BACKGROUND

DISCLOSURES: The authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities

Shreena Patel Advani1, PharmD, Saira Rab1, PharmD, BCPS, AQ-ID, Ameeta Kalokhe2, MD 1Grady Health System Department of Pharmacy and Drug Information Atlanta, Georgia

2Emory University School of Medicine Department of Medicine Atlanta, Georgia

Assessing the Management of Urinary Tract Infections at a Large, Urban Teaching Hospital

RESULTS

METHODS Urinary tract infections (UTIs) are among the most prevalent of infectious diseases1

Economic impact associated with the management of UTIs is projected to exceed 1 billion dollars1

UTIs account for approximately 100,000 hospitalizations per year2

UTIs encompass a host of conditions affecting the upper and lower urinary tracts

The Infectious Diseases Society of America (IDSA) has published guidelines outlining the appropriate diagnosis and management of UTIs

Grady Health System (GHS) has recently updated their institution specific, inpatient UTI management guidelines

Despite these institution specific recommendations, variability in the diagnosis and treatment of UTIs at GHS has been noted

The purpose of this project is to evaluate current management of UTIs at GHS

Grady Health System’s Empiric Treatment Guideline for Urinary Tract Infections4

Category Definition Empiric Treatment Definitive Treatment

Community acquired UTI

Signs/symptoms for cystitis = frequency, urgency, dysuria, suprapubic pain Signs/symptoms for pyelonephritis = cystitis PLUS costovertebral angle pain and tenderness or fever Urinalysis with leukocyte esterase/nitrite PLUS pyuria (WBC > 10) PLUS Clinical signs/symptoms

First Line Ceftriaxone 1 g q24h Severe Beta-Lactam Allergy (Anaphylaxis, throat swelling) Aztreonam 2 g q8h -------------------------------------------------- Consider vancomycin 15 mg/kg x 1 dose, then pharmacy to dose, if there is suspicion for Enterococcus UTIs

Convert to an oral regimen active against the organism with resolution of sepsis. Preferred therapy IF susceptible to these agents: Gram-negative organisms – TMP-SMX DS 1 tab BID or Cephalexin 500 mg QID Gram-positive organisms of Streptococcus and Enterococcus species – Amoxicillin 500 mg TID Treatment of culture negative pyelonephritis: Ciprofloxacin 500 mg PO BID or TMP/SMX 1 DS tablet PO BID Duration: 7-14 days, consider shorter duration of therapy in patients with resolution of symptoms within 72 hours. Longer duration is not associated with improved clinical cure but is associated with increased drug resistance.

Hospital acquired or healthcare

associated UTI

First Line Piperacillin-tazobactam 4.5 g q6h Second Line Cefepime 1 g q12h + Vancomycin 15 mg/kg x 1 dose, then pharmacy to dose Severe Beta-Lactam Allergy (Anaphylaxis, throat swelling) Aztreonam 2 g q8h +/- Tobramycin 5 mg/kg; pharmacy to dose + Vancomycin 15 mg/kg x 1 dose then pharmacy to dose, if there is suspicion for Enterococcus UTIs

Catheter associated UTI (CA-UTI)

Signs/symptoms: new onset fever, rigors, altered mental status, flank pain/tenderness, hematuria PLUS presence of >100,000 cfu of >1 bacterial species in a single catheter urine specimen Spinal cord injury: signs/symptoms include increased spasticity, autonomic dysreflexia, sense of unease Pyuria, cloudy or malodourous urine are not diagnostic of CA-UTI

Catheter Management • Discontinuation of catheter will remove source of infection as is preferred • Replacement of catheter Treatment • Based on urine culture and susceptibilities; if unavailable, base treatment on previous cultures if available • Treat as cystitis pending urine culture and susceptibilities • Treatment without removal of catheter may increase risk of relapse and resistance Duration • may be for 7 days in patients with quick resolution of symptoms

Study design: • First phase (August – October 2013): retrospective chart review for all patients with a urinalysis (UA)

• Intervention phase (November – December 2013): education for hospital staff to promote awareness of appropriate UTI management strategies

• Post-intervention phase (January – March 2013): concurrent chart review with real-time feedback for physicians managing UTIs

Participants: • Inclusion criteria: 18 years or older, UA ordered from August 1, 2013 – October 31, 2013 and January 1, 2014 – March 31, 2014

• Exclusion criteria: patients in the step down or intensive care units, initial UAs ordered on a weekend day, UAs ordered for evaluation of non-infectious conditions

• Sample size: 200 patients

REFERNCES: 1. Colgan, Richard et al. Asymptomatic Bacteriuria in Adults. American Family Physician, 2006 September 15; 74(6): 985-990. 2. Gupta, Kalpana et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical infectious Diseases, 2011; 52(5): e103-e120. 3. Nicolle, Lindsay E et al. Infectious Diseases Society of America Guidelines for the diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clinical Infectious Diseases, 2005; 40: 643-654. 4. Wong, Jordan, Kandiah, Sheetal. Empiric Inpatient Treatment Guideline for Urinary Tract Infections/Pyelonephritis. http://gradynet.gmh.edu/DocumentsandResources /Documents/Grady Antiobiotics/Grady Inpatient UTI Treatment Guidelines.pdf, April 3, 2013.

OUTCOMES Outcome measures:

• Primary: • Percentage of UTIs managed in compliance with GHS guidelines before and after pharmacist-driven educational interventions

• Secondary: • Percentage of UTIs in compliance with GHS guideline-based empiric antibiotic selection

• Percentage of UTIs in compliance with GHS guideline-based duration of therapy

• Total cost savings associated with antibiotic use

Average Duration of Therapy

Study Phase Days, SD

Pre-intervention 11.3 ± 3

Post-intervention 10.5 ± 3

Potential Cost Savings

Savings From 8 Interventions Dollars ($)

7 day course 483.42

14 day course 966.84

Estimated Annual Savings Dollars ($)

7 day course 5,041.38

14 day course 10,082.76

Percentage of UTIs Managed in Compliance with GHS Guidelines

Pre-intervention Phase (n=100) 86%

Post-intervention Phase (n=100) 90%

Percentage of UTIs Managed in Compliance with GHS Guidelines (excluding UAs ordered for non-specified reasons)

Pre-intervention Phase (n=39) 64%

Post-intervention Phase (n=42) 76%

•  Number of UTIs managed in compliance with GHS guidelines trended up after intervention (86% vs 90% P=0.512)

•  Primary outcome results potentially confounded by the indication for UA •  A majority of UAs were ordered for unspecified reasons during both the pre- and post-

intervention phases •  If antibiotics were not initiated on UAs ordered for non-specified reasons, these

encounters were deemed managed in-compliance with GHS guidelines •  Duration of therapy was in adherence to GHS guidelines both before and after

intervention

•  Non-guideline based empiric antibiotic selection trended down after intervention (66% vs 76% P=0.497)

•  Small cost savings noted from real-time feedback component