Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review.

BACKGROUND: Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes. METHODS: A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients. RESULTS: We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes. CONCLUSIONS: Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

Real-life experience with ceftolozane/tazobactam in Canada: results from the CLEAR (Canadian LEadership on Antimicrobial Real-life usage) registry.

OBJECTIVES: Ceftolozane/tazobactam is a cephalosporin/ß-lactamase inhibitor combination with activity against Gram-negative bacilli. Here we report the use of ceftolozane/tazobactam in Canada using a national registry. METHODS: The CLEAR registry uses a REDCapTM online survey to capture details associated with clinical use of ceftolozane/tazobactam. RESULTS: Data from 51 patients treated in 2020 with ceftolozane/tazobactam are available. Infections treated included hospital-acquired bacterial pneumonia (37.3% of patients), ventilator-associated bacterial pneumonia (15.7%), bone and joint infection (11.8%), complicated intra-abdominal infection (7.8%) and complicated skin and skin-structure infection (7.8%). Moreover, 17.6% of patients had bacteraemia and 47.1% were in intensive care. Ceftolozane/tazobactam was primarily used as directed therapy for Pseudomonas aeruginosa infections (92.2% of patients). Ceftolozane/tazobactam was used because of resistance to (86.3%), failure of (11.8%) or adverse effects from (2.0%) previously prescribed antimicrobials. Ceftolozane/tazobactam susceptibility testing was performed on isolates from 88.2% of patients. Ceftolozane/tazobactam was used in combination with another antimicrobial active against Gram-negative bacilli in 39.2% of patients [aminoglycosides (15.7%), fluoroquinolones (9.8%) and colistin/polymyxin B (7.8%)]. The dosage regimen was customised in all patients based on creatinine clearance. The treatment duration was primarily >10 days (60.8% of patients), with microbiological success in 60.5% and clinical success in 64.4% of patients. Moreover, 7.8% of patients had adverse effects not requiring drug discontinuation. CONCLUSION: In Canada, ceftolozane/tazobactam is used as directed therapy to treat a variety of severe infections caused by multidrug-resistant P. aeruginosa. It is commonly used in combination with other antimicrobials with relatively high microbiological/clinical cure rates and an excellent safety profile.

A recipe for antimicrobial stewardship success: Using intervention mapping to develop a program to reduce antibiotic overuse in long-term care.

OBJECTIVE: To better understand barriers and facilitators that contribute to antibiotic overuse in long-term care and to use this information to inform an evidence and theory-informed program. METHODS: Information on barriers and facilitators associated with the assessment and management of urinary tract infections were identified from a mixed-methods survey and from focus groups with stakeholders working in long-term care. Each barrier or facilitator was mapped to corresponding determinants of behavior change, as described by the theoretical domains framework (TDF). The Rx for Change database was used to identify strategies to address the key determinants of behavior change. RESULTS: In total, 19 distinct barriers and facilitators were mapped to 8 domains from the TDF: knowledge, skills, environmental context and resources, professional role or identity, beliefs about consequences, social influences, emotions, and reinforcements. The assessment of barriers and facilitators informed the need for a multifaceted approach with the inclusion of strategies (1) to establish buy-in for the changes; (2) to align organizational policies and procedures; (3) to provide education and ongoing coaching support to staff; (4) to provide information and education to residents and families; (5) to establish process surveillance with feedback to staff; and (6) to deliver reminders. CONCLUSIONS: The use of a stepped approach was valuable to ensure that locally relevant barriers and facilitators to practice change were addressed in the development of a regional program to help long-term care facilities minimize antibiotic prescribing for asymptomatic bacteriuria. This stepped approach provides considerable opportunity to advance the design and impact of antimicrobial stewardship programs.

Evaluating Antimicrobial Use and Spectrum of Activity in Ontario Hospitals: Feasibility of a Multicentered Point Prevalence Study.

BACKGROUND: Antimicrobial stewardship, a key component of an overall strategy to address antimicrobial resistance, has been recognized as a global priority. The ability to track and benchmark antimicrobial use (AMU) is critical to advancing stewardship from an organizational and provincial perspective. As there are few comprehensive systems in Canada that allow for benchmarking, Public Health Ontario conducted a pilot in 2016/2017 to assess the feasibility of using a point prevalence methodology as the basis of a province-wide AMU surveillance program. METHODS: Three acute care hospitals of differing sizes in Ontario, Canada, participated. Adults admitted to inpatient acute care beds on the survey date were eligible for inclusion; a sample size of 170 per hospital was targeted, and data were collected for the 24-hour period before and including the survey date. Debrief sessions at each site were used to gather feedback about the process. Prevalence of AMU and the Antimicrobial Spectrum Index (ASI) was reported for each hospital and by indication per patient case. RESULTS: Participants identified required improvements for scalability including streamlining ethics, data sharing processes, and enhancing the ability to compare with peer organizations at a provincial level. Of 457 patients, 172 (38%) were receiving at least 1 antimicrobial agent. Beta-lactam/beta-lactamase inhibitors were the most common (18%). The overall mean ASI per patient was 6.59; most cases were for treatment of infection (84%). CONCLUSIONS: This pilot identified factors and features required for a scalable provincial AMU surveillance program; future efforts should harmonize administrative processes and enable interfacility benchmarking.

Potential Negative Effects of Antimicrobial Allergy Labelling on Patient Care: A Systematic Review.

BACKGROUND: Antimicrobial allergy labels, either self-reported or placed in a patient's medical record, are common, but in many cases they are not associated with a true immunoglobulin E-mediated allergic response. OBJECTIVE: To assess the impact of antimicrobial allergy labels on antimicrobial prescribing, resource utilization, and clinical outcomes. DATA SOURCES: The MEDLINE, Embase, CINAHL, and Scopus electronic databases were searched for the period 1990 to January 2016. STUDY SELECTION: Controlled studies with the objective of assessing antimicrobial prescribing, resource utilization, and/or clinical outcomes associated with antimicrobial allergy labels were included. RESULTS: The search identified 560 unique citations, of which 7 articles met the inclusion criteria. One additional article identified by an expert in the field was also included. Four of the identified papers were limited to penicillin or other ß-lactam allergies. Six studies noted differences in antibiotic selection between patients with allergy labels and those without such labels. Broader-spectrum or second-line agents (e.g., vancomycin, clindamycin, and fluoroquinolones) were more commonly prescribed for patients with penicillin allergy labels. Antibiotic therapy costs were significantly higher for patients with allergy labels than for those without. The impact of allergy labels on clinical outcomes was mixed. One study indicated a longer length of hospital stay, 2 studies reported higher readmission rates, and 1 study reported a higher rate of antibiotic-resistant organisms for patients with allergy labels. CONCLUSIONS: Most of the available literature is limited to penicillin or ß-lactam allergy. The growing body of knowledge supports the concept that ß-lactam allergy labels are not benign and that labelling in the absence of a true allergy has a negative effect on patient care. Allergy labelling appears to be associated with suboptimal antibiotic selection, greater treatment costs, prolonged length of stay, greater readmission rates, and higher prevalence of antibiotic-resistant organisms. There is an opportunity for antimicrobial stewardship programs to implement systematic allergy verification to optimize antimicrobial therapy and improve patient care.

CONTEXTE: Les mentions d'allergies aux antimicrobiens, soit autodéclarées soit consignées dans un dossier médical, sont fréquentes, mais dans bien des cas elles ne signalent pas une véritable réaction allergique à médiation par l'immunoglobuline E. OBJECTIF: Évaluer l'effet des mentions d'allergie aux antimicrobiens sur les habitudes de prescription d'antimicrobiens, l'utilisation des ressources et les résultats cliniques. SOURCES DES DONNÉES: Les bases de données numériques MEDLINE, Embase, CINAHL et Scopus ont été interrogées pour la période allant de 1990 à janvier 2016. SÉLECTION DES ÉTUDES: Les essais cliniques comparatifs dont l'objectif était d'évaluer les habitudes de prescription d'antimicrobiens, l'utilisation des ressources ou les résultats cliniques associés aux mentions d'allergie aux antimicrobiens ont été inclus. RÉSULTATS: La recherche a permis de trouver 560 citations distinctes et ainsi de repérer sept articles qui répondaient aux critères d'inclusion. Un article supplémentaire signalé par un expert du domaine a été inclus à l'analyse. Quatre de ces articles se limitaient aux allergies à la pénicilline ou à d'autres ß-lactamines. Six études ont noté des différences dans le choix des antibiotiques entre les patients ayant une mention d'allergie à leur dossier et ceux n'en ayant pas. Des antibiotiques à plus large spectre ou des médicaments de deuxième intention (comme la vancomycine, la clindamycine et les fluoroquinolones) étaient plus souvent prescrits pour les patients ayant une mention d'allergie à la pénicilline. Les coûts des antibiothérapies étaient significativement plus élevés pour les patients ayant une mention d'allergie que pour ceux n'en ayant pas à leur dossier. L'effet des mentions d'allergie sur les résultats cliniques était inégal. Une étude indiquait un séjour plus long à l'hôpital, deux études indiquaient des taux de réadmission plus élevés et une étude indiquait un taux plus élevé d'organismes résistants aux antibiotiques pour les patients ayant une mention d'allergie comparativement à ceux n'en ayant pas. CONCLUSIONS: La majeure partie des articles disponibles se limitent aux allergies à la pénicilline ou à d'autres ß-lactamines. De plus en plus, le savoir vient appuyer le concept voulant que les mentions d'allergies aux ß-lactamines ne soient pas bénignes et que leur emploi en l'absence d'une allergie réelle ait un effet négatif sur les soins aux patients. Les mentions d'allergie semblent être associées à un choix sous-optimal d'antibiotiques, des coûts de traitement plus élevés, des séjours plus longs, des taux de réadmission plus élevés et une plus grande prévalence d'organismes résistants aux antibiotiques. Or, les programmes de gérance des antimicrobiens pourraient permettre de mettre en œuvre des procédures de vérification systématique des allergies afin d'optimiser l'antibiothérapie et d'améliorer les soins aux patients.

Variability in antibiotic use across Ontario acute care hospitals.

BACKGROUND: Antibiotic stewardship is a required organizational practice for Canadian acute care hospitals, yet data are scarce regarding the quantity and composition of antibiotic use across facilities. We sought to examine the variability, and risk-adjusted variability, in antibiotic use across acute care hospitals in Ontario, Canada's most populous province. METHODS: Antibiotic purchasing data from IMS Health, previously demonstrated to correlate strongly with internal antibiotic dispensing data, were acquired for 129 Ontario hospitals from January to December 2014 and linked to patient day (PD) denominator data from administrative datasets. Hospital variation in DDDs/1000 PDs was determined for overall antibiotic use, class-specific use and six practices of clinical or ecological significance. Multivariable risk adjustment for hospital and patient characteristics was used to compare observed versus expected utilization. RESULTS: There was 7.4-fold variability in the quantity of antibiotic use across the 129 acute care hospitals, from 253 to 1873 DDDs/1000 PDs. Variation was evident within hospital subtypes, exceeded that explained by hospital and patient characteristics, and included wide variability in proportion of broad-spectrum antibiotics (IQR 36%-48%), proportion of fluoroquinolones among respiratory antibiotics (IQR 40%-62%), proportion of ciprofloxacin among urinary anti-infectives (IQR 44%-60%), proportion of antibiotics with highest risk for Clostridium difficile (IQR 29%-40%), proportion of 'reserved-use' antibiotics (IQR 0.8%-3.5%) and proportion of anti-pseudomonal antibiotics among antibiotics with Gram-negative coverage (IQR 26%-40%). CONCLUSIONS: There is extensive variability in antibiotic use, and risk-adjusted use, across acute care hospitals. This could motivate, focus and benchmark antibiotic stewardship efforts.

Addressing Concerns about Changing the Route of Antimicrobial Administration from Intravenous to Oral in Adult Inpatients.

BACKGROUND: Many health care institutions are in the process of establishing antimicrobial stewardship programs. Changing the route of administration of antimicrobial agents from intravenous to oral (IV to PO) is a simple, well-recognized intervention that is often part of an antimicrobial stewardship program. However, the attending health care team may have concerns about making this switch. OBJECTIVES: To provide insights into common concerns related to IV to PO conversion, with the aim of helping antimicrobial stewardship teams to address them. DATA SOURCES: Published clinical trials and reviews were identified from a literature search of Ovid MEDLINE with the keywords (step down or switch or conversion or transition or sequential) and (antibiotics or antibacterial agents or antimicrobial or anti-infective agents). DATA SYNTHESIS: The following issues are addressed in this review: benefits of the oral route, serum concentrations yielded by the oral formulation, source of pharmacokinetic data, clinical outcomes, provision of care in the intensive care unit, fear of therapeutic failure, and administration of antimicrobials via feeding tube. CONCLUSIONS: When considering a change to oral therapy, it is important to have a thorough understanding of key aspects of the antimicrobial agent, the patient, and the disease being treated. The antimicrobial stewardship team has an important role in facilitating IV to PO conversion, educating prescribers, and addressing any concerns or reservations that may interfere with timely transition from IV to PO administration.

CONTEXTE: Bon nombre d'établissements de santé sont en voie de mettre en place de programmes de gestion responsable des antimicrobiens. Changer de voie d'administration des agents antimicrobiens en passant d'une administration intraveineuse à une administration orale est une intervention simple et reconnue qui fait souvent partie de ces programmes. Cependant, opérer un tel changement pourrait soulever des préoccupations chez les membres de l'équipe de soins de santé traitante. OBJECTIFS: Dégager une meilleure compréhension des préoccupations courantes entourant le passage de la voie d'administration intraveineuse à la voie d'administration orale dans le but d'aider les équipes de gestion responsable des antimicrobiens à y répondre. SOURCES DES DONNÉES: Des analyses documentaires ainsi que des essais cliniques publiés ont été recensés grâce à une recherche dans Ovid MEDLINE à l'aide des mots clés (step down [passage] ou switch [échange] ou conversion [conversion] ou transition [transition] ou sequential [successif]) et (antibiotics [antibiotiques]) ou antibacterial agents [agents antibactériens] ou antimicrobial [antimicrobien] ou anti-infective agents [agents anti-infectieux]). SYNTHÈSE DES DONNÉES: Les préoccupations suivantes sont abordées dans la présente analyse : les avantages de la voie orale, les concentrations sériques obtenues grâce aux préparations orales, la source des données pharmacocinétiques, les résultats cliniques, la prestation des soins à l'unité des soins intensifs, la peur de l'échec thérapeutique et l'administration des antimicrobiens par sonde gastrique. CONCLUSIONS: Lorsque l'on envisage de passer à un traitement par voie orale, il est important de posséder une connaissance approfondie des principaux aspects de l'agent antimicrobien, de l'état du patient et de la maladie traitée. L'équipe de gestion responsable des antimicrobiens détient un rôle important pour ce qui est de simplifier le passage d'une administration intraveineuse à une administration orale, d'éduquer les prescripteurs et de répondre aux préoccupations et doutes qui pourraient faire obstacle à un tel passage en temps voulu.

Risk Factors for and Outcomes of Bacteremia Caused by Extended-Spectrum ß-Lactamase-Producing Escherichia coli and Klebsiella Species at a Canadian Tertiary Care Hospital.

BACKGROUND: Antimicrobial resistance due to production of extended-spectrum ß-lactamases by Escherichia coli and Klebsiella species (ESBL-EK) is concerning. Previous studies have shown that bacteremia due to ESBL-producing organisms is associated with increases in length of stay and/or mortality rate. Rates of infection by ESBL-EK vary worldwide, and regional differences in the prevalence of risk factors are likely. Few Canadian studies assessing risk factors for ESBL-EK infections or the outcomes of empiric therapy have been published. OBJECTIVES: To determine risk factors for and patient outcomes associated with ESBL-EK bacteremia. The appropriateness of empiric antibiotic therapy and the effect of inappropriate empiric therapy on these outcomes were also examined. METHODS: In a retrospective, 1:1 case-control study conducted in a tertiary care hospital between 2005 and 2010, data for 40 patients with ESBL-EK bacteremia were compared with data for 40 patients who had non-ESBL-EK bacteremia. RESULTS: Of all variables tested, only antibiotic use within the previous 3 months was found to be an independent risk factor for acquisition of ESBL-EK bacteremia (odds ratio 5.2, 95% confidence interval 1.6-16.9). A greater proportion of patients with non-ESBL-EK bacteremia received appropriate empiric therapy (88% [35/40] versus 15% [6/40], p < 0.001). Time to appropriate therapy was longer for those with ESBL-EK bacteremia (2.42 days versus 0.17 day, p < 0.001). Patient outcomes, including length of stay in hospital, admission to the intensive care unit (ICU), length of stay in the ICU (if applicable), and in-hospital mortality were not affected by the presence of ESBL-EK or the appropriateness of empiric therapy. CONCLUSIONS: Previous antibiotic use was a significant, independent risk factor for acquiring ESBL-EK. Thus, prior antibiotic use is an important consideration in the selection of empiric antibiotic therapy and should increase the concern for resistant pathogens.

CONTEXTE: La résistance aux antimicrobiens attribuable à la production de ß-lactamases à spectre étendu (BLSE) par les espèces Escherichia coli et Klebsiella est préoccupante. Des études antérieures ont démontré que les bactériémies causées par les organismes producteurs de BLSE sont associées à une augmentation de la durée du séjour à l'hôpital ou du taux de mortalité. Les taux d'infection par les espèces E. coli ou Klebsiella productrices de BLSE varient de par le monde et les différences régionales de la prévalence des facteurs de risque sont vraisemblables. Peu d'études canadiennes évaluant les facteurs de risque de ces infections ou les résultats cliniques des antibiothérapies empiriques ont été publiées. OBJECTIFS: Déterminer quels sont les facteurs de risque des bactériémies à E. coli ou à Klebsiella productrices de BLSE ainsi que les résultats cliniques associés à ces bactériémies. De plus, étudier la pertinence de l'antibiothérapie empirique ainsi que l'effet d'une antibiothérapie empirique inappropriée sur ces résultats. MÉTHODES: Au cours d'une étude cas-témoins rétrospective d'un ratio de 1 pour 1 et réalisée dans un centre hospitalier de soins tertiaires entre 2005 et 2010, les données de 40 patients présentant une bactériémie à E. coli ou Klebsiella productrices de BLSE ont été comparées aux données de patients présentant une bactériémie à organisme non producteur de BLSE. RÉSULTATS: Parmi toutes les variables évaluées, seul l'emploi d'une antibiothérapie dans les trois derniers mois s'est révélé être un facteur de risque indépendant du développement d'une bactériémie à E. coli ou Klebsiella productrices de BLSE (risque relatif approché de 5,2, intervalle de confiance à 95 % de 1,6­16,9). Une plus grande proportion de patients présentant une bactériémie autre que celles à E. coli ou Klebsiella productrices de BLSE ont reçu une antibiothérapie empirique appropriée (88 % [35/40] contre 15 % [6/40], p < 0,001). Le temps requis pour trouver le traitement adéquat était plus long pour ceux présentant une bactériémie à E. coli ou Klebsiella productrices de BLSE (2,42 jours contre 0,17 jour, p < 0,001). La présence des espèces E. coli ou Klebsiella productrices de BLSE de même que la pertinence d'une antibiothérapie empirique n'ont pas eu de répercussion sur les résultats cliniques, notamment la durée du séjour à l'hôpital, l'admission à l'unité des soins intensifs (USI), la durée du séjour à l'USI (le cas échéant) ainsi que le taux de mortalité en hôpital. CONCLUSIONS: L'emploi d'une antibiothérapie préalable représentait un important facteur de risque indépendant de la survenue des espèces E. coli ou Klebsiella productrices de BLSE. Ce faisant, l'emploi d'une antibiothérapie préalable représente un facteur important à considérer au moment du choix d'une antibiothérapie empirique et devrait rendre sensible aux dangers des pathogènes résistants.

Practice changes to improve delivery of surgical antibiotic prophylaxis.

Timely administration of appropriate antibiotics preoperatively can decrease the incidence of surgical site infection. We evaluated compliance with quality indicators in the delivery of antimicrobial surgical prophylaxis at The Ottawa Hospital and assessed the impact of a change to the hospital's Surgical Prophylaxis Policy. An audit in 2002 revealed improvement was necessary in the timing of preoperative doses, dosing for patients with a high body mass index, and intra-operative redosing. As a result, a multidisciplinary group was formed and a new surgical prophylaxis policy was approved. The policy included administration of preoperative doses by the anesthesiologist, and an automatic substitution for higher doses of antibiotics for select patients. This practice change resulted in significant improvements to the preoperative timing and dosing in subsequent audits. A mechanism to address intra-operative redosing will be implemented.

Assessment of vancomycin use in chronic haemodialysis patients: room for improvement.

BACKGROUND: Vancomycin is frequently prescribed for the management of infections in haemodialysis patients. We evaluated the appropriateness of vancomycin use in our chronic haemodialysis population. METHODS: Charts of all chronic haemodialysis patients who received vancomycin between 1 March 2003 and 1 March 2004 were retrospectively reviewed. Indication was assessed according to the modified Hospital Infection Control Practices Advisory Committee guidelines for vancomycin prescription. The prescribed dosing regimens were evaluated. RESULTS: A total of 163 courses of vancomycin in 105 patients were assessed. Of all courses, 88% were considered to be initially appropriate, but this decreased to 63% once culture and sensitivity results were available. Use of vancomycin for the management of beta-lactam-sensitive organisms accounted for the majority of inappropriate use. The most common vancomycin-dosing regimen prescribed was 500 mg intravenously at each haemodialysis session (51%); however, considerable variability was observed. CONCLUSIONS: Although the initial indication for vancomycin use was generally appropriate, inappropriate continuation of this antibiotic, failure to obtain proper cultures to guide therapy and potentially subtherapeutic dosing regimens were some of the challenges identified. Centres providing chronic haemodialysis should take steps to optimize vancomycin prescription to improve clinical outcomes and reduce the risk of antimicrobial resistance.

Gatifloxacin-induced dysglycemia.

PURPOSE: The development of gatifloxacin-induced dysglycemia in 13 patients is described; the details of the 3 most severe cases are presented. SUMMARY: Three elderly patients developed dysglycemia after initiation of gatifloxacin therapy. Both patients who developed hypoglycemia were receiving concomitant insulin or oral antidiabetic agents. Repeated doses of dextrose were required for management. The Naranjo et al. probability rating scale revealed that gatifloxacin was the probable cause in the majority of the 13 cases, primarily because of the temporal relationship with gatifloxacin and, in some instances, resolution of dysglycemia after drug discontinuation. Although the mechanism of gatifloxacin-induced hyperglycemia is not known, in vitro studies have found that certain quinolone antimicrobials can lower serum glucose levels by blocking adenosine 5'-triphosphate-dependent potassium channels in the pancreatic beta-cell, stimulating insulin release. It is difficult to unequivocally implicate gatifloxacin as the only cause of dysglycemia in the cases presented, as there are many explanations for poor glycemic control in hospitalized patients, such as stress, infection, decreased renal function, and concomitant drug therapies. However, the patients' medication regimens appeared to be stable before gatifloxacin administration. CONCLUSION: Thirteen patients developed dysglycemia after receiving gatifloxacin. Gatifloxacin was found to be the probable cause in the majority of cases.

An evaluation of the management of asymptomatic catheter-associated bacteriuria and candiduria at The Ottawa Hospital.

BACKGROUND: Asymptomatic catheter-associated urinary tract infections (CAUTIs) are common in hospitalized patients. They are associated with a low incidence of sequelae and morbidity, and in most patients resolve spontaneously on removal of the catheter. As a result, it is not recommended that asymptomatic catheter-associated bacteriuria or candiduria be treated with antimicrobial agents while the catheter remains in place because it may lead to the evolution of resistant flora. OBJECTIVE: To assess the current management of patients with CAUTIs with respect to antimicrobial therapy at The Ottawa Hospital and the University of Ottawa Heart Institute, Ottawa, Ontario. METHODS: A prospective observational study over a period of 26 consecutive days was conducted at The Ottawa Hospital (General and Civic campuses) and the University of Ottawa Heart Institute. Inpatients with an indwelling catheter, a positive urine culture and the absence of UTI signs or symptoms were assessed. Patients were followed for five days to determine whether antimicrobials were prescribed. RESULTS: From March 3 to March 28, 2003, 29 of 119 patients screened met inclusion criteria. Of these 29 patients, 15 (52%) were prescribed antimicrobials and were therefore considered to be inappropriately managed. Differences were observed between the appropriate and inappropriate management groups in terms of duration of stay to positive urine culture and whether yeast or bacteria were isolated from the culture. CONCLUSION: Antimicrobial agents were prescribed in over one-half of CAUTI cases, contrary to recommendations from the literature. Education is required to bring this strongly supported recommendation into clinical practice.