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Patient Safety Tip of the Week
April 30, 2019
Reducing Unnecessary Urine Cultures
In this day and age of the emergence of multi-drug-resistant organisms, antibiotic stewardship is an extremely important concept. Treatment of asymptomatic bacteriuria is an example of inappropriate use of antibiotics that should be avoided in most cases. In our December 18, 2012 Patient Safety Tip of the Week “Unintended Consequences of the CAUTI Measure?” we noted that, because of CAUTI pay-for-performance (P4P) measures, many hospitals were screening for UTI’s on admission so they could use the “present on admission” provision to avoid financial penalties. That probably resulted in many patients receiving unnecessary treatment for UTI’s. In addition, at many hospitals, physicians routinely order urinalyses and urine cultures on admission.
Most guidelines do not recommend screening for UTI’s in asymptomatic patients, with certain exceptions such as pregnant women. Unnecessary screening results in increased costs due to lab costs, antibiotic costs, and possibly extension of length of stay. But it also potentially leads to development of resistant bacterial strains from overuse of antibiotics. Therefore, good antibiotic stewardship should include implementation of programs to reduce or avoid unnecessary screening for urinary tract infections.
Clinicians and researchers at Barnes-Jewish Hospital implemented a program to reduce such unnecessary screening (Munigala 2019). Their intervention consisted of notifications to providers, changes to order sets, and inclusion of urine culture reflex tests in commonly used order sets. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention), a 45% reduction in the urine cultures ordered. The intervention saved approximately $104,000 in laboratory costs alone over the 15-month period. They did not have available antibiotic costs to assess likely additional savings from reduced antibiotic use.
The CPOE intervention they implemented was setting the default option to urine dipstick testing followed by a bacterial culture if positive (i.e. reflex testing), rather than a culture alone, In our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts” we noted the importance of considering appropriate default options when designing order sets. One of the cognitive biases we see is the “default bias”, in which it is a natural tendency to select default options when several options are possible.
The authors conclude that CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.
A recent survey (Sullivan 2019) investigated interventions used by acute-care hospitals to reduce the detection of asymptomatic bacteriuria. Half of the respondents reported using reflex urine cultures but with varied urinalysis criteria and perceived outcomes. Other diagnostic stewardship interventions for urine culture ordering and specimen quality were less common.
Timely is the 2019 Update by the Infectious Diseases Society of America (IDSA) of its Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria (Nicolle 2019). It reiterates many of the recommendations from its 2005 guideline, but also addresses the issue of screening in some special populations.
The guideline still recommends screening for and then treating asymptomatic bacteriuria in pregnant women (4-7 days of antibiotics is recommended for pregnant women with asymptomatic bacteriuria). Screening and treatment is also recommended for patients undergoing endoscopic urologic procedures associated with mucosal trauma.
One special population is older patients with cognitive impairment. In those with bacteriuria and delirium or a fall and without local genitourinary symptoms or other systemic signs of infection (eg, fever or hemodynamic instability), the guideline recommends assessment for other causes and careful observation rather than antimicrobial treatment.
Another special population is the older functionally impaired adult. The guideline recommends against screening for or treating asymptomatic bacteriuria in both community-dwelling persons and those in long-term care facilities.
For high-risk neutropenia (absolute neutrophil count [ANC] <100 cells/mm3, ≥7 days’ duration, following cytotoxic chemotherapy) the guideline makes no recommendation
for or against screening for treatment of asymptomatic bacteriuria. For those with low-risk neutropenia, they note that there is no evidence to suggest that asymptomatic bacteriuria has greater risk than for the nonneutropenic population.
What about those patients with indwelling urethral catheters? For those with a short-term indwelling urethral catheter (<30 days) or those with long-term indwelling catheters, the guideline recommends against screening for or treating, though it makes no recommendation for or against screening or treating at the time of catheter removal.
For patients with spinal cord injuries (SCI), the guideline recommends against screening for or treating but acknowledges that clinical signs and symptoms of UTI experienced by patients with SCI may differ from the classic genitourinary symptoms experienced by patients with normal sensation. It notes the atypical presentation of UTI in these patients should be considered in making decisions with respect to treatment or nontreatment of bacteriuria. Note that our own practice is that, when signs and symptoms of autonomic dysreflexia increase in spinal cord-injured patients, we always look for evidence of a UTI.
The U.S. Preventive Services Task Force also has just put out a Draft Recommendation Statement on Asymptomatic Bacteriuria in Adults: Screening (USPSTF 2019). Opportunity for public comment expires on May 20, 2019 so this is not yet an official recommendation. However, you may wish to see the associated evidence review (Henderson 2019).
The IDSA guideline happens to come at the same time a study was published showing that, in elderly patients with proven or suspected UTI in the primary care setting, no antibiotics or delayed antibiotics were associated with a significant increase in bloodstream infection and all-cause mortality compared with immediate antibiotics (Gharbi 2019). That study, however, excluded patients with asymptomatic bacteriuria and those results should not dissuade us from following the ISDA guideline.
Our other columns on urinary catheter-associated UTI’s:
· May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
· January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
· April 2008 What’s New in the Patient Safety World column “More on Nosocomial UTI’s”
· June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
· April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
· June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
· March 2010 “IDSA CAUTI Guidelines”
· February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”
· January 2012 “CAUTI’s Still Get No Respect”
· May 2012 “Foley Catheter Hazards”
· November 2012 “CAUTI Conundrum”
· December 18, 2012 “Unintended Consequences of the CAUTI Measure?”
· January 2013 “Silver-Coated Urinary Catheters Don’t Reduce CAUTI’s”
· June 2013 “Barriers to CAUTI Prevention”
· November 2013 “Further Reducing Urinary Catheter Use”
· June 2014 “Updated HAI Prevention Guidelines from SHEA/IDSA”
· June 30, 2015 “What Are Appropriate Indications for Urinary Catheters?”
· December 2015 “CAUTI Prevention Tools”
· July 2016 “Holy Moly, My Patient has a FOLEY!”
· December 2016 “The Joint Commission NPSG for CAUTI’s”
· April 3, 2018 “Cost of a CAUTI”
· September 25, 2018 “Foley Follies”
References:
Munigala S, Rojek R, Wood H, et al. Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control and Hospital Epidemiology 2019; Published online: 21 February 2019: 1-6
Sullivan KV, Morgan DJ, Leekha S. Use of diagnostic stewardship practices to improve urine culturing among SHEA Research Network hospitals. Infection Control and Hospital Epidemiology 2019; 40(2): 228-231 Published online: 07 December 2018
Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2019; Published: 21 March 2019
https://www.idsociety.org/practice-guideline/asymptomatic-bacteriuria/
USPSTF (US Preventive Services Task Force). Draft Recommendation Statement. Asymptomatic Bacteriuria in Adults: Screening. USPSTF 2019
Henderson JT, Webber EM, Bean SI. Screening for Asymptomatic Bacteriuria in Adults: An Updated Systematic Review for the U.S. Preventive Services Task Force. AHRQ 2019; April 2019
Gharbi M, Drysdale JH, Lishman H, et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ 2019; 364: l525 (Published 27 February 2019)
https://www.bmj.com/content/364/bmj.l525
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