Clinical Outcomes Associated with Guideline Discordant Management of Bacteriuria in Hospitalized Patients with Neurogenic Bladder

Research Objectives: To compare outcomes associated with appropriate and inappropriate management of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) among inpatients with neurogenic bladder (NB).

Design: Multi-center, retrospective cohort study

Setting: Four VA medical centers

Participants: Veterans with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), or Parkinson’s disease (PD) hospitalized between 1/1/2017 and 12/31/2018 with ASB or UTI diagnoses, identified via ICD-10-CM codes and, for ASB diagnoses, positive urine cultures.

Interventions: Medical record review was performed for a stratified subset of patients to validate administrative ASB and UTI diagnoses with provider documentation and assign appropriate vs. inappropriate diagnosis and treatment categorizations based on national guidelines.

Main Outcome Measures: Frequencies of Clostridioides difficile infection (CDI), acute kidney injury (AKI), 90-day readmission, and multidrug-resistant organisms (MDROs) in subsequent urine cultures within 90 days, and median post-culture lengths-of-stay (LOS) were compared between those with appropriate and inappropriate management.

Results: 170 inpatients with ASB (n=51, 30%) or UTI (n=119, 70%) diagnoses were included. Most were male (85.9%) with SCI/D (n=128, 75.3%) and used bladder catheters (n=133, 78.2%). All patients with ASB diagnoses had appropriate diagnosis and most (96.1%) had appropriate treatment (i.e., no antibiotics). In contrast, 38 (31.9%) patients with UTI diagnoses had inappropriate diagnosis, including 31 (81.6%) patients with true ASB, all with inappropriate treatment. Among 81 patients with appropriate UTI diagnosis, 24 (29.6%) had inappropriate treatment, mostly inadequate antibiotics (n=22, 91.7%). For the entire cohort, 4.1% had CDI and 6.5% had AKI following ASB or UTI diagnosis; 46 (27.1%) patients were re-admitted within 90 days; 37 (21.8%) had an MDRO on subsequent urine culture. Median (IQR) post-culture length of stay was 14 (87) days. There were no significant associations between appropriate vs. inappropriate diagnosis and treatment and any outcome.

Conclusions: Almost a third of inpatients with NB and UTI diagnosis have inappropriate diagnosis and receive inappropriate treatment with antibiotics. Although this was not associated with adverse outcomes, opportunities exist to improve UTI management in hospitalized patients with NB to minimize inappropriate antibiotics.

Author(s) Disclosures: None