92 - Successful Scale-up of an Intervention to Decrease Unnecessary Urine Cultures Led to Improvements in Antibiotic Use

Background: We previously conducted a successful single-site intervention to improve compliance with antibiotic stewardship guidelines for asymptomatic bacteriuria (ASB).  In this dissemination project we explored whether we could facilitate antibiotic stewardship for ASB at a distance, in four distant VA medical centers.

Methods: Each site champion received a decision-aid algorithm, interactive teaching based on actual cases, and support with data collection. The focus of the intervention was on teaching providers in acute and long-term care to avoid ordering unnecessary urine cultures. We measured DOT (days of antibiotic therapy), LOT (length of antibiotic therapy) and urine cultures ordered per 1,000 bed-days monthly in the intervention sites and four matched control sites. Both DOT and LOT captured all systemic antibiotics initiated on day -1 to +2 of a urine culture order. We conducted segmented regression analyses for the three outcomes for the intervention and control sites separately, and difference in differences analysis for urine cultures.

Results: Over the baseline and intervention years, 12,260 urine cultures were ordered in 6823 unique patients in the acute and long-term care wards at the 8 sites. During the baseline year, the average urine-culture related DOT was 45.1 and LOT was 34.7, per 1000 bed-days. Both DOT and LOT decreased significantly over the intervention period in the intervention sites (p < 0.05 for both); a significant decrease was not seen in the control sites (Figures 1 and 2).  For urine cultures, at baseline the average number of cultures ordered per month per 1000 bed-days was 13.6. Both intervention and control sites saw a significant decrease in urine cultures over the baseline year.  In the intervention year, urine cultures continued to decrease in the intervention sites (p=0.001) but increased in the control sites (Figure 3).Figure 1. Days of Therapy (DOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture
Figure 2. Length of Therapy (LOT) per 1,000 bed-days, for antibiotics started within -1 to +2 days of a urine culture
Figure 3. Urine Cultures per 1,000 bed-days


Conclusion: Our externally-facilitated intervention significantly decreased local antibiotic use (both DOT and LOT) and urine cultures. Unnecessary urine cultures are a major driver of unnecessary antibiotic use for ASB, and our focus on diagnostic stewardship for urine cultures led to antibiotic stewardship. Our next step will be to further disseminate our intervention to other VA facilities.

Co-Author(s)

• LG

  Larissa Grigoryan, MD, PhD

  Assistant Professor
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• JV

  John Van, BA

  Research Coordinator
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• DR

  David J. Ramsey, PhD

  Sr. Biostatistician
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• MG

  Melanie Goebel, MD

  Assistant Professor
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• AW

  Annette Walder, MS

  Statistician
  Center for Innovations in Quality, Effectiveness and Safety
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• JK

  Jennifer Kramer, MPH, PHD

  Associate Professor
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• AC

  Andrew Chou, MD

  Assistant Professor
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• PP

  Payal K. Patel, MD, MPH

  Dr.
  University of Michigan
  Ann Arbor, Michigan

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• CG

  Christopher J. Graber, MD, MPH

  Associate Clinical Professor of Medicine
  VA Greater Los Angeles Healthcare System/UCLA
  Los Angeles, California

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• PL

  Paola Lichtenberger, M.D

  Associate Professor of CLinical Medicine
  University of Miami MIller School of Medicine
  Miami, Florida

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• SW

  Steven Wiseman, PharmD

  Pharmacist
  VA Ann Arbor Healthcare System
  Ann Arbor, Michigan

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• BS

  Bhavarth Shukla, MD, MPH

  Assistant Professor
  University of Miami
  Miami, Florida

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• 

  Dimitri M. Drekonja, MD, MS

  Dr.
  Minneapolis Veterans Affairs Health Care System
  Minneapolis, MN

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• FC

  Feliza Calub, NP

  Nurse Practitioner
  VA Greater Los Angeles Healthcare System
  Los Angeles, California

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
• AN

  Aanand Naik, MD

  Professor
  Baylor College of Medicine
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Presenting Author(s)

• 

  Barbara Trautner, MD, PhD

  Professor of Medicine
  Michael E DeBakey VA Medical Center
  Houston, Texas

  Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

  Slides Slides and Audio