Unnecessary treatment of asymptomatic bacteriuria (AB) is an individual and public health problem and a target for antibiotic stewardship. Although there is clear evidence against treating AB in most patients, the definition of “asymptomatic” is unclear when applied to acutely ill patients in an Emergency Department (ED) where a broad range of presenting symptoms could be potentially attributed to a urinary tract infection (UTI) and result in antibiotic treatment. This study examines the range of presenting signs and symptoms that trigger initiation of antibiotics in patients being admitted to the hospital with a diagnosis of UTI.
During 4 weeks in 4 contiguous months, we identified all adults who were admitted from the ED who had pyuria, nitrites or leukocyte esterase on urinalysis (UA) obtained in the ED. We reviewed the charts, electronic records, and laboratory data of all who received antibiotics in the ED excluding those treated for non‐urinary tract infections. We determined whether patients had symptomatic bacteriuria, defined liberally as the presence of any of the following: dysuria, increased frequency, urinary retention or incontinence, lower abdominal/flank pain, fever or leukocytosis), or whether they had asymptomatic bacteriuria.
During the study period 1163 patients were admitted to the hospital. Of those, 502 (43%) had a UA in the ED. 169 (37%) of these UAs were positive for pyuria, nitrites or leukocyte esterase. Among these, 138 (82%) received antibiotics in the ED for a diagnosis of UTI (97) or another infection with or without a UTI (41). 56 of the 97 patients (58%) treated for UTI had symptomatic bacteriuria according to the study definition. However, 41 (42%) were treated for UTI in the absence of urinary symptoms or systemic signs of infection, and none of these 41 had an indication to treat asymptomatic bacteriuria (pregnancy or planned urogenital surgery). After admission 78% of these 41 patients continued treatment for an average of 3‐4 days. Patients in this group presented with a variety of complaints (Table).
Nearly half of the patients diagnosed with a UTI in the ED before admission had asymptomatic bacteriuria without a clear indication for antibiotic treatment. Treatment was initiated in response to a wide variety of symptoms and to abnormalities in UAs that were obtained routinely on a large proportion of patients. These patients often continued antibiotics after admission. Guidelines are needed to curtail inappropriate antibiotic treatment of asymptomatic bacteriuria in the ED, where very few patients are truly asymptomatic.
Presenting complaints of the 41 patients treated for UTI who had no urinary symptoms, fever, or leukocytosis.
|Presenting complaint||n (% of total)||Average age (years)||Female sex (%)||Continued abx* after admission n (%)||Mean abx duration (days)|
|Altered Mental Status||9 (22)||76||79||9 (100)||4.3|
|GI complaints||8 (20)||52||75||3 (38)||2.3|
|Syncope||7 (17)||77||100||4 (57)||2.3|
|CNS* complaints||6 (15)||64||83||6 (100)||3.8|
|Chest Pain and/or Respiratory Distress||4 (10)||61||75||3(75)||3.5|
|Psychiatric complaints||3 (7)||37||100||3 (100)||5.7|
|Average for 41 patients||66||83||32(78)||3.4|
|*Abx = antibiotics, N/V/D = nausea/vomiting/diarrhea, GIB = gastrointestinal bleeding, LOC = loss of consciousness, CNS = central nervous system, URI = upper respiratory infection.|
To cite this abstract:Kiyatkin D, McKenzie R, Bessman E. Inappropriate Initiation of Antibiotics for Asymptomatic Bacteriuria in Patients Admitted from the Emergency Deptartment. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 119. https://www.shmabstracts.com/abstract/inappropriate-initiation-of-antibiotics-for-asymptomatic-bacteriuria-in-patients-admitted-from-the-emergency-deptartment/. Accessed December 10, 2018.