Authors: Maksudul Mowla, PharmD, Clint Borja, PharmD, BCIDP, Nicole Harrington, PharmD, BCIDP, BCPS-AQ ID, Jennifer Wolf, PharmD, BCIDP
Objective: Audience members will be able to describe the impact of stricter UARC criteria on discontinuation of antibiotics for urinary tract infection (UTI).
Background: The UARC criteria at ChristianaCare were modified to only reflex to culture if white blood cells >10 cells/hpf are present. An internal study showed a 15.2% reduction in urine cultures performed after implementation of the modified criteria.
Methods: This single-center retrospective study is an extension of the previous internal study to evaluate the impact of the modified UARC criteria on antibiotic discontinuation. Patients from the internal study who are ≥ 18 years old with an UARC performed, and an antibiotic ordered within 24 hours of an UARC order were included. Key exclusion criteria include pregnancy, transplant patients, an absolute neutrophil count of < 1000 cells/mm3, and patients receiving antibiotics for another indication.
The primary outcome is the percentage of patients with antibiotics discontinued within 24 hours of an UARC result. Key secondary outcomes include the percentage of antibiotic discontinuation within 48 hours of an UARC result, and within 24 hours of a negative urine culture.
A Chi-square test was performed to compare the primary and secondary outcomes.
Results: A randomized sample of 950 patients from the internal study was evaluated. Of these, 75 patients in the pre-cohort and 78 in the post-cohort met inclusion criteria.
The percentage of patients with antibiotics discontinued within 24 hours of an UARC result was 20% vs 23% (p = 0.64) in the pre- and post-cohort, respectively. At 48 hours, antibiotic discontinuation was 44% vs 50% (p = 0.46) between the two groups. In patients whose UARC did reflex to culture, antibiotics were discontinued within 24 hours of a negative urine culture in 67% vs 68% (p = 0.91) of patients. Stand-alone urine cultures were ordered despite a negative UARC for 2 patients in the pre-cohort and 6 in the post-cohort.
Conclusion: There was no statistical difference in the percentage of antibiotic discontinuation, though it was slightly higher in the post group (3% at 24 hours and 6% at 48 hours). These findings maybe impacted by study limitations including a small sample size and possible randomization bias. Antimicrobial stewardship principles do highlight the potential benefit of a more stringent UARC criteria, and the need for a robust analysis that includes evaluation of clinical rationale for antibiotic prescribing.
Self Assessment Question: Does the implementation of a more stringent UARC criteria always result in antibiotic discontinuation for UTI?
