Quality Improvement: Optimizing Antibiotic Use and Bacteriuria Screening in Patients with Multiple Sclerosis and Other Central Demyelinating Diseases

Background:

Persons with multiple sclerosis (MS) and other central nervous system (CNS) demyelinating diseases are at high risk for urinary tract infections (UTIs) as a result of neurogenic bladder and frequent use of urinary catheters. UTIs increase the risk of MS flares and pseudoexacerbations. Consequently, there is a high rate of UTI screening and unnecessary treatment of asymptomatic bacteriuria in this population. Unnecessary urine cultures and antibiotics lead to increased healthcare costs, risk of adverse side effects, and antimicrobial resistance.

Objectives:

A quality improvement project to reduce the number of unnecessary antibiotic prescriptions and urine cultures performed in persons with MS and other CNS demyelinating diseases.

Methods:

A single-center quality improvement study, consisting of three phases, conducted in patients with MS and other CNS demyelinating diseases seen in the Ochsner Multiple Sclerosis Center.

• Phase 1 implements a urinalysis reflex (UAR) order that triggers a urine culture only when urinalysis (UA) reveals a white blood cell count >10 cells/high-power field to limit unnecessary urine cultures.
• Phase 2 will provide patient education handouts, standardize urine collection supplies, and trial a preservative collection tube to limit sample contamination.
• Phase 3 combines both interventions to reduce antibiotic prescriptions.

Results:

Prior to intervention, 87% of UAs resulted in a urine culture. Phase 1 of the study demonstrates a statistically significant 55% decrease in the number of urine cultures ordered. Phase 1 did not result in a statistically significant decrease in the frequency of antibiotics prescribed.

Conclusions:

Data from phase 1 demonstrated that the UAR order decreased the number of urine cultures ordered. The small sample size of phase 1 limited the ability to draw conclusions regarding a decrease in frequency of antibiotic prescriptions. Phase 2 will examine the impact of interventions at the time of collection to reduce contamination, while phase 3 will examine the effect of the combined interventions. Reducing unnecessary urine cultures and antibiotic prescriptions will decrease healthcare costs, and minimize risk of adverse side effects and development of antimicrobial resistance, ultimately contributing to better patient outcomes.