Appropriateness of antibiotic use in patients with and without altered mental status diagnosed with a urinary tract infection

OBJECTIVE: The objective of this study was to determine antibiotic appropriateness based on Loeb minimum criteria (LMC) in patients with and without altered mental status (AMS). DESIGN: Retrospective, quasi-experimental study assessing pooled data from 3 periods pertaining to the implementation of a UTI management guideline. SETTING: Academic medical center in Lexington, Kentucky. PATIENTS: Adult patients aged ≥18 years with a collected urinalysis receiving antimicrobial therapy for a UTI indication. METHODS: Appropriateness of UTI management was assessed in patients prior to an institutional UTI guideline, after guideline introduction and education, and after implementation of a prospective audit-and-feedback stewardship intervention from September to November 2017–2019. Patient data were pooled and compared between patients noted to have AMS versus those with classic UTI symptoms. Loeb minimum criteria were used to determine whether UTI diagnosis and treatment was warranted. RESULTS: In total, 600 patients were included in the study. AMS was one of the most common indications for testing across the 3 periods (19%–30.5%). Among those with AMS, 25 patients (16.7%) met LMC, significantly less than the 151 points (33.6%) without AMS (P < .001). CONCLUSIONS: Patients with AMS are prescribed antibiotic therapy without symptoms indicative of UTI at a higher rate than those without AMS, according to LMC. Further antimicrobial stewardship efforts should focus on prescriber education and development of clearly defined criteria for patients with and without AMS.