Documentation of clinical indications of antibiotic use is essential for antimicrobial stewardship programs (ASP) to identify targets for improvement and implement syndrome-specific interventions. In 2016, the Centers for Medicare and Medicaid Services proposed a requirement to document clinical indication at the time of antibiotic order entry. Patient safety organizations also support this requirement. We evaluated the accuracy of clinical indications documented at the time of order entry in a sample of antibiotic orders as part of a system-wide ASP initiative.
Antibiotic orders with a documented indication of “genitourinary (GU) - cystitis” were retrospectively reviewed in adult, non-neutropenic hospitalized patients at three community hospitals from April-June 2017. Accuracy of the documented indication was evaluated via chart review. Patient demographics, initial antibiotic selection, ordering service, treatment duration, and Infectious Diseases (ID) involvement were also evaluated. Data pertaining to the appropriate diagnosis of cystitis was adjudicated by an ID physician.
A total of 122 patients treated for “GU-cystitis” were reviewed (66% female, median age 77 years). Overall, only 25% of orders reviewed were consistent with cystitis per documentation in the chart. However 42% of patients had evidence of a GU infection other than cystitis. Only 16% of patients possessed criteria for diagnosis of cystitis when adjudicated by an ID physician after additional information was obtained from the chart. About 20% of patients had evidence of asymptomatic bacteriuria and 10% of patients did not have a urinalysis and/or urine culture. The majority of patients were initially prescribed a cephalosporin (70%) or fluoroquinolone (16%). The emergency department was responsible for 52% of orders labeled as cystitis.
Cystitis was inaccurately selected as the indication for most of the orders reviewed. To improve accuracy, minimize provider fatigue, and provide better utility to ASP’s, the list of available indications should be simplified to include broader terms (i.e. GU instead of GU-cystitis). Appropriate diagnosis and treatment of cystitis remains a challenge and a target for improvement for ASPs.
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