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Implementation of pharmacist-led intervention on asymptomatic bacteriuria treatment in adults patients

Published online by Cambridge University Press:  09 September 2026

Gabriela Maria UrretaOpen the ORCID record for Gabriela Maria Urreta[Opens in a new window],
Alice Margulis Landayan,
Jeyma FernandezOpen the ORCID record for Jeyma Fernandez[Opens in a new window],
Jorge Murillo,
Stephen Breazeale and
Timothy Gauthier
Gabriela Maria Urreta*
Affiliation:
South Miami Hospital, USA
Alice Margulis Landayan
Affiliation:
South Miami Hospital, USA
Jeyma Fernandez
Affiliation:
South Miami Hospital, USA
Jorge Murillo
Affiliation:
South Miami Hospital, USA
Stephen Breazeale
Affiliation:
Baptist Health South Florida Inc, USA
Timothy Gauthier
Affiliation:
Baptist Health South Florida Inc, USA
*
Corresponding author: Gabriela Maria Urreta; Email: gabiurreta@outlook.com

Abstract

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Information

Type
Research Brief
Information
Antimicrobial Stewardship & Healthcare Epidemiology , Volume 6 , Issue 1 , 2026, e265
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2026. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Introduction

Asymptomatic bacteriuria (ASB) is the presence of bacteria in the urine without symptoms of infection (ie, dysuria, urgency, frequency, suprapubic pain). Reference Claeys, Trautner and Leekha1 The incidence of ASB is around 45% in women and 50% in individuals residing in long-term care facilities. Reference Hartlage, Bryson-Cahn and Castillo2 Current evidence-based guidelines recommend against antimicrobial treatment in most patients, as ASB is generally benign. Exceptions include pregnant individuals, individuals undergoing endourologic procedures associated with mucosal trauma, and those within one month of renal transplantation. Reference Nicolle, Gupta and Bradley3

Treatment of ASB has not been shown to improve outcomes and is associated with harms, including increased risk of Clostridioides difficile infection, antimicrobial resistance, and prolonged hospital length of stay. Reference Liu, MacDonald and Jain4 Despite these risks, inappropriate antibiotic use remains prevalent, with up to 75% of patients with ASB receiving unnecessary treatment. Reference Vaughn, Gupta and Petty5

Several antimicrobial stewardship studies have supported provider education and decision-making guidance to decrease inappropriate treatment of ASB, while also highlighting the important role of pharmacists in optimizing antimicrobial appropriateness and treatment duration. Reference Hitchins, Bouchard, Ingram and Orvin6–Reference Mahmood, Gillani, Saeed, Vippadapu and Alzaabi8 The aim for this quality improvement project was to assess the impact of pharmacist-led interventions on decreasing the use of antimicrobial therapy for ASB.

Methods

This was a single-center retrospective evaluation conducted at a 450-bed community teaching hospital. Adult patients admitted for ≥24 hours and initiated on antimicrobials for ASB were included. Patients with indications for ASB treatment (ie, pregnancy, undergoing endourologic procedures with mucosal trauma, or recent history [<1 month] of renal transplant), chronic urinary tract infection (UTI) antimicrobial prophylaxis, fever (≥38 °C), sepsis, receiving Infectious Diseases-restricted antimicrobials, infections requiring antimicrobial therapy, one-time antimicrobial doses, incarcerated individuals, comfort measures only, or hospice were excluded.

A pharmacist-led ASB intervention was implemented January 1st, 2026 through March 31st, 2026, consisting of pharmacist education, a standardized ASB assessment algorithm (Supplementary Figure 1), and a daily antimicrobial review report enabling real-time interventions. Pharmacists utilized the algorithm to differentiate ASB from symptomatic UTI and identify opportunities for antimicrobial discontinuation or duration optimization. Recommendations were communicated directly to prescribers through either verbal discussion or electronic secure messaging software. During weekdays, using a Discern Analytics® 2.0 report, designated pharmacists identified active antimicrobial orders with selected indications for “UTI,” “cystitis,” or “pyelonephritis” and assessed for appropriateness. Providers were contacted with intervention recommendations where appropriate.

Outcomes from the postimplementation period were compared to a preimplementation period in which no standardized ASB algorithm or dedicated review process existed (January 1st, 2025 through March 31st, 2025). The primary outcome was duration of antimicrobial therapy in days. Secondary outcomes included proportion of patients who received at least one antimicrobial-related pharmacist intervention, number of antimicrobial-related pharmacist interventions, adverse drug events, hospital length of stay, and 30-day infection-related outcomes. A sample size of 102 patients (51 per group) was estimated to detect a 50% reduction in therapy duration with 80% power. Categorical data was analyzed using χ 2 test or Fisher’s exact test and continuous data was analyzed with Mann-Whitney U test. Statistical significance determined by P-value < .05. This project was deemed exempt from Institutional Review Board review.

Results

A total of 291 patients preimplementation and 221 patients postimplementation were screened, with 60 and 40 patients included, respectively. The most common reason for exclusion was presence of urinary symptoms. Baseline and microbiological characteristics are presented in Table 1. Median duration of antimicrobial therapy decreased from 7 days preimplementation to 2 days postimplementation (P < .001).

Table 1.

Baseline characteristics and microbiological findings

A table comparing baseline characteristics and microbiological findings pre-implementation and post-implementation.
Table 1. Long description

A table comparing baseline characteristics and microbiological findings pre-implementation and post-implementation. The table has 18 rows and 5 columns. The columns are labeled Pre-implementation (n = 60), Post-implementation (n = 40), and p-value. The rows include various characteristics and findings such as Median age (IQR) - years, Female sex, n (%), Race or ethnicity, n (%), Altered mental status, n (%), History of dementia, n (%), Urinary catheter, n (%), Leukocytosis, n (%), Urine culture obtained, n (%), Urine culture reflexed from urinalysis, Urine culture ordered without reflex, Urine culture pathogen, n (%), and Urine culture with ESBL producing pathogen, n (%). Each row provides specific data points for pre-implementation and post-implementation groups, along with corresponding p-values. Notable trends include the percentage of urine culture obtained decreasing from 90 percent pre-implementation to 75 percent post-implementation, and the median duration of antimicrobial therapy decreasing from 7 days preimplementation to 2 days postimplementation.

IQR: interquartile range; ESBL: extended-spectrum beta-lactamase.

Successful pharmacist interventions occurred in 7 patients (12%) preimplementation compared with 36 patients (90%) postimplementation (P < .0001). Total pharmacist interventions increased from 7 to 37 following implementation, most notably driven by antibiotic discontinuation (2 vs 24, P < .0001) and shortened treatment duration (4 vs 12, P = .004). No antimicrobial-related adverse drug events were identified. Median hospital length of stay was longer in the postimplementation group (3 vs 5 d; P = .02); however, no 30-day infection-related deaths or UTI-related readmissions occurred in either group. Overall, 90% of postimplementation pharmacist interventions were accepted. Altered mental status was the most common reason for intervention rejection.

Discussion

Implementation of a pharmacist-led ASB intervention was associated with significant increases in pharmacist interventions and reductions in antimicrobial therapy duration, without increased 30-day infection-related mortality or UTI-related readmissions. These findings support guideline recommendations against the treatment of ASB in most patient populations due to the lack of clinical benefit from and the potential harm associated with unnecessary antimicrobial exposure. Reference Nicolle, Gupta and Bradley3 Limiting antimicrobial exposure and decreasing duration may reduce the risk of adverse drug events, C. difficile infection, and antimicrobial resistance. Reference Nicolle, Gupta and Bradley3

Our findings are consistent with prior studies demonstrating that pharmacist-led stewardship interventions can significantly reduce inappropriate antibiotic use in ASB. Reference Shah, Ike, Thibeaux, Rodriguez, Maddox and Daoura9 The high rate of accepted postimplementation pharmacist interventions highlights the feasibility and effectiveness of integrating pharmacists into routine stewardship workflows.

Despite these improvements, provider discomfort with discontinuing antimicrobial therapy was observed, particularly among patients with dementia or altered mental status who may be unable to reliably report urinary symptoms. Although these patients were assessed using the same standardized ASB criteria, diagnostic uncertainty remained a common barrier to intervention acceptance. Diagnostic uncertainty in such populations is a well-recognized contributor to inappropriate ASB treatment and remains a significant barrier, highlighting the need for further targeted education and clinical decision support tools that reinforce evidence-based diagnostic criteria. Reference Liu, MacDonald and Jain4

Our study has several limitations. The retrospective single-center design and small sample size may limit generalizability. The short study period limits assessment of long-term sustainability. The increased length of stay observed postimplementation likely reflects non-infectious factors, as no differences in infection-related outcomes were identified. The smaller sample size in the postimplementation group compared to the preimplementation group suggests that more patients with ASB in the postimplementation period were not prescribed antimicrobial therapy, likely secondary to ongoing discussions with providers, which contributed to increased education and appropriate ASB management.

Overall, pharmacist-led interventions targeting ASB represent a valuable component of ASP programs. By reducing unnecessary antimicrobial exposure without compromising outcomes, such interventions support high-quality evidence-based care and advance institutional stewardship goals.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/ash.2026.10841.

Acknowledgments

None.

Financial support

None reported.

Competing interests

All authors report no conflict of interest to this article.

References

Claeys, K, Trautner, B, Leekha, S, et al. Optimal urine culture diagnostic stewardship practice – results from an expert modified-delphi procedure. Clin Infect Dis 2022;75:1–8.10.1093/cid/ciab987CrossRefGoogle ScholarPubMed
Hartlage, W, Bryson-Cahn, C, Castillo, A, et al. Asymptomatic bacteriuria in critical-access hospitals: prevalence and patient characteristics driving treatment. Infect Control Hosp Epidemiol 2023;45:380–383.10.1017/ice.2023.220CrossRefGoogle ScholarPubMed
Nicolle, L, Gupta, K, Bradley, S, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019;68:75–83.10.1093/cid/ciz021CrossRefGoogle ScholarPubMed
Liu, F, MacDonald, B, Jain, R, et al. Prevalence and treatment of asymptomatic bacteriuria at academic and critical-access hospitals – opportunities for stewardship efforts. Infect Control Hosp Epidemiol 2022;44:979–981.10.1017/ice.2022.143CrossRefGoogle ScholarPubMed
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Hitchins, M, Bouchard, J, Ingram, C, Orvin, A. Implementation of an asymptomatic bacteriuria assessment protocol for patients discharged from the emergency department. Antimicrob Steward Healthc Epidemiol 2023;3:37–45.10.1017/ash.2023.117CrossRefGoogle ScholarPubMed
Baghdadi, J, Korenstein, D, Pineles, L, et al. Exploration of primary care clinician attitudes and cognitive characteristics associated with prescribing antibiotics for asymptomatic bacteriuria. JAMA Netw Open 2022;5:1–10.10.1001/jamanetworkopen.2022.14268CrossRefGoogle ScholarPubMed
Mahmood, R, Gillani, S, Saeed, M, Vippadapu, P, Alzaabi, M. Impact of pharmacist-led services on antimicrobial stewardship programs: a meta-analysis on clinical outcomes. J Pharm Health Serv Res 2021;12:615–625.10.1093/jphsr/rmab036CrossRefGoogle Scholar
Shah, P, Ike, C, Thibeaux, M, Rodriguez, E, Maddox, S, Daoura, N. Impact of antimicrobial stewardship interventions on antimicrobial utilization in asymptomatic bacteriuria. Hosp Pharm 2019;56:210–214.10.1177/0018578719888911CrossRefGoogle ScholarPubMed
Figure 0

Table 1.Baseline characteristics and microbiological findingsTable 1 long description.