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Original Investigation
Less Is More
August 26, 2019

Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients

Author Affiliations
  • 1Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
  • 2Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
  • 3Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Health System, Ann Arbor, Michigan
  • 4Internal Medicine, Division of Infectious Diseases, Beaumont Hospital, Dearborn, Michigan
  • 5Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
  • 6Department of Pharmacy, University of Michigan, Ann Arbor
JAMA Intern Med. Published online August 26, 2019. doi:10.1001/jamainternmed.2019.2871
Key Points

Question  What are the clinical characteristics and outcomes associated with antibiotic treatment of hospitalized patients with asymptomatic bacteriuria?

Findings  In this cohort study of 2733 hospitalized adults with asymptomatic bacteriuria, 82.7% received inappropriate antibiotic treatment; patients who were older, had altered mental status, or had abnormal urinalysis results were more likely to receive antibiotics. Antibiotic treatment was associated with a 37% longer duration of hospitalization after urine testing without improved clinical outcomes.

Meaning  Antibiotic treatment of asymptomatic bacteriuria in hospitalized patients appears to be common, may not be associated with improved clinical outcomes, and may be associated with longer duration of hospitalization after urine testing.

Abstract

Importance  Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined.

Objective  To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes.

Design, Setting, and Participants  A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis.

Exposures  One or more antibiotic dose for treatment of ASB.

Main Outcomes and Measures  Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post–acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing.

Results  Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting.

Conclusions and Relevance  Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

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