Authors: Emily Gunselman; Linda Johnson; Rachel Anderson; Bradley Proctor
Background/Purpose: Asymptomatic bacteriuria (ASB) is defined as “the presence of one or more species of bacteria growing in the urine at specified quantitative counts (>105 colon-forming units [CFU]/mL or >108 CFU/L), irrespective of the presence of pyuria, in the absence of signs or symptoms attributable to urinary tract infection (UTI).”.1 Urinary tract infections (UTIs) are a clinical syndrome that should be diagnosed based on symptoms such as dysuria, urgency, frequency, suprapubic pain, flank pain, and costovertebral angle tenderness with or without systemic signs of infection such as fever, chills, rigors or hemodynamic instability.2 The Infectious Diseases Society of America (IDSA) recommends against screening for and treating ASB, except in pregnant patients or prior to a planned urologic procedure.1 Treating ASB in patients, aside from the aforementioned exceptions, has shown lack of benefit and has also lead to increased risk of harm including: development of symptomatic UTI, colonization with multi-drug resistant gram negative rods, and increased risk of developing Clostridiodes difficile infection (CDI).3,4,5 The Emergency Department (ED) is the most common location for the ordering of urine cultures and early treatment for a suspected UTI. In August of 2025, CHI Memorial Hospital approved an Expected Practice document providing leadership support to not treat ASB.6 Additionally, a guidance document on the management of UTIs was created which detailed empiric treatment recommendations with regards to drug, route, dose, and duration based on national guidelines as well as local antibiogram data for both patients discharging from the ED and those being admitted. Didactic education was provided to the ED clinicians and the guidance documents were made available. The goal of this project was to evaluate appropriateness of ED antibiotic use for ASB and suspected urinary tract infections pre- and post- stewardship intervention.
Methods: This is a single-center, IRB approved, quasi-experimental study. Adult patients seen in the ED with positive urine cultures showing a uropathogen were included. Patients were excluded if they had an outpatient diagnosis of UTI, another suspected source of infection, or neutropenic fever. The primary outcome of this study is to evaluate the appropriateness of empiric antibiotic therapy pre- and post- intervention. Secondary outcomes include safety of intervention, new positive cultures showing resistant organism growth, CDI, and re-presentation to the ED with the same diagnosis within 30 days.
Results:
Primary Outcome: Appropriateness of empiric antibiotic treatment choice for UTI did not improve post-intervention. However, the number of patients who had ASB and received antibiotics did decrease post-intervention.
Secondary Outcomes: There was no shown difference in development of symptomatic UTI, development of CDI, or re-presentation to the ED within 30 days for the same diagnosis between patients that were appropriately treated vs not. However, more patients developed new resistant organism growth in subsequent urine cultures in the group of patients that were not appropriately treated.
No values were found to be statistically significant.
Conclusion:
- The educational intervention was not effective at guiding provider empiric antibiotic choice in the ED
- ASB was often treated in the pre- and post-intervention periods
- The expected practice document was not an effective tool in altering clinical behavior in the ED
