Urine Culture Collection Research Articles

Analysis of CAUTIs and Projected Effect of Increasing Pyuria Threshold in Urinalysis with Reflex to Culture

Background: Catheter-Associated Urinary Tract Infections (CAUTI) are preventable hospital acquired infections that contributes to patient morbidity, prolonged hospital stays and increased healthcare costs. Complete compliance to the CAUTI bundle is critical for preventing infection—not only reducing catheter days, but also ensuring appropriate indications are present for urine culture collection. Methods: This retrospective study included 145 patients diagnosed with CAUTI per NHSN definitions from July 1, 2020 to June 30, 2023. Data collected included laboratory data, catheter duration, catheter indication, urinalysis/culture indication and if foley was appropriately removed/changed prior to specimen collection. A urinary catheter indication order was implemented in February 2021 requiring providers to select specific criteria for catheter placement/maintenance. In July 2023, the threshold for urinalysis to reflex to culture was increased to ≥10 WBCs and this criteria was applied to these cases to estimate the effect on diagnosis of CAUTI. Results: The most common indications for urinary catheters were input and output monitoring 76 (52%) and urinary retention/obstruction 34 (23%). No indication was entered on 22 (15%) patients. No difference was seen in the number of catheters without an indication before or after the 2021 order update. Mean catheter duration was 11.5 days with a median of 7 days. The most common indications for obtaining a urine specimen were leukocytosis/fever/sepsis 91 (63%), urinary symptoms/abdominal/flank pain 13 (9%), urine appearance 6 (4%), and altered mental status 4 (3%). In 31 (21%) patients, no indication was identified. A urinalysis with reflex to culture was completed in 105 (72%) and the catheter was removed prior to culture collection in 68 (47%). Of the 127 patients with a urinalysis and culture, 11 had 0-5 WBCs, 16 had 6-9 WBCs, 15 had 10-20 WBCs and 85 had >20 WBCs. Using the new pyuria criteria for urinalysis to reflex to culture, 27 (19%) CAUTIs could have been avoided. Conclusion: Review of CAUTI cases identified opportunities for improving documentation and education of appropriate indications for urinary catheters and evaluation of urinary tract infection. The majority of urine cultures were obtained due to non-specific symptoms and less than 10% had specific urinary symptoms indicating need for continued education and diagnostic stewardship. Increasing the pyuria threshold needed to reflex to culture has the potential to significantly reduce CAUTIs but additional education is needed to ensure catheters are changed prior culture collection and specimens are only sent when signs and symptoms of urinary tract infection are present.

Beyond urinalysis: evaluation of various clinical and laboratory reflex criteria to warrant urine culture collection in the emergency department

BackgroundClinical criteria are essential for diagnosing urinary tract infections (UTIs) followed by urine testing, including urinalysis (UA). No study has evaluated the potential related factors that may guide the appropriate collection of urine cultures. Therefore, we aimed to assess the factors that may guide the appropriate collection of urine cultures.MethodsThis was a case-control study of patients for whom a urine culture and a UA were ordered in the emergency department (ED) between February 2018 and December 2022. The cases included patients with positive cultures, whereas the controls included patients without growth. Patients were excluded if they were pregnant, underwent any urological procedure, received antibiotics within 3 days before ED presentation, or before culture collection.ResultsOf the 263 patients, 123 had growth and 140 did not have growth in urine cultures. In the univariate analysis, female gender, urinary symptoms, urinary white blood cell (WBC) count > 5 cells/hpf, and nitrite in urine were significantly associated with growth (P < 0.05). However, only female gender (aOR, 1.86; 95% CI, 1.06–3.24), urinary WBC count > 5 cells/hpf (aOR, 4.60; 95% CI, 2.21–9.59), and positive nitrite in urine (aOR, 21.90; 95% CI, 2.80–171.00) remained significant in the multivariable analysis. These factors also remained significant in the subgroup of patients with urinary symptoms, except for the female gender.ConclusionA high urinary WBC count and positive nitrite in UA should be utilized as a guide to collect urine culture, particularly in female patients, to limit the unnecessary ordering of urine culture in the ED. These factors can be used as evidence-based UA reflex criteria as an antimicrobial stewardship intervention.

Comparative analysis of different loop types for urine culture collection: Implications for quantitative bacterial growth and culture results

We hypothesized that the loop material and size could affect the results of the culture when compared to the calibrated pipette. A total of 484 urine samples were included in the study, and each sample was plated by using different loop types and the calibrated pipette. The bacterial counts per milliliter were calculated and compared, with a focus on the important cutoff values of 10³ and 10⁴ CFU/ml for further identification. When considering the 10³ CFU/ml as cutoff value, 1 µl and 10 µl plastic loops gave the highest sensitivity (86.8 %), whereas the 10 µl metal loop had the lowest sensitivity (64.2 %). For the 10⁴ CFU/ml cutoff value, 1 µl plastic loop inoculation demonstrated the highest sensitivity (75.9 %), while the 10 µl metal loop provided the lowest sensitivity (26.5 %). These results suggest that the single use plastic loops are functional, sensitive, useful especially for critical sample.

A pharmacist-driven deprescribing protocol for negative urine and sexually transmitted infection cultures in the emergency department increases antibiotic-free days.

Emergency department (ED) pharmacists commonly perform positive culture follow-ups that result in optimized antibiotic prescribing. The purpose of this study was to evaluate the potential positive impact on the outcome of antibiotic-free days through an ED pharmacist-driven protocol to contact patients with negative urine cultures and sexually transmitted infection (STI) test results who were discharged with antibiotics. This was a single-center, prospective, observational, pre-post intervention study to determine antibiotic use in patients with negative urine cultures who were discharged from the Loyola Medical University Center ED with antibiotics prescribed. Patients were identified through daily positive culture reports. The primary outcome was days free of antibiotics, defined as the number of calendar days within 28 days after urine culture or STI test collection on which the patient did not receive any antibiotic treatments. One hundred ninety-two patients were screened. Sixty-three and twenty-six patients met the inclusion criteria in the pre- and postintervention groups, respectively. The study identified 163/465 (35.1%) antibiotic free days for the preintervention group, compared to 150.5/187 (80.5%) antibiotic-free days for the postintervention group. A majority of the patients did not have urinary tract infection as the chief complaint. The most common urinary and STI symptoms upon ED admission in the pre- and postintervention groups were dysuria (19.2% vs 28.1%) and unusual discharge (30.8% vs 28.6%), respectively. This study showed that a pharmacist-driven protocol increased the number of antibiotic-free days for patients prescribed empiric antibiotic therapy and discharged from the ED with subsequent negative urine cultures and STI results. We propose taking a novel approach in discontinuation of antibiotics by implementing an expansion of ED culture programs to include negative cultures that promote antimicrobial stewardship.

Prevalence of and risk factors for bacteremic UTIs in hospitalized adults without definitive signs or symptoms of UTI

Background: IDSA guidelines recommend withholding treatment in patients with asymptomatic bacteriuria in the absence of systemic signs of infection. However, some patients with bacteriuria may not be able to express symptoms either due to presence of indwelling catheter, underlying complicated urologic anatomy, dementia, or altered mental status (AMS). Clinicians frequently treat bacteriuria in this population with antimicrobial therapy due to concern for sepsis. To determine treatment need, we aimed to review prevalence and risk factors for bacteremic urinary tract infection (UTI) in a cohort of hospitalized inpatients without definitive signs and symptoms of a UTI. Methods: This retrospective cohort study of inpatients with a positive urine culture who presented without definitive signs or symptoms of a UTI was conducted between July 1, 2017, and June 30, 2022, in 68 academic and community hospitals (Michigan Hospital Medicine Safety Consortium). Signs and symptoms were obtained from medical record review 3 days before and after urine-culture collection. Bacteremic UTI was defined as any positive blood culture growing at least 1 organism matching the urine culture. Risk factors for bacteremic UTI were assessed using multivariable logistic regression models with results expressed as odds ratios (ORs) for dichotomous variables and relative risks (RRs) for continuous variables. Results: Of 11,793 patients meeting study criteria, 73.6% were female with a median age of 78.2 years. Overall, 41.8% had AMS, 33.8% had dementia, 15.6% had an indwelling urinary catheter, and 54.6% had complicated urologic history (eg, urologic surgery). Of these, 166 patients (1.4%) developed bacteremic UTI. On adjusted analysis, male sex, hypotension, heart rate &gt;90, urinary retention, fatigue, log of serum leukocytosis [1 log increase in serum WBC = 2.718 × serum white blood cell count (WBC)], and pyuria with &gt;25 WBC per high-powered field (WBC/hpf) on urinalysis were associated with bacteremic UTI (Table). Older age, presence of an indwelling catheter, complicated urologic history, functional decline, AMS, dementia, and change in urine were not associated with higher odds for bacteremic UTI (Table). Of patients with AMS and no definitive signs or symptoms of a UTI, only 89 (1.8%) of 4,932 developed a bacteremic UTI. Conclusions: Bacteremic UTI is relatively rare in hospitalized inpatients presenting with bacteriuria without symptoms of UTI. Predictors of bacteremic UTI included male sex, hypotension, tachycardia, urinary retention, fatigue, serum leukocytosis, and higher levels of pyuria (&gt;25 WBC/hpf) on urinalysis. Our findings provide stewards a framework to risk stratify inpatients of older age who present with positive urine cultures but without (or are unable to express) signs or symptoms of UTI.Disclosures: None

Using clinical decision support to improve urine testing and antibiotic utilization.

Urine cultures collected from catheterized patients have a high likelihood of false-positive results due to colonization. We examined the impact of a clinical decision support (CDS) tool that includes catheter information on test utilization and patient-level outcomes. This before-and-after intervention study was conducted at 3 hospitals in North Carolina. In March 2021, a CDS tool was incorporated into urine-culture order entry in the electronic health record, providing education about indications for culture and suggesting catheter removal or exchange prior to specimen collection for catheters present >7 days. We used an interrupted time-series analysis with Poisson regression to evaluate the impact of CDS implementation on utilization of urinalyses and urine cultures, antibiotic use, and other outcomes during the pre- and postintervention periods. The CDS tool was prompted in 38,361 instances of urine cultures ordered in all patients, including 2,133 catheterized patients during the postintervention study period. There was significant decrease in urine culture orders (1.4% decrease per month; P < .001) and antibiotic use for UTI indications (2.3% decrease per month; P = .006), but there was no significant decline in CAUTI rates in the postintervention period. Clinicians opted for urinary catheter removal in 183 (8.5%) instances. Evaluation of the safety reporting system revealed no apparent increase in safety events related to catheter removal or reinsertion. CDS tools can aid in optimizing urine culture collection practices and can serve as a reminder for removal or exchange of long-term indwelling urinary catheters at the time of urine-culture collection.

2228. Antibiotic Appropriateness for UTI Treatment on Monday vs Friday in a NYC Hospital ED

Abstract Background Urinary tract infections (UTI) are common and often lead to an antibiotic prescription. Prior studies have shown that antibiotic prescriptions can vary between weekdays and weekends. Methods This is a retrospective case series of female patients ≥18 years with simple cystitis presenting to the ED between 2019 to 2021 in a NYC community hospital. Our primary objective was to determine how often the appropriate antibiotic was prescribed and compare this between Monday and Friday. Antibiotic appropriateness was defined using the 2011 Infectious Disease Society of America clinical practice guidelines for acute uncomplicated cystitis. Criteria included antibiotic selection, dose, frequency, and duration. Per the NYC outpatient UTI antibiogram, Amoxicillin, Ampicillin, Ciprofloxacin, and TMP/SMX were not appropriate empiric therapies. Categorical data is reported as counts (%) and compared with Chi-square; age (nonparametric) is reported as median (range) and compared with Mann-Whitney. Sample size calculation estimated that 71 subjects were needed on each day to detect an effect size of 20% difference in our primary outcome (90% antibiotic appropriateness on Monday and 70% on Friday) with 80% power and an alpha error of 0.05. Results 160 subjects were included, 80 seen on Mondays and 80 seen on Fridays. Demographics were similar between groups, except for antibiotic allergies (Table 1). There was no difference between appropriate antibiotics prescribed on Mondays compared to Fridays, 54/80 (67.5%) vs 60/80 (75%) (p-value = 0.29). Failure to meet criteria for appropriateness was due to inappropriate prescription duration (44/160) or selection (14/160). All prescriptions met criteria for dose and frequency. There was no difference in antibiotic selection, dose, frequency, or duration of prescription on Monday vs Friday (Table 2). More urine cultures were collected on Mondays (62/80) vs Fridays (49/80) (p =.03). Conclusion 1 in 3 patients were prescribed inappropriate antibiotics for simple cystitis, though there was no difference between Mondays and Fridays. Inappropriate antibiotic duration and differences in urine culture collection indicate an inconsistent approach to treatment and missed opportunity to course correct in cases of pathogen resistance. Disclosures Cara Grimes, MD, MAS, Johnson and Johnson: Expert Testimony|Provepharm, Inc: Advisor/Consultant.

997. Burden of Inappropriate Urine Culture Collection and Processing on the Environment

Abstract Background Healthcare is the second-most energy-intensive commercial sector in the United States. Clinical laboratories make up a large portion of that energy use and contribute significantly to waste production (7, 8, 9, 10). We aimed to estimate the environmental impact of urine cultures and suggest inappropriate culturing as a target for diagnostic stewardship and waste mitigation. Methods The total number of urine cultures performed by our facility’s microbiology laboratory was gathered. The plastic components, including bacterial culture plates, urine sample collection cups, and biohazard bags, were weighed. Results Between 3/07-03/13/21, 533 urine cultures were processed by our facility. Since the number of bacterial culture plates varies between samples, we calculated a range from 2 cell-culture plates (clean catch sample) to 4 cell-culture plates (in-and-out catheterization sample), with an additional 1-2 plates per isolate for susceptibility testing. This yielded a range of 3-6 total plates (30g for bacterial culture plates, 120g for susceptibility plates) used per processed urine culture. Each sample also requires a collection cup (27.2g or 19.1g) and a biohazard bag (4.1g) yielding a range of 95 - 192kg of plastic waste over the study period. Assuming this week represents an average week, our projected annual waste is between 6.5 to 12 tons for urine culture collection and testing. Conclusion In this single-center pilot study, urine cultures produced an estimated 6.5 to 12 tons of plastic waste annually. Prior studies suggest that 58%-68% of urine cultures are not clinically indicated (2, 3). This includes up to 35% of emergency department urine cultures being done in the context of a negative urinalysis, 20% of urine cultures sent without a urinalysis, and a urine culture contamination rate of at least 5% (4). While the effects of inappropriate urine cultures on length of hospital stay, antibiotic stewardship, and healthcare costs have been investigated, the subsequent impact on the environment has not been well studied (5). Although this study was limited by its reliance on estimated numbers, the sizable impact on healthcare’s net waste production suggests that further quantifying inappropriate culturing and how to alleviate it is an important area for further investigation. Disclosures All Authors: No reported disclosures.

2240. Implementation of a Clinical Decision Support Panel for Urine Culture Ordering

Abstract Background Standard urine culture collection techniques have a high risk of false positive results in catheterized patients. IDSA guidelines recommend replacing long-term catheters before specimen collection for cultures. Our goal was to evaluate the impact of clinical decision support (CDS) during the urine culture computerized provider order entry (CPOE) on test use and patient-level outcomes. Methods In March 2021, CDS was added to the urine culture CPOE in the electronic health record (EHR). The order panel includes education regarding appropriate clinical indications for urine culturing, and protocolizes urine collection to determine (A) if a urinalysis was ordered, (B) if special patient population (i.e., PICU), (C) the presence and duration of an indwelling urinary catheter, and (D) whether the catheter had difficulty with placement. Depending on the criteria identified in A, B, C, and D, the panel recommends catheter removal prior to urine culture (Figure 1). We retrospectively evaluated the impact of panel implementation in our pre- (7/2020- 3/2021) and post-intervention periods (4/2021- 3/2022) using an interrupted time series analysis with Poisson regression. Outcomes included urine cultures/1000 patient days (pd), number of catheter removal orders, catheter-associated urinary tract infection (CAUTI)/1000 catheter days, and days of antibiotic therapy with urinary tract infection (UTI) indication/1000pd Order Panel Framework Results Clinicians selected catheter removal in 183 of 2133 (8.5%) instances of ordering a urine culture when a catheter was detected by the panel (Figure 2). Analysis revealed a significant decrease in urine culture orders (1.1% decrease/month, p&amp;lt; 0.05), a decreasing trend of antibiotic use with UTI indications (Figure 3, 2.8% decrease/month, p&amp;lt; 0.05), but no significant change in CAUTI rates (Figure 4). Evaluation of the safety reporting system revealed no identifiable increase in safety events related to catheter removal or reinsertion. Catheter Associated Urinary Tract Infections Black boxes indicate Poisson regression model estimates Black boxes indicate Poisson regression model estimates Conclusion CDS can aid in improving urine culture practice habits, including removal of long-standing catheters before urine culture. The decreasing trend in total urine culture orders (Figure 5) may reflect a ”culture change” over time to avoid urine cultures in inappropriate instances. Total Urine Cultures Ordered Black boxes indicate Poisson regression model estimates. Red circles indicate predicted outcome without ‘intervention’. Disclosures Sonali D. Advani, MBBS, MPH, FIDSA, Locus Biosciences: Advisor/Consultant|Locus Biosciences: Honoraria|Sysmex America: Advisor/Consultant.

Prevalence and predictors of urine culture contamination in primary care: A cross-sectional study

BackgroundAntimicrobial resistance is a global health threat. To slow resistance and preserve antibiotics, stewardship interventions are increasingly promoted and mandated. Urine cultures are the most common microbiological test in the outpatient setting. Contamination most likely occurs during urine collection from surrounding vaginal, perineal, and epidermal flora. Sample contamination can lead to incorrect diagnosis, unnecessary or inappropriate treatment, poor patient outcomes, and higher costs. Therefore, ensuring proper collection of urinary samples serves as a prime diagnostic stewardship target, one that international nursing societies increasingly endorse as an opportunity for nurse involvement. ObjectivesDetermine the prevalence, predictors, and antibiotic prescribing associated with contaminated urine cultures in primary care clinics. DesignCross-sectional study. SettingTwo adult safety-net clinics in Houston, Texas. Participants1265 clinical encounters among 1114 primary care patients. MethodsWe reviewed charts from office visits among patients who had a urine culture ordered between November 2018 and March 2020. Patient demographics, culture results and prescription orders were captured for each visit. Culture results were defined as no growth, contaminated (i.e., mixed flora, non-uropathogens, or ≥3 bacterial species isolated), or low-count (102–105 colony forming units (CFU)/mL) or high-count (>105 CFU/mL) uropathogen-positive. We performed multinomial logistic regression to identify predictors independently associated with contaminated cultures. ResultsOur study evaluated 1265 cultures from 1114 patients that were primarily female (84 %), of Hispanic/Latino (74.4 %) or Black/African American (18.9 %) race/ethnicity with a mean age of 43 years. Out of 1265 urine cultures, 264 (20.9 %) had no growth, 694 (54.9 %) were contaminated, 159 (12.6 %) were low-count positive, and 148 (11.7 %) were high-count positive. Female sex, pregnancy, and obesity were associated with contaminated cultures (multinomial adjusted odds ratios: 15.89, 14.34, 1.93, respectively; 95 % confidence intervals: 10.25–24.61, 8.03–25.61, 1.32–2.81, respectively). Antibiotic prescribing was significantly higher among symptomatic patients with contaminated cultures compared to those with no growth. ConclusionUrine culture contamination occurred frequently in our clinics, and obesity, female sex and pregnancy were independent risk factors for contamination. The association of pregnancy and contamination is particularly concerning as pregnant females are routinely screened and treated for asymptomatic bacteriuria in the United States. Culture contamination may obscure underlying uropathogens, leading to pyelonephritis or potential neonatal infection if untreated. Conversely, overtreatment of false positive bacteriuria could lead to adverse effects from antibiotics and increased risk for antibiotic resistance. As nurses play a prominent role in patient education, diagnostic stewardship interventions may want to utilize nurses' educational capabilities to improve urine culture collection. Tweetable abstract55 % of urine cultures collected in primary care clinics were contaminated, revealing a major opportunity for nurse-driven diagnostic stewardship interventions.

83. Impact of a Urine Culture Best Practice Advisory on Collection of Urine Cultures and Subsequent Antibiotic Therapy

BackgroundIn the acute care setting, urinary tract infections (UTIs) may be over diagnosed in up to 40% of cases. In most scenarios, asymptomatic bacteriuria (ASB) is not an indication for antibiotic therapy; inappropriate therapy is associated with a higher incidence of antibiotic-resistant bacteria and adverse drug reactions. Limiting inappropriate collection of urine cultures may decrease unnecessary treatment of ASB. The objective of this study is to assess the impact of a urine culture best practice advisory (BPA) on collection of unnecessary urine cultures. MethodsThis retrospective, observational, single-center study included adult inpatients with an order for urinalysis/urine culture. Those who were pregnant, had a concomitant infection other than UTI and/or were taking antimicrobials for a non-UTI indication, and were undergoing urological procedures were excluded. Duplicate urine culture collections and/or admissions were excluded. Incorporation of a BPA into computerized provider order entry, allowing providers to assess need and document indication for urine culture collection, was implemented on July 2019. The following clinical outcomes were assessed: number of unnecessary urine cultures collected, number of antibiotic treatments, and antibiotic-associated adverse reactions. ResultsTwo hundred met criteria for inclusion; 96 in the pre-BPA group (Aug – Oct 2018) and 104 in the post-BPA group (Aug – Oct 2019). Seventy-four (37%) were male and the mean age was 64 and 70 years (p=0.249), respectively. The Charlson Comorbidity Index (CCI) was similar between groups (4 vs. 5, p=0.162) and majority were admitted to a general medical ward (94.5%). Seventy patients (72.9%) in the pre-BPA group and 47 (51.6%) in the post-BPA group had inappropriately ordered urinalysis/urine cultures (OR 0.40; 95% CI 0.22-0.73; p=0.003). Of these patients, 15 (21.4%) and 9 (19.1%) from the pre- and post-BPA groups, respectively, were treated (p=0.077). Among those treated, only two adverse drug reactions were reported. ConclusionImplementation of a BPA significantly reduced the number of inappropriate urinalysis/urine culture orders. There was a trend towards decreased antibiotic use for ASB. Future studies are warranted to assess sustainability of these results. Disclosures All Authors: No reported disclosures

PD01-01 PREVALENCE OF URINARY TRACT INFECTIONS IN WOMEN WITH INTERSTITIAL CYSTITIS

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Interstitial Cystitis (PD01)1 Sep 2021PD01-01 PREVALENCE OF URINARY TRACT INFECTIONS IN WOMEN WITH INTERSTITIAL CYSTITIS Kyle Smith-Honore, Alexandra Dubinskaya, Catherine Bresee, Kai Dallas, Kamil Barbour, Jayoung Kim, Stephen Freedland, and Jennifer Anger Kyle Smith-HonoreKyle Smith-Honore More articles by this author , Alexandra DubinskayaAlexandra Dubinskaya More articles by this author , Catherine BreseeCatherine Bresee More articles by this author , Kai DallasKai Dallas More articles by this author , Kamil BarbourKamil Barbour More articles by this author , Jayoung KimJayoung Kim More articles by this author , Stephen FreedlandStephen Freedland More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001965.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Flares, or the sudden increase in symptoms, are common in patient with interstitial cystitis/bladder pain syndrome (IC/BSP). Symptoms flares often have a clinical presentation similar to urinary tract infections (UTI), with pain, frequency and urgency. However, the prevalence of culture-proven UTIs that occur in women with an IC/BPS diagnosis is not well established. METHODS: This is a retrospective study of all women carrying an ICD-9/10 code for IC/BPS (595.1/N30.10) in the VA system between October 2004–July 2016 who presented to the clinic at least once with concern for IC/BPS symptom exacerbation. Female patients older than 18 years of age were identified as having IC/BPS if they had a diagnosis code for IC/BPS. Patient demographics, visit chief complaint, urine culture collection and urine culture positivity were assessed. Associations between the patients presenting symptom, and urine culture testing and results were compared with the chi-square test. RESULTS: Overall, 469 women (1,444 total visits) were identified with 0.8 average visits per year. The most common visit chief complaint was pelvic pain (n=734, 50.8%) (Table 1). A urine culture was more likely to be collected (122 of 200, 61.0%) if dysuria was present as compared to visits were only pelvic pain was present (213 of 734, 29.0%, p<0.001 ) or neither pelvic pain nor dysuria were present (51 of 262, 19.5%, p<0.001). If a culture was sent, a complaint of dysuria only was associated with the highest rate of culture positivity (23 of 122, 18.9%, p=0.001) as compared to all other groups. CONCLUSIONS: Overall, positive cultures in women with IC/BPS flares were relatively low. A positive urine culture was most common in visits where only dysuria was present. This data thus supports carrying a higher index of suspicion of UTI if patients present in this fashion. Source of Funding: CDC © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e30-e30 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Smith-Honore More articles by this author Alexandra Dubinskaya More articles by this author Catherine Bresee More articles by this author Kai Dallas More articles by this author Kamil Barbour More articles by this author Jayoung Kim More articles by this author Stephen Freedland More articles by this author Jennifer Anger More articles by this author Expand All Advertisement Loading ...

Urine Trouble: Reducing Midstream Clean Catch Urine Contamination Among Children 3-17 Years Old.

Children, caregivers, and clinicians often prefer midstream clean catch technique to urethral catheterization for obtaining urine cultures. However, contamination is common, potentially resulting in unnecessary medical intervention and cost. With this resident-led initiative, we aimed to reduce pediatric midstream clean catch urine culture contamination over 6 months. A bundled intervention was implemented in the emergency department, inpatient units, and outpatient clinics at our institution. Baseline contamination rates were collected April 2016 to September 2017; the intervention was introduced October 2017 to March 2018 and evaluated April 2018 to September 2018. Sustainability was measured October 2018 to September 2020. Balancing measures included rates of repeat urine cultures, positive cultures, and contaminated cultures by urethral catheterization. Rates of midstream clean catch urine culture contamination were 45.3% preintervention and 30.9% postintervention, a 14.7% (95% confidence interval: 8.0% to 21.5%) absolute decrease. Before and after intervention, girls and patients 16 to 17 years old had the highest rates of midstream clean catch contamination. Six months postintervention, the rate of repeat urine culture decreased from 4.9% to 0.9% with no change in positive culture results or contaminated cultures by urethral catheterization. Over the subsequent 2 years, the impact of the intervention decreased (rate of contamination over 30 months postintervention: 38.4%, a 7.3% [95% confidence interval: 2.9% to 11.6%] absolute decrease; rate of repeat urine culture: 3.2%). An intervention to improve midstream clean catch urine culture collection was associated with a clinically meaningful decrease in contamination. Impact of the resident-led intervention decreased over time.

Identification of Potentially Unnecessary Micafungin Use Patterns: Opportunities for Antifungal Stewardship Interventions

Background: Echinocandins are used as first-line therapy for suspected and confirmed Candida spp, and its indiscriminate use may drive selection for echinocandin resistance. We evaluated patterns of use of micafungin to identify opportunities for antifungal stewardship. Methods: We identified all micafungin completed orders and microbiological test result data from July 2018 to November 2020 among hospitalized patients in Barnes-Jewish Hospital. Continuous micafungin courses with &lt;48 hours of interruption were considered independent courses. We evaluated micafungin use in 3 scenarios in which its use may be unnecessary: (1) patients with blood cultures negative for Candida spp, (2) patients with recovery of yeast or Candida spp from tracheal aspirates, and (3) patients with recovery of yeast or Candida spp from urine cultures. We only included micafungin courses if they were initiated within 5 days of blood culture collection or up to 4 days after tracheal or urine culture collection to account for incubation and decision to initiate treatment. Results: We found 3,381 micafungin courses in 3,287 admissions. Of these, 2,532 courses had blood culture collection around micafungin initiation and were included in the first analysis: 1,879 (74%) were negative, 149 (6%) had Candida spp isolated in the blood, and 504 (20%) had positive blood cultures for other organisms. Micafungin was given for a median duration of 3 days (IQR, 2–7) to those with negative blood cultures and for 3 days (IQR, 1–5) to those with positive blood cultures without candidemia (p &lt; 0.001), and prolonged durations of more than 5 days was seen in 768/1879 (41%) and 143/504 (28%) of courses, respectively (p &lt;0.001). A total of 487 micafungin courses were initiated after tracheal aspirate culture collection. Those with yeast isolated (n = 100, 21%) received similar micafungin duration compared to those that had no yeast isolated [3 (2-7 IQR) vs. 3 (2-7) days, respectively; p = 0.56). Finally, a total of 844 micafungin courses started after urine culture collection. A total of 49 (6%) had yeast isolated from the urine and treatment duration was similar to those that did not [3 (1-6 IQR) vs. 3 (2-6) days, respectively; p = 0.87). Conclusions: Echinocandin treatment courses did not differ when a yeast was identified from a tracheal isolate or urine specimen. However, a substantial proportion of treatment courses were prolonged in those with negative Candida spp in the blood, suggesting opportunities for antifungal stewardship interventions.Funding: NoDisclosures: None

The clinical utility of intrapartum screening urinalysis for the prevention of postpartum pyelonephritis

ObjectivesUrinary tract infection (UTI) is the most common bacterial infection to complicate pregnancy. Medical authorities recommend screening for asymptomatic bacteriuria (ASB) in pregnancy; albeit there is no consensus on ideal timing and frequency for testing. Due to the persistent physiologic changes of pregnancy postpartum, a recent trend to perform urinalysis upon presentation for delivery has been adopted at our institution and various satellite hospitals to putatively minimize cases of postpartum pyelonephritis. The aim of this study is to examine whether routine testing with urinalysis and screening for ASB following suspicious urinalysis with treatment can decrease the incidence of postpartum pyelonephritis, and to determine whether certain urinalysis parameters are more predictive of a positive urine culture. Study designA retrospective chart review study of all term deliveries was conducted over two years at the American University of Beirut Medical Center, a university teaching hospital. A total of 2359 deliveries of women with no increased susceptibility to UTIs were reviewed. None had urinary symptoms upon presentation. Urinary parameters including time of urinalysis and urine culture collection with respect to time of delivery, corresponding results and mode of urine collection were correlated to intrapartum course, incidence of ASB and of postpartum pyelonephritis. ResultsThe incidence of ASB among women presenting for delivery was 4.83 %, with Escherichia coli as the most commonly detected pathogen. The presence of nitrite on urinalysis was significantly associated with a positive urine culture (p-value<0.001). Women with history of antenatal ASB or UTI were more likely to have ASB intrapartum with an odds ratio of 3.14 (95 % CI 1.71–5.75, p-value <0.001). Intrapartum urinalysis with subsequent diagnosis and treatment of ASB did not significantly affect the incidence of postpartum pyelonephritis (p-value 0.280). Similarly, intrapartum urinalysis in the setting of positive history of antenatal ASB or UTI did not increase the incidence of postpartum pyelonephritis compared to women with no such history (p-value 0.659). ConclusionsUrinalysis screening intrapartum does not decrease the incidence of postpartum pyelonephritis. Universal urinalysis screening intrapartum is not warranted and should be reserved for women reporting urinary symptoms and/or women at high risk of UTI.

Contamination rates of different methods of urine culture collection in children: A retrospective cohort study.

Urinary tract infection is a common cause of paediatric morbidity. However, there is no consensus on the default method for urine culture collection in children. This study aimed to examine the contamination rates of different urine collection methods. This was a retrospective cohort study in a paediatric emergency department. Data were collected from electronic health records on all children whose urine culture samples were obtained in the paediatric emergency department between March 2018 and March 2019. Different methods of urine collection included the midstream (MS) method, clean catch (CC), transurethral bladder catheterisation and suprapubic aspiration. Contamination rates and positive urine culture rates were calculated and compared for sex, age, and collection method. Urine culture samples were collected from 1507 children. There were 284 (18.8%) cultures that were positive with significant growth and 52 (3.5%) that were defined as 'contaminated'. The contamination rates for the midstream method in toilet-trained children were 1.6% (10/609), 4.9% (17/348) for CC in pre-continent children, 4.9% (25/515) for transurethral bladder catheterisation and 0% (0/35) (P=0.006) for suprapubic aspiration. There was no significant difference in contamination rates of urine cultures collected by CC and catheterisation in the compared groups. The rates of positive cultures in the subgroup of children with high suspicion for Urinary tract infection were also found to be similar. Our study shows that CC is non-inferior to catheterisation for collecting urine cultures in young children.

234. Improving Antibiotic Prophylaxis Selection for Patients Undergoing Urology Procedures

BackgroundEvidence evaluating prescribing patterns in antibiotic (ABC) prophylaxis (PPX) for urology (UGY) procedures is limited. Although national guidelines give direction on the ABC PPX for specific procedures, ABC PPX should also be based on local ABC resistance patterns, individual host factors and procedure type factors. Our institution’s urine culture antibiogram illustrates increasing resistance to Cefazolin, a national guideline preferred ABC. The purpose of this study is to assess the impact of a quality improvement intervention on prescribing practices for ABC PPX in patients undergoing UGY procedures.MethodsThis is a retrospective study evaluating all patients receiving perioperative ABC PPX for UGY procedures from 01/01/2019 to 07/31/2019. The intervention (focusing on UGY provider education for ABC PPX based on local ABC resistance patterns, host factors and UGY procedure type) occurred on multiple in-person sessions during 04/2019. Emphasis occurred with replacing Cefazolin with Ceftriaxone, given local resistance patterns. We compared patient characteristics, appropriate ABC PPX use (deemed by local ABC Stewardship Team) and postoperative infections between the “pre” (01/01/2019 – 03/31/2019) and “post” (05/01/2019 – 07/31/2019) groups.ResultsThe “pre” group had 85 patients and the “post” group had 80 patients. 62% had a same day UGY procedure with the most common procedures designated as “clean-contaminated” (81.8%) and ASA physical status classification as “ASA II” (53.9%). After the intervention, appropriate ABC PPX choice improved (14.5% to 76%, P < 0.001) based on local ABC resistance patterns. No significant difference is noted in urine culture collection before procedure (36.4% to 43.7%, P = 0.3), ABC PPX choice based on prior patient-specific culture results including multi-drug resistant pathogens (75% to 82.3%, P = 0.6), use of ABC PPX post-procedure (40% to 35%, P = 0.5) and postoperative infections (7% to 11.2%, P = 0.4).ConclusionUtilization of education sessions as a quality improvement intervention resulted in significant improvement in ABC PPX choice for UGY procedures based on local ABC resistance patterns. Further interventions are necessary to optimize additional areas related to ABC PPX use for UGY procedures.Disclosures All Authors: No reported disclosures

219. Characteristics Associated with Inappropriate Antibiotic Prescribing in Patients with Asymptomatic Bacteriuria (ASB)

BackgroundAntibiotic treatment of asymptomatic bacteriuria (ASB) is considered inappropriate, does not improve patient outcomes, and may lead to adverse events such as antibiotic resistance and Clostridioides difficile infection. Previous stewardship interventions have focused on reducing unnecessary urine culture collection in individuals without urinary symptoms; however, further interventions to reduce inappropriate prescribing in ASB are warranted. This study sought to identify characteristics associated with treatment of ASB in order to implement future stewardship interventions.MethodsThis two-center, retrospective cohort study included unique emergency department or inpatient adults with consecutive non-duplicate monomicrobial urine isolates of Enterobacterales or Pseudomonas aeruginosa collected between 8/2013 and 1/2014 from two academic hospitals in Boston, Massachusetts. Patients with ASB (without chart-documented urinary-specific symptoms) were identified through chart review and stratified into two groups: those treated with empiric urinary tract infection (UTI) antibiotics and those untreated. Logistic regression analyses were performed to identify variables independently associated with antibiotic treatment of ASB.ResultsDuring the study, 255 patients were determined to have ASB and a majority (80.8%) were treated with empiric UTI antibiotics. Most patients were female (71.4%) and elderly (mean age 70 years). The most common organisms isolated were Escherichia coli (59.2%), Klebsiella spp. (23.1%), and P. aeruginosa (9.8%). The presence of isolated fever (OR, 7.83 [95% confidence interval, 1.51, 144.20]); p = 0.05), urinalysis positive for pyuria (>10 white blood cells) (OR, 2.52 [95% CI, 1.15, 5.54]; p = 0.02), and Klebsiella spp. urine isolate (OR, 2.99 [95% CI, 1.19, 8.60]; p = 0.02) were independently associated with treatment.ConclusionA large proportion of ASB patients were treated with antibiotics despite clinical practice guidelines recommending against this practice. Isolated fever, pyuria, and Klebsiella spp. culture were all significantly associated with the treatment of ASB; targeted review of these patients by stewardship programs may help to reduce inappropriate ASB treatment within these institutions.Disclosures Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support) Nabriva Therapeutics (Advisor or Review Panel member)

Catheter-Associated Urinary Tract Infections (CAUTIs) Reduction: A Multidisciplinary Approach

Background: CAUTIs remain one of the most common hospital-acquired infections (HAIs) accounting for prolonged hospital stay and increased healthcare costs. According to the NHSN, the standardized infection ratio (SIR) at our institution was 1.6 compared to national average of 0.84 in 2018. We highlight the interventions implemented in our institution to prevent CAUTIs. These interventions have shown a reduction in the rate of CAUTIs, the SIR, Foley catheter days, and institutional cost. Methods: In addition to standard CAUTI prevention practices, we hypothesized that we could decrease CAUTIs through the daily implementation of specific practices. We developed a comprehensive interdisciplinary team which included the staff or charge registered nurse (RN), the unit manager, an infection preventionist, an advanced practice registered nurse (APRN), a pharmacist with an antimicrobial focus, and a physician from the infectious disease department who would conduct daily rounds on different units in the institution for education and assessment of catheter indications. A detailed review and analysis of the urine culture orders for patients with a Foley catheter was performed. A nurse-driven Foley catheter removal protocol before urine culture collection was initiated. We implemented a Foley catheter bundle that has guidelines for Foley insertion, best practice competency, and urinary catheter best practice algorithm and advocated alternative use of male or female external catheter. We educated physicians about ordering a reflexive urine analysis test followed by urine culture instead of testing either individually after removal of a Foley catheter. Lastly, we performed a root-cause analysis on all reported CAUTIs. These policies were implemented in a 435-bed tertiary-care center in November 2018, and we present data from 1-year before and after the interventions. Results: At our institution, we had 71 CAUTIs, with an SIR of 1.6, a standardized utilization ratio (SUR) of 0.92, 27,621 Foley days, and institutional cost of $979,303 compared to 40 CAUTIs with an SIR of 1, an SUR of 0.88, 24,193 Foley days, and institutional cost $537,927 after implementing our interventions. Conclusions: CAUTIs can be reduced by implementing specific measures that include infection control team rounds, nurse-driven protocol, and the use of Foley catheter bundles. Measures should be undertaken to prioritize these practices as part of a protocol. We advocate further studies to evaluate these measures. Education programs for healthcare professionals concerning CAUTIs and its complications can be implemented to carry out the prevention methods efficiently.Funding: NoneDisclosures: None

2261. Oral Fosfomycin for Treatment of Urinary Tract Infections Due to Extended-Spectrum β-Lactamase and Carbapenem-Resistant Enterobacteriaceae

BackgroundUrinary tract infections (UTIs) caused by extended spectrum β-lactamase (ESBL) and carbapenem-resistant Enterobacteriaceae (CRE) pose a significant challenge due to limited treatment options. The objective of this study was to compare outcomes in patients treated with standard IV therapy or oral fosfomycin for ESBL and CRE UTIs.MethodsRetrospective cohort review of inpatients diagnosed with ESBL and CRE UTIs between June 2016 and September 2017 at a seven-hospital system. Patients with polymicrobial UTI, bloodstream infections, additional anatomical site with ESBL/CRE, or those requiring renal replacement therapy were excluded. Only patients with documented fosfomycin susceptible isolates in vitro were included. Eligible patients were divided into two groups: standard IV therapy (SDTx) or fosfomycin therapy (FOS). FOS group could receive ≤72 hours of other active antibiotics from urine culture collection (UTI onset) to the first dose of fosfomycin. Quick sequential organ failure assessment (qSOFA) scores were calculated at UTI onset. The primary endpoint was functional cure defined as resolution of symptoms without microbiological failure. Microbiological failure was defined as a positive urine culture within the index hospitalization or 30 days.ResultsThere were 70 patients included: 31 treated with SDTx and 39 with FOS. ESBL Echerichia coli was most common, accounting for 58% of UTIs in SDTx and 71.8% in FOS. ESBLs accounted for 71% (n = 22/31) of UTIs in SDTx and 89.7% (n = 35/39) in FOS. The overall qSOFA score was 0.7 (range, 0–3) with the majority of patients scoring < 2 (80.6% in SDTx vs. 92.3% in FOS; P = 0.29). There was no significant difference in functional cure rate (n = 30, 96.8% SDTx vs. n = 37, 94.9% FOS; P = 0.83). SDTx patients had a longer length of stay (15.3 days vs. 7.3 days with FOS; P = 0.04), duration of active therapy (7.6 days vs. 3 days with FOS; P < 0.0001), and time from UTI onset to discharge (10.3 days vs. 6.6 days with FOS; P = 0.002). There were no adverse drug events reported.ConclusionOral fosfomycin was a safe and effective alternative to standard IV therapy for ESBL and CRE UTIs in this investigation and demonstrated similar functional cure rates. Additionally, patients treated with fosfomycin had shorter hospitalizations and durations of antibiotic therapy. Disclosures All authors: No reported disclosures.