Effect of a Stewardship Intervention on Adherence to Uncomplicated Cystitis and Pyelonephritis Guidelines in an Emergency Department Setting

<div><p>Objective</p><p>To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.</p><p>Methods</p><p>The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).</p><p>Results</p><p>Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (<i>P</i>≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (<i>P</i><.001 and <i>P</i> = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (<i>P</i><.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.</p><p>Conclusions</p><p>A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.</p></div

Percentage of cases deemed unlikely or rejected at baseline and during the tiered stewardship intervention.

<p>The percentages in the boxes are the average of the 4 time points during each period.</p

Patient characteristics by study time period.

<p>Data are no. or proportion (%) of patients, unless otherwise indicated.</p>a<p>Renal conditions include history of kidney stones, recent acute or chronic kidney disease, urinary incontinence with or without previous surgery for this condition.</p>b<p>STI, sexually transmitted infection.</p>c<p>Documented post-menopausal status or age > 50 if status not documented.</p

Antibiotic use, treatment failures, and adverse events for study patients at baseline and during intervention Period 1 and Period 2.

a<p>Including only trimethoprim-sulfamethoxazole and ciprofloxacin containing regimens.</p>b<p>A change in the initially prescribed UTI treatment regimen within 2 weeks of prescription due to clinical failure, isolation of a resistant organism, or adverse effects.</p>c<p>Including allergic reactions, gastrointestinal side effects, and vaginal yeast infections occurring within 8 weeks of treatment and felt to be related to the antibiotic prescribed for UTI.</p>d<p>Including return visits to the ED or other hospital sites for persistence of UTI symptoms or for additional treatment for alternative diagnoses related to UTI symptoms, missed STI diagnoses, or for treatment of a recurrent UTI (separate from initial UTI) occurring within 8 weeks of the initial ED visit.</p

Percentage of cases adherent to UTI guidelines at baseline and during the tiered stewardship intervention.

<p>The percentages in the boxes are the average of the 4 time points during each period.</p