Deimplementation strategy to reduce overtreatment of asymptomatic bacteriuria: a study protocol for a stepped-wedge cluster randomised trial

Abstract

Introduction: Antimicrobial treatment of asymptomatic bacteriuria (ASB) is one of the most common unnecessary uses of antimicrobials. Earlier studies have shown that the prevalence of this inappropriate treatment ranges from 45% to 83%. Multifaceted interventions based on international guidelines and antimicrobial stewardship can decrease overtreatment of ASB. We have designed a study protocol with the main objective of reducing overtreatment of ASB by 50% through use of a deimplementation strategy.

Methods and analysis: We will use a stepped-wedge cluster randomised design, comparing outcomes before and after introduction of our intervention in the emergency department (ED) of five hospitals (clusters) in the Netherlands. All patients (≥18 years old) who have a urine test performed in the ED will be screened for eligibility. The deimplementation strategy consists of a combination of interventions, including education, audit and feedback. The primary endpoint is overtreatment of ASB in patients without risk factors (eg, pregnancy, planned invasive urological procedures and neutropenia). Secondary endpoints are the duration of antimicrobial treatment for ASB, the number of urine cultures and urinalysis per 1000 patients, and overtreatment of positive urinalysis in asymptomatic patients.

Ethics and dissemination: Ethical approval was obtained from the medical ethics research committee of the Academic Medical Centre (Amsterdam, the Netherlands) with a waiver for informed consent. Local feasibility was obtained by the local institutional review boards of all participating hospitals. Our study aims to reduce inappropriate screening and treatment of ASB in EDs, improve healthcare quality, lower the increase in antimicrobial resistance and save costs. If proven (cost)-effective, this study provides a well-suited strategy for a nationwide approach to reduce overtreatment of ASB. Relevant results of our study will be disseminated through publications in peer-reviewed journals and presentations at relevant (scientific) conferences.

Trial registration number: NL8242; Pre-results.

Keywords: diagnostic microbiology; infectious diseases; internal medicine; urinary tract infections.

Figure 1

Stepped wedge design for deimplementation strategy.

Figure 2

Study profile. *Risk factors are pregnancy, patients prior to planned urological procedures associated with mucosal trauma and high-risk neutropenia. ASB, asymptomatic bacteriuria; UTI, urinary tract infection.

Figure 3

(A) Algorithm of indications for urinalysis and cultures in symptomatic patients. (B) Algorithm of indications for urinalysis and cultures in asymptomatic patients. *Fever (>38°C), painful urination, urinary urgency, frequent miction, suprapubic pain, flank pain. SWAB, Stichting Werkgroep Antibiotica Beleid (the Dutch Working Party on antibiotic policy); UTI, urinary tract infection.