Urinary Antigen Testing Can Help Improve Antibiotic Stewardship

Only 15.5 percent of adult patients with pneumonia received pneumococcal urinary antigen testing (UAT), a useful tool that, when it yields positive findings, can help physicians reduce the time that patients in stable condition need to take broad-spectrum antibiotics, according to an AHRQ study published in Clinical Infectious Diseases. The researchers used data from a national discharge hospital database over a five-year period, from 2010 to 2015. Although UAT is fast, accurate and inexpensive, its utilization remains low. The authors suggest that increased use of UAT can improve antibiotic stewardship efforts. Access the abstract.

2019 Oct 7. pii: ciz983. doi: 10.1093/cid/ciz983. [Epub ahead of print]

Pneumococcal urinary antigen testing in US hospitals: A missed opportunity for antimicrobial stewardship.

Schimmel JJ1, Haessler S1, Imrey P2,3, Lindenauer PK4,5, Richter SS6, Yu PC2, Rothberg MB7,3.

Author information

1: Division of Infectious Diseases, University of Massachusetts Medical School-Baystate, Springfield, MA.
2: Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
3: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.
4: Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA.
5: Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.
6: Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH.
7: Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH.

Abstract

BACKGROUND:

The Infectious Disease Society of America recommends pneumococcal urinary antigen testing (UAT) when identifying pneumococcal infection would allow for antibiotic de-escalation. However, the frequencies of UAT and subsequent antibiotic de-escalation are unknown.

METHODS:

We conducted a retrospective cohort study of adult patients admitted with community-acquired or healthcare-associated pneumonia to 170 US hospitals in the Premier database from 2010-2015, to describe variation in UAT use, associations of UAT results with antibiotic de-escalation, and associations of de-escalation with outcomes.

RESULTS:

Among 159,894 eligible admissions, 24,757 (15.5%) included UAT performed (18.4% of ICU and 15.3% of non-ICU patients). Among hospitals with ≥100 eligible patients, UAT testing proportions ranged from 0%-69%. Compared to patients with negative UAT, 7.2% with positive UAT more often had a positive S. pneumoniae culture (25.4% vs. 1.9%, p<0.001) and less often had resistant bacteria (5.2% vs. 6.8%, p<0.05). Of patients initially treated with broad-spectrum antibiotics, most were still receiving broad-spectrum therapy 3 days later, but UAT-positive patients more often had coverage narrowed (38.4% vs. 17.0% UAT-negative and 14.6% untested patients, p<0.001). Hospital rate of UAT was strongly correlated with de-escalation following a positive test. Only 3 patients de-escalated after positive UAT were subsequently admitted to ICU.

CONCLUSIONS AND RELEVANCE:

UAT is not ordered routinely in pneumonia, even in ICU. A positive UAT was associated with less frequent resistant organisms, but usually did not lead to antibiotic de-escalation. Increasing UAT and narrowing therapy after a positive UAT are opportunities for improved antimicrobial stewardship.