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June/July 2013
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EIN Update: Asymptomatic Bacteriuria and Antimicrobial Stewardship

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds EIN. The reader assumes all risks in using this information.

EIN members recently discussed addressing asymptomatic bacteriuria in hospitalized patients, an increasingly important topic given concerns about antibiotic misuse and overuse. A member in Texas asked if others “have an initiative at their institutions to eliminate or limit the treatment of asymptomatic bacteriuria as part of their antibiotic stewardship program.”

“As part of our institution-specific ‘ID Treatment Guidelines,’ available to clinicians in our health system via the intranet, we have long offered a guideline on asymptomatic bacteriuria, to which we allude in various teaching presentations on antibiotic use,” an EIN respondent in Illinois wrote. “There usually are hyperlinks that guide clinicians rapidly to extramural resources—e.g., the IDSA guideline—and to tables listing restricted drugs, important drug interactions, and recommendations for renal dose adjustment.

“While this problem seems less frequent in recent years, it still does occur,” the member added.

A respondent in Florida described another approach: “We've been spelling out when to screen for urinary tract infections (UTIs), when not to screen, and when to treat and not treat, whenever we get a consultation for this,” the member wrote. “We also have been educating our hospitalists and house staff.”

The ability to provide electronic consults for quick questions, like what to do about a positive urine culture, “has improved our contact with practitioners with whom we have less direct contact, such as those in ambulatory care. Awareness seems to be slowly increasing, but it's the comfort level with not treating a positive culture that may lag when you don't see your patient every day.”

A respondent in Iowa described an institution’s analysis of antimicrobial use in patients undergoing total hip or total knee arthroplasty, which found that a large percentage “received treatment for ‘UTIs,’ ” which was driven by a positive leukocyte esterase, the member wrote. “When we showed the data to a new surgeon who does total joint arthroplasties, he immediately changed the protocol. Patients who have a positive leukocyte esterase and positive nitrite now have a urine culture. If the urine culture is positive for > 100,000 colony-forming units (CFUs) of a single organism, the patient is treated. We are assessing the change in antimicrobial use.”

An EIN member in North Carolina also weighed in. “I think that most treatment for asymptomatic bacteriuria actually happens in situations where the clinician doesn't realize it's asymptomatic bacteriuria,” the member wrote. “There are a lot of sick / symptomatic patients who coincidentally have bacteriuria and pyuria, and the clinician misattributes nonspecific symptoms to their urinalysis (UA)/urine culture results (UCx).”

The member noted that “in many cases, clinicians don't regard the absence of urinary symptoms as a way to lower their pretest probability of a UTI -- so they treat just based on the testing results. This probably happens far more commonly than treatment of a truly asymptomatic patient whose UA/UCx was done just for screening.”

Similarly, treatment is often driven by automatic responses to automatic notifications, such as nurses or lab techs who call on-call physicians with test results, a respondent in New Mexico added. “With the volume of calls, the lack of personal knowledge of the patient (on both ends), an order is entered as the easiest way to settle the encounter. One response is to address the set points for lab notifications to reduce the load of calls that do not need actual responses.”

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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