Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting.
OBJECTIVE
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.


METHODS
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).


RESULTS
Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .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 (P<.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.


CONCLUSIONS
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.
Department of Medicine, Division of Infectious Diseases, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America.
Michelle T
MT
Hecker
School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America.
Clinton J
CJ
Fox
Department of Pharmacy, MetroHealth Medical Center, Cleveland, Ohio, United States of America.
Andrea H
AH
Son
Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America.
Rita K
RK
Cydulka
Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America.
Jonathan E
JE
Siff
Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America.
Charles L
CL
Emerman
Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, United States of America.
Ajay K
AK
Sethi
Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, United States of America.
Christine P
CP
Muganda
Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, United States of America.
Curtis J
CJ
Donskey
D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003556:Cystitis / Q000175:diagnosis / Q000188:drug therapy*; D004636:Emergency Service, Hospital; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011704:Pyelonephritis / Q000175:diagnosis / Q000188:drug therapy*; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000188:drug therapy*
D000900:Anti-Bacterial Agents