title: Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria.
abstract: OBJECTIVE
  Overtreatment of asymptomatic bacteriuria (ASB) in patients with urinary catheters remains high. Health care professionals have difficulty differentiating cases of ASB from catheter-associated urinary tract infections.
  
  
  OBJECTIVE
  To evaluate the effectiveness and sustainability of an intervention to reduce urine culture ordering and antimicrobial prescribing for catheter-associated ASB compared with standard quality improvement methods.
  
  
  METHODS
  A preintervention and postintervention comparison with a contemporaneous control group from July 2010 to June 2013 at 2 Veterans Affairs health care systems. Study populations were patients with urinary catheters on acute medicine wards and long-term care units and health care professionals who order urine cultures and prescribe antimicrobials.
  
  
  METHODS
  A multifaceted guidelines implementation intervention.
  
  
  METHODS
  The primary outcomes were urine cultures ordered per 1000 bed-days and cases of ASB receiving antibiotics (overtreatment) during intervention and maintenance periods compared with baseline at both sites. Patient-level analysis of inappropriate antimicrobial use adjusted for individual covariates.
  
  
  RESULTS
  Study surveillance included 289,754 total bed-days. The overall rate of urine culture ordering decreased significantly during the intervention period (from 41.2 to 23.3 per 1000 bed-days; incidence rate ration [IRR], 0.57; 95% CI, 0.53-0.61) and further during the maintenance period (to 12.0 per 1000 bed-days; IRR, 0.29; 95% CI, 0.26-0.32) (P < .001 for both). At the comparison site, urine cultures ordered did not change significantly across all 3 periods. There was a significant difference in the number of urine cultures ordered per month over time when comparing the 2 sites using longitudinal linear regression (P < .001). Overtreatment of ASB at the intervention site fell significantly during the intervention period (from 1.6 to 0.6 per 1000 bed-days; IRR, 0.35; 95% CI, 0.22-0.55), and these reductions persisted during the maintenance period (to 0.4 per 1000 bed-days; IRR, 0.24; 95% CI, 0.13-0.42) (P < .001 for both). Overtreatment of ASB at the comparison site was similar across all periods (odds ratio, 1.32; 95% CI, 0.69-2.52). When analyzed by type of ward, the decrease in ASB overtreatment was significant in long-term care.
  
  
  CONCLUSIONS
  A multifaceted intervention targeting health care professionals who diagnose and treat patients with urinary catheters reduced overtreatment of ASB compared with standard quality improvement methods. These improvements persisted during a low-intensity maintenance period. The impact was more pronounced in long-term care, an emerging domain for antimicrobial stewardship.
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas2Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Barbara W
authors.initials: BW
authors.lastname: Trautner
authors.affiliation: Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Larissa
authors.initials: L
authors.lastname: Grigoryan
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas4Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texa.
authors.forename: Nancy J
authors.initials: NJ
authors.lastname: Petersen
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas4Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texa.
authors.forename: Sylvia
authors.initials: S
authors.lastname: Hysong
authors.affiliation: Department of Medicine, South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Affairs Hospital, San Antonio6Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center at San Antonio.
authors.forename: Jose
authors.initials: J
authors.lastname: Cadena
authors.affiliation: Department of Medicine, South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Affairs Hospital, San Antonio6Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center at San Antonio.
authors.forename: Jan E
authors.initials: JE
authors.lastname: Patterson
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Aanand D
authors.initials: AD
authors.lastname: Naik
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001437:Bacteriuria / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D008297:Male; D010818:Practice Patterns, Physicians'; D019564:Unnecessary Procedures; D014546:Urinary Catheterization / Q000009:adverse effects*; D014728:Veterans / Q000706:statistics & numerical data