Combined Training Intervention Targeting Medical and Nursing Staff Reduces Ciprofloxacin Use and Events of Urinary Tract Infection

Inappropriate diagnosis of urinary tract infections (UTI) contributes to antimicrobial overuse. A combined training intervention for medical and nursing staff mainly addressing the analytic process reduced UTI events (9.20 vs. 7.36 per 1000 PD, −20.0%,  = 0.003) and the utilization rate of ciprofloxacin (11.6 vs. 3.5, −69.6  = 0.001) in a Bavarian University Hospital. Combined training intervention—as part of an antibiotic stewardship program—can be effective in avoiding unnecessary urinalysis and reducing antibiotic consumption.

1. Introduction
Urinary tract infections (UTIs) are the third most common type of healthcare-associated infections in Germany and the fifth most common in the United states accounting for a considerable amount of in-hospital antibiotic consumption [1, 2]. UTIs have been successfully addressed by antibiotic stewardship programs (ASP) [3], and the current IDSA guideline on antimicrobial stewardship strategies highlights the challenge of preventing antibiotic treatment for asymptomatic bacteriuria (ASB). Fluoroquinolones were commonly used to treat UTI in the outpatient setting, but due to severe adverse events and high resistance rates among E. coli, they are a major target of ASPs [4]. Especially, the adverse events prompted to national and international safety warnings discouraging the empiric treatment of mild/moderate infections with fluoroquinolones including uncomplicated urinary tract infections [5, 6]. ASPs put emphasis on improving the quality of antibiotic prescribing; interventions targeting the analytic process are particularly suitable to avoid analyzing and reporting and hence triggering unnecessary treatment of ASB.

The analytic process consists of preanalytics (indication, sampling, and transport), analytics (species identification and antibiotic susceptibility testing), and postanalytics (interpretation of findings in the clinical context). Analytics and early stages of postanalytics (i.e., selective reporting) are subjects to the laboratory process and may therefore be controlled straightforwardly [7]. However, it takes more effort to modify pre and postanalytical procedures, as they are executed outside the laboratories by healthcare staff.

Education can change behavior of medical personnel. It is a core element of ASPs and has the power to influence all persons responsible in the pre and postanalytical processes [8]. Nursing staff was recognized as a potential player in the implementation of ASP, and nurse-driven antibiotic stewardship practices (need for urine cultures and ensuring the proper culturing technique) were identified [9]. Potential effective measures of ASPs to partner with nursing staff need to be investigated. This study evaluates the effect of a combined training intervention for medical and nursing staff on diagnosis and treatment of urinary tract infections.