Ingalls Emily M, Veillette John J, Olson Jared, May Stephanie S, Dustin Waters C, Gelman Stephanie S, Vargyas George, Hutton Mary, Tinker Nick, Fontaine Gabriel V, Foster Rachel A, Stallsmith Jena, Earl Ali, Buckel Whitney R, Vento Todd J
Intermountain Medical Center, Murray, UT, USA.
Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA.
Hosp Pharm. 2023 Aug;58(4):401-407. doi: 10.1177/00185787231159578. Epub 2023 Mar 5.
Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.
尿路感染（UTIs）在急诊科（ED）存在过度诊断和过度治疗的情况，这导致了不必要的抗生素暴露和可避免的副作用。然而，缺乏描述有效的大规模抗菌药物管理计划（ASP）干预措施以改善急诊科尿路感染和无症状菌尿（ASB）管理的数据。我们在犹他州和爱达荷州的23家社区医院急诊科实施了多方面干预措施，包括对急诊科开处方者进行面对面教育、更新电子医嘱集，以及为我们的医疗系统实施/传播尿路感染指南。我们将2021年（干预后）急诊科尿路感染抗生素处方情况与2017年（干预前）的基线数据进行了比较。主要结局是膀胱炎患者使用氟喹诺酮类药物或延长抗生素疗程（>7天）的百分比。次要结局包括符合无症状菌尿标准的尿路感染治疗患者百分比，以及14天内与尿路感染相关的再入院率。膀胱炎延长治疗疗程的情况（29%对12%，<0.01）以及使用氟喹诺酮类药物治疗膀胱炎的情况（32%对7%，<0.01）均有显著下降。干预后，符合无症状菌尿标准的尿路感染治疗患者百分比没有变化（干预前为28%，干预后为29%，P = 0.97）。亚组分析表明，无症状菌尿的处方在不同医疗机构（范围为11%-53%）和不同提供者（范围为0%-71%）之间差异很大，且由少数高处方者主导。该干预措施与改善膀胱炎的抗生素选择和疗程有关，但未来可能需要采取干预措施来改善尿液检测并提供个性化的处方者反馈，以改善无症状菌尿的处方实践。
