(Poster 124) Selective Single Dose Macrobid for Post-UDS UTI Prevention: A QI Initiative

Objectives: Our primary aim was to decrease rate of urinary tract infections (UTI) following urodynamic studies (UDS) at our tertiary academic urogynecology clinic.

Methods: This multidisciplinary quality improvement (QI) project comprises included development of a new antibiotic prophylaxis algorithm using retrospective chart review data and engagement of stakeholders, implementation of the algorithm including provider education, and evaluation of initiative efficacy by pre- and post-implementation surveillance of post-UDS UTI and bacteriuria rates. Three Plan Do Study Act (PDSA) cycles were completed monitoring need for nursing phone calls and rates of antibiotic prescription. Positive urine culture results were those with at least 10E5 CFU/ml of a single bacteria.

Results: Pre-implementation retrospective chart review of 191 patients having UDS noted only 74% completion rate of the post-UDS culture. Multivariable logistic regression used to determine risk factors for UDS in the urogynecology population and age>70 was a risk factor for positive post-UDS culture. A collaborative multidisciplinary team including infectious disease antibiotic stewardship team developed and algorithm for antibiotic prophylaxis based on patient demographics and local antibiotic resistance patterns. Prophylactic pre-procedure nitrofurantoin 100mg was introduced for patients with recurrent UTI and those over age 70. Given the low risk of single dose nitrofurantoin and low rates of renal dysfunction in our population nitrofurantoin was selected as the preferred agent with TMP/SMX or ciprofloxacin provided to patients not eligible for nitrofurantoin.
In the first PDSA cycle adherence to the new antibiotic regimen was noted to be poor with only half of patients receiving prophylaxis per protocol. Post-cycle end-user interviews found that rates of administration were higher than documented. After targeted provider education, another PSDA cycle was completed and although post-UDS urine culture results were more often negative (46% at baseline , 54% after the first PSDA cycle and 71% after second PSDA cycle, p< 0.001), the rate of antibiotics prescribed for suspected UTI at the time of UDS or for positive culture with symptoms post-UDS did not change.

Conclusions: Pre-implementation retrospective chart review of 191 patients having UDS noted only 74% completion rate of the post-UDS culture. Multivariable logistic regression used to determine risk factors for UDS in the urogynecology population and age>70 was a risk factor for positive post-UDS culture. A collaborative multidisciplinary team including infectious disease antibiotic stewardship team developed and algorithm for antibiotic prophylaxis based on patient demographics and local antibiotic resistance patterns. Prophylactic pre-procedure nitrofurantoin 100mg was introduced for patients with recurrent UTI and those over age 70. Given the low risk of single dose nitrofurantoin and low rates of renal dysfunction in our population nitrofurantoin was selected as the preferred agent with TMP/SMX or ciprofloxacin provided to patients not eligible for nitrofurantoin.
In the first PDSA cycle adherence to the new antibiotic regimen was noted to be poor with only half of patients receiving prophylaxis per protocol. Post-cycle end-user interviews found that rates of administration were higher than documented. After targeted provider education, another PSDA cycle was completed and although post-UDS urine culture results were more often negative (46% at baseline , 54% after the first PSDA cycle and 71% after second PSDA cycle, p< 0.001), the rate of antibiotics prescribed for suspected UTI at the time of UDS or for positive culture with symptoms post-UDS did not change.