Urine Culture Optimization: A Powerful Antimicrobial Stewardship Strategy
Background: Inappropriate collection of urine cultures (UC) has the potential to increase the likelihood of antimicrobial prescription for asymptomatic bacteriuria. Antimicrobial overuse can lead to increased cost, mortality and morbidity related to antimicrobial resistance and Clostridium difficile. We postulated that a quality improvement strategy to optimize collection of UCs would effectively reduce the unnecessary use of antibiotics.
The Antimicrobial Stewardship (ASP) team at our hospital initiated interventions aimed at optimizing UC collection in our Emergency Department(ED). Our interventions consisted of a creation of a Working Group involving the ED staff and an Infection Preventionist (IP) trained in Frontline Ownership (FLO) techniques. Thinking sessions involving staff were facilitated by the same IP utilizing FLO principles; the sessions reviewed process, policy and encouraged UC utilization dialogue. Session summaries and UC volume run charts were shared biweekly serving as continuous feedback to the ED. Antimicrobial use was determined through financial charge data and standardized as defined daily doses/1000 patient days.
Pre-intervention UC rate was (0.09 per ED patient visit) compared to after intervention (0.06 per ED patient visit), representing a 24% reduction (p<0.002) (Figure 1). Use of ciprofloxacillin in the ED from 9.8 to 8.0 (DDD/1000 ED Visits) an 18 %( p=0.02) reduction (Figure 2).
Our intervention in the ED using FLO methodology, effectively reduced UC testing and in turn reduced the ciprofloxacin. Our novel intervention represents an upstream approach to ASP, capitalizing on frontline staff engagement in stewardship interventions. Optimizing microbiologic evaluation is an important stewardship tool to prevent inappropriate use of antimicrobial agents.
Figure 1: Urine Culture (UC) testing reduction in the Emergency Department(ED) 2013 from pre-intervention UC rate was (0.09 per ED patient visit) compared to after intervention (0.06 per ED patient visit) a 24% reduction (p<0.002).
Figure 2: A reduction of Ciprofloxacillin's Daily Defined Dose (DDD) for the Emergency Department in 2013 from pre-intervention mean 9.8 (DDD/1000 ED Visits) to post intervention mean of 8.0(DDD/1000 ED Visits) an 18 %( p=0.02) reduction