?

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S693-S693
Author(s):  
Okan I Akay ◽  
Rohini Dave ◽  
Amit Khosla ◽  
CherylAnn Kraska ◽  
Brian J Hopkins ◽  
...  
Keyword(s):  
Primary Care ◽  
Adverse Drug Events ◽  
Antibiotic Use ◽  
Outpatient Setting ◽  
Control Group ◽  
Upper Respiratory Infection ◽  
Primary Care Clinics ◽  
Ed Visits ◽  
The Impact ◽  
Order Set

Abstract Background Inappropriate antibiotic use is a growing problem in the outpatient setting. Approximately 90% of all antibiotics are prescribed in outpatient practices. Nonetheless, 30–70% of antibiotic prescriptions (ARx) are unnecessary. Outpatient antimicrobial stewardship (AS) is much needed and the best approach is unknown. We used a bundle approach to outpatient AS during the winter months, by implementing a peer comparison (PC) report, upper respiratory infection (URI) order set and broad education. Methods This is a quasi-experimental project during the period October 2018 to March 2019 (FY19) to evaluate the impact of a bundled intervention in primary care clinics at the VA Maryland Health Care System. A historical control group from the same period the previous year (FY18) was used for comparison. The intervention included an AS directed didactic and URI order set followed by an email in 1/2019 with: (1) censored PC report (ARx/1,000 encounters) with outliers defined as above 1.5 × interquartile range, (2) URI order set reminder, and (3) education. The primary outcome was total ARx per 1,000 encounters in primary care clinics. A random sampling of 200 charts was done to compare proportion of antibiotic appropriateness and number of emergency department (ED) visits and adverse drug events (ADEs) in FY19 Q1 and FY19 Q2. Poisson regression was carried out, in addition to Χ2-statistic. Results There were 3,799 vs. 3,429 ARx in FY18 and FY19, respectively, with a rate difference of 3.3 ARx per 1,000 encounters (P = 0.0056). Q1 to Q2 ARx rate increased by 7.8 and 8.0 ARx per 1,000 encounters in FY18 and FY19, respectively. Forty-eight percent (28/58) of the providers confirmed receipt of email. There were 3 and 4 outliers in FY19 Q1 and Q2, respectively. Appropriate ARx for FY19 Q1 and Q2 was found to be 45% and 35% (P = 0.44), respectively. The most common indications were URI (18% vs. 18%), urinary tract infection (13% vs. 21%). ED visits (10% vs. 6%) were uncommon and there were no ADEs. Conclusion E-mail communication with bundled approach had no effect on ARx or antibiotic appropriateness; however general AS presence and URI order set tempered some use. Removing peer censoring, providing face-to-face education and intensifying antibiotic order sets are additional interventions to be implemented. Disclosures All authors: No reported disclosures.

scholarly journals 585. A Cost-Effective Implementation Reducing The Number Of Urine Cultures In An Acute Care Community Hospital

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S356-S357
Author(s):  
Rohit Jain ◽  
Nitasa Sahu ◽  
Denise Marsh ◽  
Shannon Raines ◽  
Kirk Jones ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Urine Analysis ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Common Finding ◽  
Clinical Indication ◽  
Inpatient Setting ◽  
The Impact ◽  
Order Set

Abstract Background Asymptomatic bacteriuria is a common finding in hospitalized patients. This is defined as bacteriuria of ≥105 colony-forming units (cfu) per mL without any genitourinary signs or symptoms. Treatment for such leads to increased antimicrobial resistance and is especially common in the inpatient setting. One study showed a lack of appropriate clinical indication to order a urinalysis in more than half of the patients. In order to expedite a patient’s care, it is common to order a urinalysis and urine culture together and await the results. One study evaluated the impact of changing the order set in inpatients and yielded a 45% reduction in the urine cultures ordered and cost savings as high as $103,845. Reflex testing is used to facilitate effective and efficient patients care while remaining compliant with state and federal regulations in the ordering of lab test. Methods Starting October 25, 2019, the electronic medical record order set was changed so there were only 2 options from the previous 9 options. The modified options included a “Urine analysis with reflex culture” and “Urine analysis with microscopy.” The reflex was not encouraged to be used for those who were pregnant, neutropenic, or had any evidence of immunocompromise. Results Following the implementation of this initiative in October 2019, there was a decrease in overall urine culture cost. From Jan 2019 to September 2019, the cost ranged between $13428.96 to $15157.44/month in the Emergency Department. On the inpatient side, it ranged between $5141.12 to $6559.36/month. After revision of the new order set, the ED cost had dropped to as low as $5672.96/month and $3811.52/month for inpatients. This is a cost reduction of approximately $9484.48 and $2747.84 for the ED and inpatient, respectively.The total number of cultures also reduced from an average of 326/month in the ED to 193/month. The inpatient number of cultures dropped from an average of 130/month to 102/month. Conclusion Modifying the process of urine culture ordering has significantly cut down cost for both the hospital and patient. With clear education and modification of the electronic medical record, such interventions can dramatically improve the unnecessary testing for UTI’s. Disclosures All Authors: No reported disclosures

scholarly journals 670. Precision Metagenomic (PM) Sequencing Outperforms Conventional Urine Culture in Detecting Clinically Relevant Microorganisms

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S437-S438
Author(s):  
Rita C Stinnett ◽  
Bethany Kent ◽  
Marta Mangifesta ◽  
Anagha Kadam ◽  
Heng Xie ◽  
...  
Keyword(s):  
Antimicrobial Resistance ◽  
Pathogen Detection ◽  
Urine Culture ◽  
Diagnostic Yield ◽  
Panel Member ◽  
Reference Method ◽  
Antibiotic Use ◽  
Transmitted Infection ◽  
Phenotypic Resistance ◽  
The Impact

Abstract Background Morbidity from urinary tract infection (UTI) is high. Urine culture is the reference method for UTI diagnosis. Its diagnostic yield is limited as prior antibiotic use prevents growth of established uropathogens, many emerging uropathogens do not grow under routine culture conditions, and results interpretation can be subjective. Faster, more comprehensive diagnostics could help manage recurrent and/or drug-resistant infections. We evaluated the diagnostic yield of a precision metagenomic (PM) workflow for pathogen detection & antimicrobial resistance (AMR) characterization directly from urine. Methods Residual urine samples from symptomatic adults evaluated by culture & susceptibility were identified by a combination of consecutive & stratified random sampling (n=480; 79% culture positive). DNA was extracted with modifications to the Quick-DNA Urine Kit (Zymo). Libraries were generated with Illumina DNA Prep with Enrichment for clinically relevant targets (191 pathogens, 1976 AMR markers) with the Explify Urinary ID/AMR Panel (UPIP, IDbyDNA). Enriched libraries were sequenced on the NextSeq550 (Illumina) and data analyzed with the Explify UPIP Data Analysis Solution (IDbyDNA). Results For bacterial uropathogens, 94% positive agreement was observed between this PM workflow and culture. PM detected fastidious and/or anaerobic potential uropathogens in 30% and 7% of samples reported as culture-negative or positive for other bacteria, respectively. Total agreement between AMR marker detection and phenotypic resistance was 78%. Notably, PM predicted phenotypes of ESBL E. coli and K. pneumoniae (10/10), MRSA (9/9), and vancomycin-resistant E. faecium (4/5). PM also detected pathogens associated with sexually-transmitted infection (C. trachomatis, HSV) and bacterial vaginosis (G. vaginalis). PM produced complete results within 24-36 hours of sample receipt (vs culture & susceptibility: 42-72 hrs). Conclusion The sensitivity of PM for uropathogen detection was noninferior to culture (Δ = 0.05; Nam RMLE; p < 0.0005). PM predicted antimicrobial resistance phenotypes for common uropathogens and identified potential pathogens not detected by conventional culture. Future studies should assess the impact of PM-guided management on clinical outcomes. Disclosures Rita C. Stinnett, PhD, MHS, IDbyDNA (Employee) Marta Mangifesta, PhD, IDbyDNA (Employee) Anagha Kadam, PhD, IDbyDNA (Employee) Heng Xie, PhD, IDbyDNA (Employee) Stacie Stauffer, BS, IDbyDNA (Employee) Jamie Lemon, PhD, D(ABMM), IDbyDNA (Employee) Benjamin Briggs, MD, PhD, IDbyDNA (Employee) Lauge Farnaes, MD, PhD, Cardea Bio (Advisor or Review Panel member)IDbyDNA (Employee) Robert Schlaberg, MD, MPH, IDbyDNA (Consultant, Shareholder, Co-founder)

Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: A multicenter experience

2020 ◽  
Vol 41 (5) ◽  
pp. 564-570
Author(s):  
Kaitlin J. Watson ◽  
Barbara Trautner ◽  
Hannah Russo ◽  
Kady Phe ◽  
Todd Lasco ◽  
...  
Keyword(s):  
Urinary Tract ◽  
Electronic Health Record ◽  
Urine Culture ◽  
New Order ◽  
Health Record ◽  
Days Of Therapy ◽  
Electronic Health ◽  
Tract Infections ◽  
The Impact ◽  
Order Set

AbstractObjective:Despite evidence to the contrary, many practitioners continue to inappropriately screen for and treat bacteria in the urine of clinically asymptomatic patients. The purpose of this study was to evaluate the impact of a new order set on the number of urine culture performed, antibiotic days of therapy (DOT), catheter-associated urinary tract infections (CAUTI), and associated financial impact.Design:A quasi-experimental before-and-after intervention.Setting:We conducted this study at 5 Catholic Health Initiative (CHI) hospitals in Texas that use the same electronic health record (EHR) system.Patients:The study populations included adult patients who had urine culture performed from June 2017 to June 2019.Intervention:The intervention (implemented June 25, 2018) was the addition of a new order set in the electronic health record that required practitioners to choose an indication for the type of urine study. The primary outcome was number of urine cultures performed adjusted for the number of total patient days.Results:Following implementation of the new order set, the number of urine cultures performed among the 5 sites decreased from 1,175.8 tests per 10,000 patient days before the intervention to 701.4 after the intervention (40.4% reduction; P < .01). Antibiotic DOT for patients with a urinary tract infection indication decreased from 102.5 to 86.9 per 1,000 patient days (15.2% reduction; P < .01). The CAUTI standardized infection ratio was 1.0 before the intervention and 0.8 after the intervention (P = .23). The estimated yearly savings following the intervention was US$535,181.Conclusions:The addition of a new order set resulted in decreases in the number of urine cultures performed and the antibiotic DOT, as well as substantial financial savings.

Evaluation of a Novel Light Scattering Methodology for the Detection of Pathogenic Bacteria in Urine

2020 ◽  
Vol 5 (2) ◽  
pp. 370-376
Author(s):  
Elizabeth Davaro ◽  
Andrew P Tomaras ◽  
Robin R Chamberland ◽  
T Scott Isbell
Keyword(s):  
Light Scattering ◽  
Pathogenic Bacteria ◽  
Detection Method ◽  
Urine Culture ◽  
Reference Method ◽  
Antibiotic Use ◽  
Positive Urine Culture ◽  
Positive Urine ◽  
Tract Infections ◽  
Urine Specimens

Abstract Background Urine culture, the gold standard for detecting and identifying bacteria in urine, is one of the highest volume tests in many microbiology laboratories. The inability to accurately predict which patients would benefit from culture leads not only to monopolization of laboratory resources, but also to unnecessary antimicrobial exposure as patients receive empirical treatment for suspected or presumed urinary tract infections (UTI) while awaiting culture results. A common approach to decrease unnecessary urine culture is screening samples using urinalysis (UA) parameters to determine those that should proceed to culture (reflex). In this study, we compared the performance of a novel uropathogen detection method to urinalysis for purposes of UTI screening. Methods Urine specimens submitted for culture (n = 194) were evaluated by urinalysis and a novel light scattering device (BacterioScan 216Dx UTI System) capable of detecting the presence of bacteria in urine. Sensitivity and specificity for prediction of a positive urine culture by UA and 216Dx were determined relative to urine culture results. A positive urine culture was defined as growth in culture of one or two uropathogens at concentrations of ≥50,000 CFU/mL. Results 194 urine samples were evaluated by UA, 216Dx, and urine culture. The 216Dx demonstrated a 100% [95%CI: 88.43%–100.0%] sensitivity and 81.71% [95%CI: 74.93%–87.30%] specificity for the detection of bacteriuria, vs UA with a sensitivity of 86.67% [95%CI 69.28%–96.24%] and specificity of 71.95% [95%CI: 64.41%–78.68%] when compared to urine culture (diagnostic reference method). Conclusions BacterioScan allows for an alternative method of screening with satisfactory sensitivity and improved specificity that may facilitate a reduction of unnecessary cultures. Additional studies are required to determine if a concomitant decrease in inappropriate antibiotic use can be realized with the 216Dx technology.

scholarly journals Oral Antibiotic Use Following Stented Hypospadias Repair: Does It Play a Role in the Prevention of Urinary Tract Infections?

2020 ◽  
Vol 12 (3) ◽  
Author(s):  
Mohammed Suoub ◽  
Fadi Sawaqed
Keyword(s):  
Urine Culture ◽  
Antibiotic Use ◽  
Oral Antibiotic ◽  
Hypospadias Repair ◽  
Oral Antibiotics ◽  
Positive Urine ◽  
Group A ◽  
Group B ◽  
Tract Infections

Background: There is a lack of consensus regarding the role of oral antibiotics following hypospadias repair. Objectives: The study aimed to evaluate the role of oral antibiotic use following stented Tubularized incised plate urethroplasty (TIPU) in the prevention of bacteriuria and urinary tract infections (UTIs). Methods: A prospective study was conducted on 40 patients undergoing stented TIPU for coronal hypospadias between January 2014 and December 2016. The average age of the subjects was 13.2 months at the time of surgery, ranging from 11 to 16 months. The patients were divided into two groups. Group A consisted of 20 patients receiving oral antibiotics until urethral catheter removal, whereas group B consisted of 20 patients without any oral antibiotics postoperatively. Results: The two groups were followed for three years. The urethral catheter was removed eight days postoperatively in the two groups. In group A, the patients received oral antibiotics as long as the catheter was left in situ. Urine samples were collected from the patients and sent for analysis and culture at the time of stent removal and after three weeks. The results showed that 3/20 (15%) patients from group A had pyuria and bacteriuria, while all of them had negative urine culture results. On the other hand, in group B, 8/20 (40%) patients had pyuria and bacteriuria (P > 0.05), and four (20.0%) patients had positive urine cultures for Escherichia coli (P < 0.05), sensitive to co-trimoxazole. None of the patients in the two groups had febrile UTI. Conclusions: The use of oral antibiotics for patients following stented TIPU reduces pyuria and significantly decreases positive urine culture results and the risk of UTI after surgery.

Urine Culture on Admission Impacts Antibiotic Use and Length of Stay: A Retrospective Cohort Study

2018 ◽  
Vol 39 (5) ◽  
pp. 547-554 ◽  
Author(s):  
Molly J. Horstman ◽  
Andrew M. Spiegelman ◽  
Aanand D. Naik ◽  
Barbara W. Trautner
Keyword(s):  
Cohort Study ◽  
Length Of Stay ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Urine Culture ◽  
Antibiotic Use ◽  
The United States ◽  
Targeted Interventions ◽  
Bed Days ◽  
The Impact

OBJECTIVETo examine the impact of urine culture testing on day 1 of admission on inpatient antibiotic use and hospital length of stay (LOS).DESIGNWe performed a retrospective cohort study using a national dataset from 2009 to 2014.SETTINGThe study used data from 230 hospitals in the United States.PARTICIPANTSAdmissions for adults 18 years and older were included in this study. Hospitalizations were matched with coarsened exact matching by facility, patient age, gender, Medicare severity-diagnosis related group (MS-DRG), and 3 measures of disease severity.METHODSA multilevel Poisson model and a multilevel linear regression model were used to determine the impact of an admission urine culture on inpatient antibiotic use and LOS.RESULTSMatching produced a cohort of 88,481 patients (n=41,070 with a culture on day 1, n=47,411 without a culture). A urine culture on admission led to an increase in days of inpatient antibiotic use (incidence rate ratio, 1.26; P<.001) and resulted in an additional 36,607 days of inpatient antibiotic treatment. Urine culture on admission resulted in a 2.1% increase in LOS (P=.004). The predicted difference in bed days of care between admissions with and without a urine culture resulted in 6,071 additional bed days of care. The impact of urine culture testing varied by admitting diagnosis.CONCLUSIONSPatients with a urine culture sent on day 1 of hospital admission receive more days of antibiotics and have a longer hospital stay than patients who do not have a urine culture. Targeted interventions may reduce the potential harms associated with low-yield urine cultures on day 1.Infect Control Hosp Epidemiol 2018;39:547–554

scholarly journals A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Sara Malone ◽  
Virginia R. McKay ◽  
Christina Krucylak ◽  
Byron J. Powell ◽  
Jingxia Liu ◽  
...  
Keyword(s):  
Public Health ◽  
Clinical Outcomes ◽  
Antibiotic Stewardship ◽  
Implementation Strategies ◽  
Antibiotic Use ◽  
Low Risk ◽  
Stepped Wedge ◽  
Cluster Randomized ◽  
The Impact ◽  
Order Set

Abstract Background Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown. Methods/design A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children’s Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members’ assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented. Discussion This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation. Trial registration NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440.

Aviation and the Microbiome

2020 ◽  
Vol 91 (8) ◽  
pp. 651-661
Author(s):  
Joshua T. Davis ◽  
Hilary A. Uyhelji
Keyword(s):  
Psychological Health ◽  
Aviation Safety ◽  
Autism Spectrum ◽  
Unintended Consequences ◽  
Microbial Colonization ◽  
Future Research ◽  
Aerospace Medicine ◽  
Medical Certification ◽  
Physical Disorders ◽  
The Impact

INTRODUCTION: Although the impact of microorganisms on their hosts has been investigated for decades, recent technological advances have permitted high-throughput studies of the collective microbial genomes colonizing a host or habitat, also known as the microbiome. This literature review presents an overview of microbiome research, with an emphasis on topics that have the potential for future applications to aviation safety. In humans, research is beginning to suggest relationships of the microbiome with physical disorders, including type 1 and type 2 diabetes mellitus, cardiovascular disease, and respiratory disease. The microbiome also has been associated with psychological health, including depression, anxiety, and the social complications that arise in autism spectrum disorders. Pharmaceuticals can alter microbiome diversity, and may lead to unintended consequences both short and long-term. As research strengthens understanding of the connections between the microbiota and human health, several potential applications for aerospace medicine and aviation safety emerge. For example, information derived from tests of the microbiota has potential future relevance for medical certification of pilots, accident investigation, and evaluation of fitness for duty in aerospace operations. Moreover, air travel may impact the microbiome of passengers and crew, including potential impacts on the spread of disease nationally and internationally. Construction, maintenance, and cleaning regimens that consider the potential for microbial colonization in airports and cabin environments may promote the health of travelers. Altogether, the mounting knowledge of microbiome effects on health presents several opportunities for future research into how and whether microbiome-based insights could be used to improve aviation safety.Davis JT, Uyhelji HA. Aviation and the microbiome. Aerosp Med Hum Perform. 2020; 91(8):651–661.

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