LOS UTI ABx
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Clinical Question
In adult patients requiring hospital admission, does the utilization of 4 quality improvement markers improve hospital length of stay.
Bottom Line
Using the 4 QI markers in the trial demonstrated a decreased hospital length of stay, largely driven by following local antimicrobial prescribing guidelines and early switching from IV to oral therapy when the patient meets criteria.
Major Points
Antimicrobials are a finite resource, each and every dose we use today will be one-less we have available the future; medical science stuck its nose in an arms race that was already occurring on the cellular level between these organisms and their learned resistance is a natural process in the life of these microorganisms. Appropriate antimicrobial use has been demonstrated to improve clinically relevant outcomes such as mortality and ICU admission.
This retrospective chart review compared patients that received 4 quality improvement (QI) markers for urinary tract infections: urine culture collected prior to initiation of treatment, empiric antibiotics in accordance with guidelines, step-down from intravenous to oral treatment within 72 hours, and tailoring therapy based on culture results. They reviewed a total of 1252 patients and found that for patients that received all 4 QI markers a significant short length of hospital stay of 7.2 days as compared to 9.3 days for those that did not. This was largely driven by prescribers adhering to local empiric guidelines (LOS 7.3 vs. 8.7 days, P = 0.02) —interesting there was no affect when comparing the national Dutch guidelines— and step-down from IV to oral within 72 hours (LOS 4.8 vs 9.1 days, P < 0.001).
There are limitations with this trail with its retrospective design, no severity of illness was determined, and that some of the QI interventions were interdependent. This does however show that implementation of a QI bundle can improve clinical important outcomes for patients when treating UTI.
Design
- Multicenter, observational, retrospective, cohort study
- N=1252
- Urine culture (n=1284)
- Guideline antibiotics (n=1165)
- IV to PO step-down within 72 hours (n=542)
- tailoring therapy (n=850)
- Setting: 19 university, teaching, and nonteaching hospitals in the Netherlands
- Enrollment: February to November 2009
- Primary Outcome: Length of stay
Population
Inclusion Criteria
- adults (aged ≥16 years)
- admitted / diagnosed with a complicated UTI
- defined as: catheter-associated UTIs, male sex, any functional or anatomical abnormality of the urinary tract, pregnancy, immunocom- promising disease or medication, or a UTI with symptoms of tissue invasion or systemic infection (pyelonephritis, urosepsis, prostatitis)
- whom antibiotic therapy initiated
Exclusion Criteria
- hospital-acquired UTIs
- UTIs without Dutch national guideline treatment recommendations (ie, UTIs in patients with a nephrostomy or after a urological procedure)
- treatment for concurrent infection
- transfer from/to another hospital
- direct admission to ICU
Baseline Characteristics
- Mean age: 63 years
- male 41%
- Comobidities: Urological 22.9%, Other (CVD, DM, CKD, etc) 48.8%
- Admission: Mean hospital length of stay 8 days, ICU 2.9%
- in-hospital mortality: 2.6%
Interventions
- Patients who had 4 quality indicators of urinary tract infection care[1]:
- 1) Urine culture collected prior to initiation of treatment
- 2a) Empiric antibiotics in accordance with national Dutch guidelines
- 2b) Empiric antibiotics in accordance with local hospital guidelines
- 3) step-down from intravenous to oral treatment within 72 hours
- 4) tailoring therapy based on culture results
Outcomes
Comparisons are QI interventions vs. No QI intervention.
Primary Outcomes
- Length of stay for all QI components
- 7.2 days vs. 9.3 days, P < 0.05
Secondary Outcomes
Quality Improvement markers
- 1) Urine culture collected prior to initiation of treatment
- n=1250, 80.2%
- LOS 8.1 vs 7.4 days, P = 0.16
- 2a) Empiric antibiotics in accordance with national Dutch guidelines
- n=1167, 65.6%
- LOS 7.6 vs. 8.5 days, P = 0.32
- 2b) Empiric antibiotics in accordance with local hospital guidelines
- n=983, 46.3%
- LOS 7.3 vs. 8.7 days, P = 0.02
- 3) step-down from intravenous to oral treatment within 72 hours
- n=543, 54.3%
- LOS 4.8 vs 9.1 days, P < 0.001
- 4) tailoring therapy based on culture results
- n=851, 71.7%
- LOS 8.7 vs. 9.0 days, P = 0.92
Criticisms
- Retrospective chart-review design
- severity of illness outside of ICU admission was determined
- correlation but not causation may be drawn from this trial
Funding
- Zon/MW, the Netherlands Organisation for Health Research and Development (project 993002)