Briefly describe your antimicrobial stewardship program's initiative to avoid treatment of asymptomatic bacteriuria and why this is important for patient care.

One of the first initiatives our antimicrobial stewardship program implemented was curbing treatment of asymptomatic bacteriuria (ASB).  This is important for patient care because giving antibiotics when they are not needed can result in the selection of antibiotic-resistant organisms, super infections such as Clostridioides difficile infection, and other antibiotic adverse events. Initially, we focused on generating awareness, educating clinicians, and providing patient-specific prospective audit and feedback to providers. While these approaches were helpful, it was hard to outpace the underlying cultural and systematic barriers that led to treatment of ASB. To address the root issues, we teamed up with primary stakeholders (informatics, laboratory, microbiology, and emergency medicine and hospitalist providers) to address myths, map out processes, and identify key areas of opportunity that lead to inappropriate prescribing in ASB. First, we removed inappropriate pre-checked urine cultures on order sets and optimized the lab’s automatic reflex-to-culture criteria on urinalyses. By doing this, we saw a ~40% decline in the number of urine cultures performed and a subsequent reduction in the treatment of ASB. Second, we worked with our orthopedic and cardiothoracic surgery groups to reduce routine pre-operative urine cultures in asymptomatic patients at their pre-operative appointment. Third, we collaborated with informatics to require providers to select a urinary tract infection (UTI) sign or symptom on orders for a urinalysis with culture reflex or urine culture. This helped serve as a reminder to the ordering providers and made it possible to track why urine cultures were being ordered. In our skilled nursing facility, we found ~20% of urine cultures were being ordered for nonspecific or unexplained reasons. We then worked with our medical director and team to further develop guidance in these scenarios and are currently in the process of creating a UTI order set specific to our skilled nursing facility. For all of the aforementioned strategies, what I learned most was that mapping out and evaluating the processes with key stakeholders created a sense of ownership from all involved parties and had much greater impact on cultural changes and ultimately patient care.  

How do you educate all hospital pharmacists to assess antibiotic orders and the likelihood of ASB?

For a pharmacist to know when an antibiotic is indicated, it is important to understand the signs and symptoms of a UTI. The Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America and other articles such as the Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections and Urinalysis in Acute Care of Adults: Pitfalls in Testing and Interpreting Results have been helpful in educating our pharmacists. If the antibiotic being utilized is for a suspected UTI, evaluating the chart for, or asking the provider about signs and symptoms of a UTI, is paramount to differentiating between ASB and UTI.

What does "Being Antibiotics Aware" mean to you?

"Being Antibiotics Aware" is deeply rooted in me for many reasons, but especially because I have children and fear for their future. I think “Being Antibiotics Aware” means not taking antimicrobials for granted, understanding the threat of antimicrobial resistance, and being involved in the solution. It is about finding ways to connect and influence cultural changes in both medical and non-medical societies.

What is another way all pharmacists can Be Antibiotics Aware?

All pharmacists can Be Antibiotics Aware by being curious, getting involved, and utilizing resources to continually improve knowledge and experiences related to optimal use of antibiotics. Pharmacists are in a prime position to identify patterns and processes that are contributing to suboptimal use of antibiotics. Inform your leaders and team members, and ask how you can become more involved in improving antibiotic use at your institution.   

Michael Geisler, PharmD, BCPS

Antimicrobial Stewardship Pharmacist

Memorial Regional Health Services, BJC HealthCare, Belleville & Shiloh, IL

PharmD, Southern Illinois University Edwardsville School of Pharmacy

PGY1 Residency, Indianapolis Richard L. Roudebush Veterans Affairs Medical Center