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We read with great interest the original research done by Stagg et al where rates of unnecessary antibiotic use for asymptomatic bacteriuria (ASB) were decreased by implementing a two-step urine culture algorithm in the emergency department (ED).  We want to congratulate the authors for their successful research, and hope that algorithms such as the two-step ordering process will be implemented as widespread protocol to help decrease the overutilization of antibiotics for ASB.
We have presented the findings of our own retrospective observational IRB-approved study performed at a 695-bed academic medical center to discern the downstream impact of routine urinalysis and urine cultures ordered from the ED on antibiotic prescribing. We hope these results will add to the growing body of evidence for stricter protocol regarding urine testing and subsequent treatment. The primary objective of our study was to evaluate the incidence of antibiotic treatment based on urinalysis and urine culture results with or without associated urinary symptoms. Secondary objectives included: incidence of symptoms documented in the medical record for patients who were ordered a urinalysis with or without urine culture, incidence of antibiotic treatment of ASB, and quantification of mean antibiotic dose given to patients with clinically defined ASB.
Adult patients who had urinalysis with or without a urine culture performed in the ED were identified and randomized by reports genera...
Adult patients who had urinalysis with or without a urine culture performed in the ED were identified and randomized by reports generated through the quality department from 2016. Patients were excluded if they were incarcerated, had other indications of antibiotics on admission, had a planned urological procedure within 48 hours, pregnant, or had charts containing incomplete data. The final convenience sample size of 432 included patients were analyzed.
In general, patients were more likely not to have classical urinary symptoms (symptomatic: n=65, 15%; asymptomatic: n=367, 85%). Urine cultures were ordered in 151 patients (symptomatic: n=33, 51%; asymptomatic: n=118, 32%; p=0.004); of which, 53 (35%) had a positive culture result. Most of these patients (n=38, 72%) were asymptomatic; yet, they received inappropriate antibiotics for treatment of ASB (n=25, 66%). Typically, patients received third-generation cephalosporins (n=16, 64%) or a fluoroquinolone (n=4, 16%) and were treated for an average of 3 days. This correlates with our previously published data showing a 62% inappropriate treatment rate of ASB at our institution five years prior to this cohort. Previously, we decreased this rate to 26% following an education period. 
Lab ordering algorithms, such as the one used by Stagg et al, would address the issues found in our institution. We educated prescribers on the overtreatment of ASB, but demonstrated that educational initiatives at academic hospitals lose effectiveness over time. Antimicrobial stewardship programs (ASPs) can leverage electronic medical record prescribing to educate clinicians on appropriate ordering of urine tests when patients lack classical and non-classical urinary symptoms. Two-step urine culture ordering, combined with additional rationale for urine culture processing (documentation of urinary symptoms in the processing order), would allow for additional stop measures to ensure appropriate urine culture ordering, provide documentation for clinicians to retrospectively audit the process, and promote lab stewardship on the front lines. Inappropriate management of patients with ASB has been a substantial challenge for ASPs over the past ten years that has brought unfortunate burdens on the healthcare system that we as clinicians have the power to stop.
1 Stagg A, Lutz H, Kirpalaney S, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf. 2018;2:140-147.
2 Kelley D, Aaronson P, Poon E, et al. Evaluation of an antimicrobial stewardship approach to minimize overuse of antibiotics in patients with asymptomatic bacteriuria. Infect Control Hosp Epidemiol. 2014;2:193-5.