title: Urine culture guided antibiotic interventions: A pharmacist driven antimicrobial stewardship effort in the ED.
abstract: BACKGROUND
  Antibiotics are overprescribed for abnormal urine tests including asymptomatic bacteriuria (AB), contributing to rising antimicrobial resistance rates. Pharmacists reviewed urine cultures daily from emergency department (ED) encounters to assess antibiotic appropriateness. We studied antibiotic prescribing practices and assessed compliance to national guidelines, correlations with urine analysis (UA) components, and opportunities for antimicrobial stewardship in the ED.
  
  
  METHODS
  This quality improvement project (QIP) was a prospective cohort study at a community hospital ED, with data collected from finalized urine cultures resulting October 30, 2014 through January 5, 2015. Analyses were conducted using Chi-squared and Fisher Exact tests and stepwise multiple logistic regression.
  
  
  RESULTS
  Urine cultures from 457 encounters were reviewed, of which 136 met the inclusion criteria as non-pregnant and asymptomatic for urinary tract infection (UTI). 43% of 136 patients were treated with antibiotics, for a total of 426 antibiotic days. Pharmacist interventions for these patients resulted in 122/426 (29%) of potential antibiotic days saved. Factors found to significantly increase the odds of antibiotic prescribing in asymptomatic patients included presence of leukocyte esterase (OR=4.5, 95% CI: 1.2-17.2; p=0.03) or nitrites (OR=10.8, 95% CI: 1.7-68.1; p=0.01) in the urine and age≥75 (OR=3.5, 95% CI: 1.2-9.6, p=0.02).
  
  
  CONCLUSIONS
  Pharmacist intervention in discontinuing or modifying antibiotics for asymptomatic patients with urine cultures reduced unnecessary antibiotic exposure and was a first step in antimicrobial stewardship efforts in the ED. Future work includes limiting urine tests and subsequent antibiotic therapy for non-pregnant asymptomatic patients.
authors.affiliation: Department of Pharmacy, MultiCare Auburn Medical Center, 202 North Division Street, Auburn, WA 98001, USA. Electronic address: Cassie.Zhang@multicare.org.
authors.forename: Xi
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Department of Pharmacy, MultiCare Auburn Medical Center, 202 North Division Street, Auburn, WA 98001, USA. Electronic address: Nicole.Rowan@multicare.org.
authors.forename: Nicole
authors.initials: N
authors.lastname: Rowan
authors.affiliation: MultiCare Institute for Research & Innovation, 314 MLK Jr. Way, Suite 402, Tacoma, WA, 98405, USA. Electronic address: Bethann.Pflugeisen@multicare.org.
authors.forename: Bethann Mangel
authors.initials: BM
authors.lastname: Pflugeisen
authors.affiliation: Department of Pharmacy, MultiCare Auburn Medical Center, 202 North Division Street, Auburn, WA 98001, USA. Electronic address: Sanjin.Alajbegovic@multicare.org.
authors.forename: Sanjin
authors.initials: S
authors.lastname: Alajbegovic
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D058345:Asymptomatic Infections; D001437:Bacteriuria / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology; D002265:Carboxylic Ester Hydrolases / Q000652:urine; D015331:Cohort Studies; D046508:Culture Techniques; D004636:Emergency Service, Hospital; D005260:Female; D006764:Hospitals, Community; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009573:Nitrites / Q000652:urine; D016017:Odds Ratio; D010595:Pharmacists; D010818:Practice Patterns, Physicians'; D024382:Professional Role; D011446:Prospective Studies; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D009573:Nitrites; C021443:leukocyte esterase; D002265:Carboxylic Ester Hydrolases
keywords: Antimicrobial stewardship; Asymptomatic bacteriuria; Emergency; Urine