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Reduce Testing and Treatment of Asymptomatic Bacteriuria (ASB)
Background, Rationale and Suggested Implementation Strategies
- Educate providers, including hospitalists, internal medicine, family medicine, emergency medicine physicians, residents, advanced practice professionals (APPs), and nursing staff regarding the diagnosis of ASB vs UTI.
- Educate patients and family members regarding the diagnosis of ASB vs UTI.
- Review ASB cases identified by HMS to direct high-yield intervention for recurrent problems.
- Evaluate and understand differences in provider groups (e.g., hospitalists, emergency department physicians). Target interventions to specific provider groups as necessary.
- Evaluate existing order sets to ensure preferred antibiotic options, doses, and durations are consistent with institutional UTI guidelines (including pre-operative order sets, ED admission sets, “commonly ordered test” lists).
- Utilize clinical decision support tools to discourage inappropriate urine culture testing in the absence of urinary symptoms, by requiring documentation of symptom(s) as indication for the test.
- Utilize checklists to discourage ordering of urine cultures in the absence of urinary symptoms by frontline clinical care team.
- Require documentation of dose and indication of antibiotics prescribed in the antibiotic order. Consider adding documentation of urinary symptom(s) necessitating treatment.
- Encourage documentation of dose, indication, and duration of antibiotics in the progress note.
- Encourage documentation of the total duration of antibiotics in discharge summary, potentially incorporating an area for antibiotic duration to be filled out in an automated discharge process.
- Provide audit and feedback directly to individual providers regarding their rates of testing and treatment for ASB.
- Consider performing urine cultures only when indicated (example: reflex culture only with positive urinalysis).
- Consider suppressing urine culture results by requiring providers to call the microbiology lab to request results (for non-catheterized patients).
- Create a protocol assessing for UTI in patients whose primary symptom is altered mental status (AMS).
- Consider implementing a diagnostic stewardship intervention. Examples include: removal of urine cultures from a) preoperative, b) emergency department, c) admission, or d) other order sets; addition or removal of reflex testing; hiding urine culture results in some settings; requiring physician order to run urine cultures in ED; two-step urine culture initiative to reduce urine cultures in ED; framing urine culture results in test reporting; AND/OR rejection of some urine culture samples (e.g., based on squamous cells)
Resources and Tools
- Review HMS site reports (hard copy distributed at collaborative wide meetings and live reports available daily via the HMS data entry
system) for the following:- Testing for Asymptomatic Bacteriuria
- Treatment of Asymptomatic Bacteriuria with Antibiotics
- Types of Reports Available via HMS Registry: Hospital Specific, Provider Group Specific (i.e. hospitalist v. emergency room physician), or Provider Specific
- HMS Guideline
- Educational Videos:
- Nurse Education Video: ASB vs UTI (Presentation by Dr. Lindsay Petty)
- Patient Education Video: Antibiotic Awareness – UTI, Cystitis, or Bladder Infection (Washington State Dept. of Health)
- Provider Education Video: The Dangers of Overtreating Asymptomatic Bacteriuria (B. Trautner)
- Provider Education Video: Appropriate Treatment for Asymptomatic Bacteriuria (B. Trautner)
- Checklist for Appropriate Urine Culture Ordering
- Johns Hopkins Medicine: Urine Cultures One Pager
- Tools for assessing Urinary Tract Infection (UTI) in patients with Altered Mental Status (AMS)
- Example of hospital newsletter incorporating HMS Data #1 (Corewell Health – Previously Beaumont)
- Patient Education Materials:
- ASB Patient Flyer: Suspect a Urinary Tract Infection? How taking antibiotics when you don’t need them can cause more harm than good (AHRQ)
- ASB Patient Flyer: Management of Urinary Tract Infections (Corewell Health – Previously Beaumont)
- Provider Education Materials:
- ASB Provider Flyer: Symptom-Free Pee – Let It Be Poster (Trinity Health Grand Rapids)
- ASB Provider Flyer: When it Comes to Urine Testing, Hold it. (Beaumont)
- ASB Provider Flyer: Asymptomatic Bacteriuria (AHRQ)
- CDC poster: Avoid Treatment of Asymptomatic Bacteriuria
- Presentation by Dr. Valerie Vaughn at Infectious Diseases Week 2022: Reducing Unnecessary Antibiotic Treatment for Asymptomatic Bacteriuria: Diagnostic vs. Antibiotic Stewardship
- Presentations (For HMS Members – Additional authentication may be required):
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- Presentation by Lisa Dumkow (Antimicrobial Stewardship Pharmacist, Mercy Health St. Mary’s) at the November 12, 2019 HMS Collaborative Wide Meeting: Addressing the “Culture of Culturing” in Patients with Asymptomatic Bacteriuria
- Presentation by Dr. Anu Malani (Medical Director for Infection Prevention and Antimicrobial Stewardship, Trinity Health) at the November 14, 2017 HMS Collaborative Wide Meeting: Successful Interventions for Asymptomatic Bacteriuria and Urinary Tract Infections
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Example ASB Fallout Letter for sending to providers (adapted from MyMichigan Medical Center Midland)\
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Example ASB Positive Feedback Letter commending ASB case managed without antibiotic treatment (adapted from MyMichigan Medical Center Midland
References
- Advani S, et al. Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges. Curr Infect Dis Rep 2021.
- The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting.
- Claeys K, et al. Optimal Urine Culture Diagnostic Stewardship Practice – Results from an Expert Modified-Delphi Procedure. Clin Infect Dis 2022.
- A multidisciplinary expert panel utilized a RAND-modified Delphi approach to ascertain diagnostic stewardship best practices. The panel reached a conclusion and provided 18 guidance statements to optimize use of urine cultures for better patient outcomes.
- Collins CD, et al. Impact of an Antimicrobial Stewardship Care Bundle to Improve the Management of Patients with Suspected or Confirmed Urinary Tract Infection. Infect Cont Hosp Epi 2016.
- Implementation of an antimicrobial stewardship program bundle for urinary tract infections among 92 patients led to a higher rate of discontinuation of therapy for asymptomatic bacteriuria (52.4% vs 12.5%; P =.004), more appropriate durations of therapy (88.7% vs 63.6%; P =.001), and significantly higher overall bundle compliance (75% vs 38.2%; P < .001).
- Daniel M, et al. An Implementation Guide to Reducing Overtreatment of Asymptomatic Bacteriuria. JAMA Intern Med 2017.
- Review of different approaches used in prior studies to decrease treatment of ASB, with recommendations on steps to take to improve use in your own hospital
- Drekonja D, et al. Teamwork and Safety Climate Affect Antimicrobial Stewardship for Asymptomatic Bacteriuria. Infect Con Hosp Epi 2019.
- Revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.
- Hartley SE, et al. Evaluating a Hospitalist-Based Intervention to Decrease Unnecessary Antimicrobial Use in Patients with Asymptomatic Bacteriuria. Infect Cont Hosp Epi 2016.
- A hospitalist-focused educational and pharmacist-led intervention significantly reduced inappropriate treatment of asymptomatic bacteriuria across three hospitals, especially in patients without UTI symptoms or with catheters, highlighting the value of tailored antimicrobial stewardship strategies.
- Jones CW, et al. Reflect urine culture cancellation in the emergency department. J Emerg Med 2014
- In the ED, authors estimate a 40% reduction in urine cultures if a culture was cancelled when urinalysis did not meet criteria (one of the following: white blood cell >10, + leukocyte esterase, + nitrites, + bacteria)
- Kelley D, et al. Evaluation of an Antimicrobial Stewardship Approach to Minimize Overuse of Antibiotics in Patients with Asymptomatic Bacteriuria. Infect Cont Hosp Epi 2014.
- An antimicrobial stewardship educational initiative provided to physicians and pharmacists was evaluated at an academic medical center to minimize inappropriate treatment of asymptomatic bacteriuria (ASB). A significant decrease in empirical antimicrobial use for ASB was observed after education. Multifaceted educational initiatives can reduce inappropriate antimicrobial treatment of ASB.
- Kiyatkin D, et al. Impact of Antibiotic Choices Made in the Emergency Department on Appropriateness of Antibiotic Treatment of Urinary Tract Infections in Hospitalized Patients. Journ of Hosp Med 2015.
- In a 4-week period, medical records were reviewed for all patients admitted to Johns Hopkins Bayview Medical Center who had antibiotic treatment for UTI initiated in the ED. According to study criteria, initiation of antibiotics was inappropriate for 59% of patients, and continuation after admission was inappropriate for 68% of patients. Failure to reevaluate the need for antibiotics initiated in the ED to treat UTIs may lead to overuse of antibiotics in hospitalized patients.
- Krouss M, et al. Choosing Wisely Initiative for Reducing Urine Cultures for Asymptomatic Bacteriuria and Catheter-Associated Asymptomatic Bacteriuria in an 11-Hospital Safety Net System. Am Journ Inf Con 2023.
- Two electronic health record interventions successfully reduced urine cultures by more than 20% in a large safety net system: a mandatory indication on urine culture and a best practice advisory for urine cultures on patients with urinary catheters.
- Lamb MJ, et al. Elimination of Screening Urine Cultures Prior to Elective Joint Arthroplasty. Clin Infec Dis 2017.
- Discontinuing routine processing of screening urine cultures prior to elective joint arthroplasty resulted in substantial reduction in urine cultures ordered and antimicrobial prescriptions for asymptomatic bacteriuria, without any significant impact on incidence of prosthetic joint infection. This simple change would be scalable across institutions with potential for significant healthcare savings.
- Leis JA, et al. Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among noncatheterized inpatients: a proof of concept study. Clin Infect Dis 2014.
- This proof-of-concept study demonstrates that no longer routinely reporting urine culture results from noncatheterized medical and surgical inpatients can greatly reduce unnecessary antimicrobial therapy for ASB without additional workload for the laboratory.
- Morgan DJ, et al. Diagnostic Stewardship – Leveraging the Laboratory to Improve Antimicrobial Use. JAMA 2017.
- Suggests that implementing stewardship practices in the diagnostic testing process could positively impact the reliability of antibiotic use, reduce unintended harms, and improve the safety of care.
- Munigala S, et al. Impact of order set design on urine culturing practices at an academic medical center emergency department. BMJ Qual Saf 2017.
- Removing all urine culture orders except “urinalysis with reflex to microscopy” from frequently ordered list of tests for the ED resulting in decreasing daily urine culture rate by about half
- O’Brien WJ, et al. Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture. JAMA Netw Open 2024.
- This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.
- Petty LA, et al. Risk Factors and Outcomes Associated with Treatment of Asymptomatic Bacteriuria in Hospitalized Patients. JAMA IM 2019.
- Cohort study of ~2700 ASB patients revealed that ~83% received inappropriate antibiotic treatment, which was associated with longer lengths of hospital stays without improvements in outcomes.
- Petty LA, et al. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020.
- Cohort study of ~2400 ASB patients who received antibiotics which found that ED physicians commonly initiated urine testing and antibiotic treatment, with most antibiotics continued by inpatient providers. Antibiotic treatment in these patients was not associated with an improvement in clinical outcomes; however, it was associated with a longer length of inpatient stay and C.diff infections.
- Salazar JG, et al. Association of Screening and Treatment for Preoperative Asymptomatic Bacteriuria with Postoperative Outcomes Among US Veterans. JAMA Surg 2018.
- A national study of ~68,000 veterans showing that screening patient urine cultures for ASB prior to major surgical procedures, and subsequently treating with antibiotics, did not reduce the incidence of post-op infections and, thus, should not be continued as part of routine practice.
- Sarg M, et al. Impact of Changes in Urine Culture Ordering Practice on Antimicrobial Utilization in Intensive Care Units at an Academic Medical Center. Infect Cont Hosp Epi 2019.
- A change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.
- Schulz L, et al. Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections. J Emerg Med 2016
- Asymptomatic bacteriuria is common in all age groups and is frequently over-treated. A UTI diagnosis should be based on a cominbation of clinical symptoms and supportive laboratory information. This review will assist providers in navigating common pitfalls in the diagnosis of UTI.
- Shirley D, et al. Optimizing Inpatient Urine Culture Ordering Practices Using the Electronic Medical Record: A Pilot Study. Inf Cont Hosp Epi 2016.
- A prospective quasi-experimental before-and-after study of an electronic medical record–anchored intervention of embedded education on appropriate urine culture indications and indication selection reduced the number of urine cultures ordered for catheterized patients at an academic medical center. This intervention could be a component of CAUTI-reduction bundles.
- Stagg A, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2017.
- In the ED, urine samples collected by nurses, then saved for 48 hours, and not processed without additional physician order
- Resulted in a decrease of urine cultures processed, decreased need for patient callbacks for positive cultures, and decrease in antibiotics prescribed for a urinary indication for those admitted
- Trautner B, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter–Associated Asymptomatic Bacteriuria. JAMA 2015.
- A multifaceted educational implementation strategy in the VA to reduce urine culture ordering and inappropriate antibiotic prescribing in catheterized patients
- See Supplement- CAUTI Diagnostic Algorithm and Audit and Feedback Script
- Vaughn V, et al. Revisiting the panculture. BMJ Qual Saf 2016.
- Pan culturing for fever is costly and contributes to unnecessary cultures and inappropriate antibiotic use
- Vaughn V, et al. Addressing the Overuse of Cultures to Optimize Patient Care. Annals of Int Med 2019.
- Exploration of the mental models and social contexts that influence overuse of microbiological testing in order to help reduce over-diagnosis and over-treatment of infections.
- Vaughn V, et al. SHEA Featured Oral Abstract: Reducing Unnecessary Antibiotic Treatment for Asymptomatic Bacteriuria: A Statewide Collaborative Quality Initiative. Open Forum Inf Dis 2022.
- Across 46 hospitals within the HMS Collaborative, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement.
- Vaughn V, et al. A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria. JAMA IM 2023.
- Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize diagnostic stewardship to reduce antibiotic treatment related to ASB.