BLADDER score: evaluating a tool to support urinary diagnostic and antibiotic stewardship in hospitalized adults

OBJECTIVE: Antibiotic overuse for asymptomatic bacteriuria is common in older adults and can lead to harmful outcomes including antimicrobial resistance. Our objective was to evaluate the impact of a simple scoring tool on urine culturing and antibiotic prescribing for adults with presumed urinary tract infections (UTI). DESIGN: Quasi-experimental study using interrupted time series with segmented regression to evaluate urine culturing and urinary antibiotic use and length of stay (LOS), acute care transfers, and mortality 18 months before and 16 months after the intervention. SETTING: 134-bed complex continuing care and rehabilitation hospital in Ontario, Canada. PARTICIPANTS: Nurses, nurse practitioners, physicians, and other healthcare professionals. INTERVENTION: A multifaceted intervention focusing on a 6-item mnemonic scoring tool called the BLADDER score was developed based on existing minimum criteria for prescribing antibiotics in patients with presumed UTI. The BLADDER score was combined with ward- and prescriber-level feedback and education. RESULTS: Before the intervention, the mean rate of urine culturing was 12.47 cultures per 1,000 patient days; after the intervention, the rate was 7.92 cultures per 1,000 patient days (IRR 0.87; 95% CI, 0.67-1.12). Urinary antibiotic use declined after the intervention from a mean of 40.55 DDD per 1,000 patient days before and 25.96 DDD per 1,000 patient days after the intervention (IRR 0.68; 95% CI, 0.59-0.79). There was no change in mean patient LOS, acute care transfers, or mortality. CONCLUSIONS: The BLADDER score may be a safe and effective tool to support improved diagnostic and antimicrobial stewardship to reduce unnecessary treatment for asymptomatic bacteriuria.