A pharmacist writes a prescription

Diagnostic stewardship — making sure patients receive the right tests at the right time — appears to work better than antibiotic stewardship to halt unnecessary treatment for asymptomatic urinary tract infections, a new study has found. The findings are particularly relevant to long-term care facilities, the authors said.

“Most efforts to combat antimicrobial resistance have focused on prescribing, but our research indicates that more progress can be made by looking further upstream — before a prescription is ever written,” researcher Valerie Vaughn, MD, MSc, of the University of Utah, said.

The scourge of UTIs

Urinary tract infections are a common problem seen across healthcare settings, and notably prevalent in long-term care facilities. UTIs that have no symptoms but a positive urine culture (asymptomatic bacteriuria, or ASB) may not require an antibiotic. Yet up to 80% of patients with ASB are treated with antibiotics, leading to potential antibiotic resistance without improving patient outcomes, the authors noted.

The study took place across 46 hospitals that used pay-for-performance metrics to curb unnecessary treatment of ASB. The percentage of ASB patients treated with antibiotics declined from 29% to 17% during the study period, with diagnostic stewardship linked to nearly all improvements, the investigators reported.

Overdiagnosis in LTC

Diagnostic stewardship focuses on laboratory testing to inform decision-making. Antibiotic stewardship, meanwhile, refers to an institutional commitment to careful prescribing. 

Despite a push toward antibiotic stewardship on the federal level, overdiagnosis of UTIs is a long-standing issue in skilled nursing facilities and remains a problem in those settings. “Overuse and misuse of antibiotics is a major cause of adverse drug events, antibiotic resistance and Clostridium difficile in nursing facilities,” according to the authors of an older study.

It is therefore “especially important” for long-term care providers to ensure the efficacy of stewardship, Vaughn said. “Because patients who have asymptomatic bacteria tend to be older and chronically ill, these patients are already more likely to experience adverse events from antibiotics,” she said.

The new findings were presented last week at the IDWeek conference, a joint annual meeting of infectious disease experts.

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