Antibiotic stewardship program for asymptomatic bacteriuria may be effective

1. In a major Veterans Affairs Medical Center, the interventional campaign, Kicking CAUTI: No Knee-Jerk Antibiotics, was effective at significantly lowering the rates of inappropriate urine cultures ordered and antibiotics prescribed amongst a catheterized population with asymptomatic bacteruria.

2. Neither feat was achieved at the comparison site VA, where the only intervention present was the dissemination of Infectious Diseases Society of America guidelines.

Evidence Rating Level: 2 (Good)

Study Rundown: Overuse of antibiotics is a major public health concern, both in terms of incurred costs and the prevalence of antibiotic resistance. Asymptomatic bacteriuria (defined as presence of bacteria in the urine without being symptomatic), especially in instances associated with catheters, is a common instance in which antibiotics are used unnecessarily. An interventional campaign, Kicking CAUTI (catheter-associated urinary tract infection): No Knee-Jerk Antibiotics, was created to reduce unnecessary urine cultures obtained, which is the major driver for antibiotic use. This study was conducted to evaluate the effectiveness of this campaign in a Veterans Affairs Medical Center. The results of the study showed that, after the targeted intervention, there was significantly fewer inappropriate urine cultures ordered and antibiotics prescribed for cases of asymptomatic bacteriuria (ASB). In addition, the effectiveness of the campaign remained during the maintenance period, one year after the official intervention was finished.

The strength of the study was in the number of residents that were included in the study, along with the ability to review the chart on all the patients to determine the appropriateness of urine cultures and antibiotic prescriptions. The population was also similar between the two hospital centers, though they may not necessarily be applicable to non-VA centers. Also, the maintenance follow-up period of one year may be too short to determine the longevity of the campaign’s message.

Click to read the study, published today in JAMA Internal Medicine

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Relevant Reading: Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes

In-Depth [preintervention and postintervention comparison]: This study was conducted to determine the effectiveness of the campaign, Kicking CAUTI: No Knee-Jerk Antibiotics. The intervention site was the Michael E. DeBakey Veterans Affairs Medical Center and the comparison site was the South Texas Veterans Health Care System. The study, which ran from 2010 to 2013, included all catheterized inpatients. In the first year, baseline incidences, screenings, and treatments of ASB and CAUTI were calculated. In the second year, the intervention, which included distribution of a diagnostic algorithm, case-based audit and feedback, and interactive slide presentations, was performed in one health care system based on the campaign. The comparison system received the existing guidelines regarding ASB and CAUTI in didactic and email form. Finally, in the third year, the maintenance of this intervention was determined.

At the intervention site, the rate of inappropriate urine culture ordering decreased significantly during the intervention period (from 41.2 to 23.3 per 1000 bed-days; incidence rate ratio [IRR] 0.57, p < 0.001) and during the maintenance period (12.0 per 1000 bed-days; incidence rate ratio 0.29, p < 0.001). Treatment for ASB also fell at the intervention site during the intervention period (from 1.6 to 0.6 per 1000 bed-days, IRR 0.35, p < 0.001) and during the maintenance period (to 0.4 per 1000 bed-days, IRR 0.24, p < 0.001). At the comparison site, ordering of inappropriate urine culture and unnecessary treatment of ASB remained the same throughout both periods.

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