Stewardship Intervention Reduces Overuse of Antibiotics in the Treatment of Asymptomatic Bacteriuria among Veterans
BACKGROUND:
The CDC estimates that more than $1 billion is spent on unnecessary antibiotics annually, and that drug-resistant pathogens cause 2 million illnesses and 23,000 deaths in the U.S. each year. The use of antibiotics to treat asymptomatic bacteriuria (ASB) is a significant contributor to antibiotic overuse in hospitalized and nursing home patients, especially among patients with urinary catheters. In catheterized patients, ASB is often incorrectly diagnosed and treated as catheter-associated urinary tract infection (CAUTI). The Kicking CAUTI: The No Knee-Jerk Antibiotics Campaign intervention to reduce ASB overtreatment features case-based audit and feedback and an actionable algorithm to distinguish ASB from CAUTI. This study evaluated the effectiveness of the Kicking CAUTI intervention in two VAMCs between July 2010 and June 2013. The primary outcomes were urine cultures ordered per 1,000 bed-days and cases of ASB receiving antibiotics (overtreatment) during the intervention and maintenance (after cessation of the active intervention) periods – compared with baseline – at the intervention site versus the comparison site. Using VA data, investigators identified Veterans with urinary catheters on acute medicine wards and long-term care units, and then determined whether they had received urine cultures and antibiotics to treat urinary organisms. The study included 289,754 total bed days, with 170,345 at the intervention site and 119,409 at the comparison site.
FINDINGS:
- At the intervention site, the Kicking CAUTI intervention successfully decreased inappropriate screening for ASB and decreased ASB overtreatment with antimicrobials, without increasing the undertreatment of CAUTI. In stratified analysis, the effect of the intervention was more significant in long-term care wards and was modest on acute medicine wards.
- The overall rate of ordering urine cultures decreased during the intervention period – from 41.2 to 23.3 per 1000 bed-days, and even further during the maintenance period – to 12.0 per 1000 bed-days. At the comparison site, cultures ordered did not change significantly across periods.
- Overtreatment of ASB at the intervention site fell significantly during the intervention period from 1.6 to 0.6 per 1000 bed-days, and these reductions persisted during the maintenance period – to 0.4 per 1000 bed-days. Overtreatment of ASB at the comparison site was similar across all periods.
LIMITATIONS:
- Investigators do not know which part of their intervention had the greatest impact, or whether the entire bundle (audit, feedback, and algorithm) is necessary to achieve the same results.
- Pre-intervention rates of ASB overtreatment differed across the study sites.
IMPACT:
- VA mandates that all facilities adopt antimicrobial stewardship, and this study demonstrates that a guideline implementation intervention can lead to sustainable reductions in overuse.
AUTHOR/FUNDING INFORMATION: This study was funded by HSR&D. Dr. Trautner, Petersen, Hysong, and Naik are part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety in Houston, TX.
Trautner B, Grigoryan L, Petersen N, Hysong S, Cadena J, Patterson, J, and Naik A. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Internal Medicine. July 1, 2015;175(7):1120-27.
