1852. Rethinking Empirical Treatment for Urinary Tract Infections in the Outpatient Setting
Session: Poster Abstract Session: Antimicrobial Stewardship: Outpatient Settings
Saturday, October 6, 2018
Room: S Poster Hall
Posters
  • GMA.UTI_ID_Week_Poster_091418_FINAL.pdf (396.7 kB)
  • Background: Antibiograms can be useful for guiding empirical treatment. The Tufts Medical Center microbiology laboratory generates an antibiogram for the adult primary care (PC) clinic consisting of urinary isolates of E. coli to guide empirical treatment for UTI. Standard antibiograms arranged by organism are of limited utility for infections like UTI which are caused by a wide array of bacteria. Furthermore, some providers only send urine cultures from patients after clinical failure. This results in overestimation of resistance.

    Methods: For 2 months, PC clinicians were instructed to alter practice by sending a UA with reflex to culture for all patients suspected of having UTI. A retrospective chart review collected antibiotic prescriptions, UA and culture results. We generated a combination UTI-specific antibiogram (CUSA) based on data from all urine cultures sent from this clinic. Using the CUSA we developed an empirical UTI treatment algorithm and evaluated prescribing trends before and after its implementation.

    Results: The CUSA as compared with the E. coli urinary antibiogram for the PC clinic is shown in Table 1. Distribution of organisms is represented by Figure 1. Based on the CUSA, a treatment algorithm was developed that included preference for nitrofurantoin and TMP/SMX for patients with cystitis, and allowed for use of TMP/SMX even in pyelonephritis cases without risk factors for resistance. Cephalosporins were advised over fluoroquinolones. Of 304 patients in whom urine cultures were sent pre-implementation, 178 empirical antibiotic prescriptions were written, while 126 were written for 388 patients after implementation. Nitrofurantoin prescriptions increased (47% to 55%), TMP/SMX (19%) and cephalosporin use (4%) remained the same, and fluoroquinolone prescribing decreased (28% to 20%).

    Conclusion: We used a CUSA to develop a treatment guideline more reflective of our causative pathogens and institutional resistance patterns. We saw a shift in usage from antibiotics with more to antibiotics with less collateral damage.

    Table 1: E. coli urine antibiogram vs. CUSA

    Amox

    Amox/Clav

    Cephalexin

    Cefpodoxime

    Cipro

    TMP/SMX

    Nitrofurantoin

    PC Urine E. coli Antibiogram (99)

    54

    62

    82

    84

    82

    77

    98

    CUSA (157)

    69

    78

    86

    97

    83

    86

    87

    Figure 1

    Macintosh HD:Users:Wiz:Desktop:Screen Shot 2018-05-01 at 2.47.08 PM.png

    Christopher Wisnik, MS1, Gabriela M Andujar Vazquez, MD2, Kirthana R. Beaulac, PharmD3 and Shira Doron, MD, MS, FIDSA2, (1)Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, (2)Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, (3)Department of Pharmacy, Tufts Med. Ctr., Boston, MA

    Disclosures:

    C. Wisnik, None

    G. M. Andujar Vazquez, None

    K. R. Beaulac, None

    S. Doron, None

    Findings in the abstracts are embargoed until 12:01 a.m. PDT, Wednesday Oct. 3rd with the exception of research findings presented at the IDWeek press conferences.