Discussion

In this study of 275 patients, we observed a 58.5% prevalence of ASB, ranging between 48.8% at CAHs and 62.8% at academic and community hospitals, respectively. The frequency of ASB treatment was 69.6%, varying between 62.5% at academic and community hospitals and 90.2% at CAHs, respectively. ASB is highly prevalent, and inappropriate treatment of ASB is common at both large and critical-access hospitals, a finding consistent with previously published studies. ^{Reference Flokas, Andreatos, Alevizakos, Kalbasi, Onur and Mylonakis2,Reference Grein, Kahn and Eells4,Reference Petty, Vaughn and Flanders5} Although the prevalence of ASB was lower in CAHs, suggesting more selective criteria for sending urine culture, the high rate of antibiotic prescribing reveals opportunities for targeted stewardship interventions, specifically establishing diagnostic and treatment criteria and shortening treatment durations as recommended by the Centers for Disease Control and Prevention. ⁶

In our study, urine cultures were primarily ordered in the ED, which may be a high-yield area for stewardship interventions. Shallcross et al ^{Reference Shallcross, Rockenschaub, McNulty, Freemantle, Hayward and Gill7} reported that >60% of patients treated for UTI syndromes in the ED lacked clinical evidence of infection, yet antibiotics were continued in >75% of patients. Their finding is supported by another study in which failure to re-evaluate the need for antibiotics initiated in the ED for presumed UTI led to inappropriate continuation of therapy in hospitalized patients. ^{Reference Kiyatkin, Bessman and McKenzie8}

The median treatment duration for ASB was 6.5 days in our study, which represents another stewardship opportunity. Guidelines for UTI in women recommend 3–5 days as the shortest effective therapy. ^{Reference Gupta, Hooton and Naber9} Furthermore, each day of antibiotic therapy is associated with 4% increased odds of experiencing an adverse event. ^{Reference Curran, Lo and Leung10} Even if treatment of ASB cannot be completely avoided, shortening duration of therapy may be a compromise to reduce unnecessary antibiotic exposure and potential harm.

Although data to guide interventions in CAHs are limited, we must consider that CAHs experience unique challenges related to their size and remote locations. These challenges include access to and turnaround time with microbiology data; many hospitals outsource testing to a reference or commercial laboratory, which may be far away. Healthcare personnel often include traveling locums, which may impede a consistent practice environment or shared decision making between providers who order and interpret a urine culture.

The strength of our study is the chart review of individual patient records to ascertain and adjudicate ASB cases and treatment, therefore minimizing the potential for misclassification. Our study had several limitations. The sample size was small due to lower patient volume in critical-access hospitals and by a 1-time timeframe for our data collection. Additionally, the CAHs that participated in this review were self-selected and do not necessarily represent the full spectrum of ASB management among CAHs. To our knowledge, this is the first study that has attempted to characterize the prevalence and treatment of ASB in less-studied CAH settings.

In conclusion, our findings illustrate the widespread overtreatment of ASB and highlighted areas for targeted interventions. However, we cannot effectively address the downstream effects of the overtreatment of ASB without directing interventions upstream to reduce the detection and overdiagnosis of ASB in the first place. ^{Reference Munigala, Rojek and Wood11} Although the excessive ordering of urine culture is a strong driving factor that perpetuates the inappropriate treatment of ASB, it is also important to recognize that CAHs may face unique barriers. We call for not only of diagnostic and antimicrobial stewardship to promote prudent use of urine testing and thoughtful antibiotic prescribing but also pinpointing CAH-specific challenges as a patient safety and quality improvement initiative.