Urine Culture Collection Research Articles

1106. Assessment of Fluoroquinolone Appropriateness for Hospitalized Patients with Asymptomatic Bacteriuria and Cystitis: A Multi-Hospital Cohort Study

BackgroundFluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis.MethodsThis is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering.ResultsOf 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2).ConclusionHospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use. Disclosures All authors: No reported disclosures.

Variations in indwelling urinary catheter use in four Australian acute care hospitals.

To identify the point prevalence of indwelling urinary catheters (IDCs) in adult inpatients in acute care hospitals, and to describe the indications for IDC insertion based on patient age, gender, specialty and hospital. Catheter-associated urinary tract infections (CAUTIs) are preventable healthcare-associated infections. IDC duration is the strongest predictor of CAUTI, and little is known about characteristics of patients who receive an IDC. Two single-day point prevalence surveys collected baseline patient data as part of a larger pre-post control-intervention study. Surveys were conducted at four acute care hospitals in NSW, Australia, for all adult patients. Data collection included IDC presence, insertion details and urine culture collection. Point prevalence data were linked with electronically extracted patient demographic data. This study is presented in line with STROBE checklist (See Supplementary File 1). Data from 1,630 patients were analysed, with 196 patients (12%) identified as having an IDC on the survey dates. IDC prevalence rates were higher in males (13%) than in females (11%). Critical care had the highest rate of patients with IDCs (42%). Urine cultures were collected in 70 patients with an IDC (43%). Findings indicated similar rates of IDC use in males and females, and there was no significant difference in age between patients with or without an IDC. However, indication for IDC varied by patient age and gender. High rates of urine culture collection may represent routine collection. IDC use is found across genders, all age groups and specialties. Nurses should be aware that any of their patients may have an IDC and be particularly aware of certain indications based on patient age and gender. Routine urine culture collection is not advised, and instead, nurses should be guided by clinical decision-making tools.

Impact of an Altered Mental Status (AMS)/Suspected Urinary Tract Infection (UTI) Protocol on Urine Culture Collection and Antibiotic Consumption in a Long-Term Care Facility

Impact of an Altered Mental Status (AMS)/Suspected Urinary Tract Infection (UTI) Protocol on Urine Culture Collection and Antibiotic Consumption in a Long-Term Care Facility

Comparison of Uriswab to alternative methods for urine culture collection and transport: confirmation of standard culture methodology for investigation of urinary tract infections

The ability to isolate and identify causative agents of urinary tract infections relies primarily on the quality of the urine sample that is submitted to the microbiology. The most important factors are the method of collection, the maintenance of viability of the potential pathogens during transport, and standardization of the culturing of the urine sample. This report is a composite of several investigations comparing collection and transport on urine culture paddles, with a preservative urine sponge (Uriswab), and a comparison of Uriswab with the BD preservative transport tube as methods of preservation of urinary pathogens. Primary studies showed that Uriswab maintained significantly more urinary pathogens than the urine culture paddle with fewer mixed or contaminated cultures. The two preservative transport systems were comparable for maintenance of viability of the pathogens, but there were fewer mixed cultures when samples were collected with Uriswab. This study confirms the importance of a standard volume of 1 μL of urine for culture.

Systematic review of the validity of urine cultures collected by sterile perineal bags

Abstract Introduction The perineal adhesive bag is the most commonly used method in our country for urine culture collection in infants, despite having a high risk of contamination and false-positive results. We aim to quantify both types of risks through a systematic review. Methods Search updated in May 2014 in PUBMED, SCOPUS (includes EMBASE), IBECS; CINAHL, LILACS AND CUIDEN, unrestricted by language or date. Percentage of contaminated samples, false positives, sensitivity and specificity (with respect to catheterization or bladder puncture) were recorded. Results A total of 21 studies of medium quality (7659 samples) were selected. The pooled percentage of contaminated samples was 46.6% (15 studies; 6856 samples; 95% confidence interval [95% CI]: 35.6–57.8%; I2: 97.3%). The pooled percentage of false positives was 61.1% (12 studies; 575 samples; 95% CI: 37.9–82.2%; I2: 96.2%). Sensitivity (88%; 95% CI: 81–93%; I2: 55.2%) and specificity (82%; 95% CI: 75–89%; I2: 41.3%) were estimated in five studies, but without including contaminated samples. Conclusion The perineal adhesive bag is not a valid enough method for urine culture collection, because almost half of all samples are contaminated, and two out of three positives are false. Although these estimates are imprecise, because of their great heterogeneity, they should be considered when choosing the method of urine collection. The estimates of sensitivity and specificity are not applicable because they do not take into account the risk of contamination.

Revisión sistemática de la validez de los urocultivos recogidos con bolsa estéril perineal

IntroductionThe perineal adhesive bag is the most used method in our country for urine culture collection in infants, despite having a high risk of contamination and false-positive results. We aim to quantify both types of risks through a systematic review. MethodsSearch updated in May 2014 in PUBMED, SCOPUS (includes EMBASE), IBECS; CINAHL, LILACS AND CUIDEN, without language or time limits. Percentages of contaminated urines, false positives, sensitivity and specificity (with respect to catheterization or bladder puncture) were recorded. ResultsA total of 21 studies of medium quality (7,659 samples) were selected. The pooled percentage of contaminated urines was 46.6% (15 studies; 6856 samples; 95% confidence interval [95% CI]: 35.6 to 57.8%; I2: 97.3%). The pooled percentage of false positives was 61.1% (12 studies; 575 samples; 95% CI: 37.9 to 82.2%; I2: 96.2%). Sensitivity (88%; 95% CI: 81-93%; I2: 55.2%), and specificity (82%; 95% CI: 75-89%; I2: 41.3%) were estimated in five studies, but without including contaminated urines. ConclusionThe perineal adhesive bag is not a valid enough method for urine culture collection, because almost half are contaminated and, if they are positive, two out of three are false. Although these estimates are imprecise, because of their great heterogeneity, they should be considered when choosing the method of urine collection. The estimates of sensitivity and specificity are not applicable because they do not take into account the risk of contamination.

How and When Nurses Collect Urine Cultures on Catheterized Patients: A Survey of 5 Hospitals

Catheter-associated urinary tract infections (CAUTIs) account for a large proportion of healthcare-associated infections. Urine samples are collected when CAUTI is suspected, often triggered by nursing staff in the setting of fever or change in urine appearance/odor. Unnecessary urine culture collection may lead to inappropriate antimicrobial use and resistance. Evaluating nurses’ knowledge regarding appropriate reasons for obtaining urine cultures and Methods used to collect these specimens are the first steps to improving practice.

Editorial Commentary: Doing the Right Thing for Asymptomatic Bacteriuria: Knowing Less Leads to Doing Less

Clinical practice guidelines are the preferred method among professional societies for defining safe and effective healthcare. Despite widespread dissemination by professional societies, the impact of guidelines on routine clinical practice remains suboptimal [1]. The Infectious Diseases Society of America guidelines for asymptomatic bacteriuria (ASB) are a particularly salient example [2], with one-third to two-thirds of patients with ASB inappropriately receiving treatment with antimicrobial agents [3, 4]. Urine cultures are often ordered reflexively when patients are admitted to the hospital or have any change in status in long-term care, regardless of the absence of urinary symptoms [3–5]. Clinicians react to positive results on these cultures by prescribing unnecessary antimicrobial agents, frequently swayed by guidelinesdiscordant cognitive biases regarding older age and frailty, pyuria on urinalysis, and the particular types of bacterial organisms (eg, gram-negative rods) on urine culture results [3, 5]. In this context, the very simple intervention by Leis et al [6] published in this edition of Clinical Infectious Diseases is particularly elegant. The authors explored the effectiveness of suppressing reporting of urine culture results when ordered for noncatheterized patients. Instead of receiving urine culture results as the default option, clinicians received a standardized statement declaring, “The majority of positive urine cultures from inpatients without an indwelling urinary catheter represent asymptomatic bacteriuria” [6]. They were encouraged to call the microbiology laboratory if they “strongly suspected” a urinary tract infection. The positive results of this study are provocative on many levels. First, they confirm the significantly higher prevalence of ASB (86%) vs urinary tract infections (14%) among the 74 cultures from patients without urinary catheters. Second, in patients whose urine cultures were reported openly, as per the standard approach, nearly half of all patients with confirmed ASB received antibiotics. Third, the intervention design had a strong effect on clinician behavior. When the default of reporting culture results was removed, the rate of guidelinesdiscordant treatment for ASB dropped from 48% to 12%, and clinicians called the microbiology laboratory for only 14% (5 of 37) of suppressed culture results. Only 4 urinary tract infections occurred in noncatheterized patients, and in each of these cases clinicians had empirically started therapy, with the presumption that clinically significant symptoms of urinary tract infection were present. Furthermore, no untreated patients had clinically significant signs of sepsis or urinary tract infection 72 hours after urine culture collection. The study has limitations that should be addressed prior to conducting a large-scale evaluation. The investigators acknowledge that they studied a small sample of patients and clinicians at only one institution. The rationale for using patients with urinary catheters as the comparison group to the intervention sample of noncatheterized patients is not clear. Treatment decisions may differ between these groups in ways that are better explained by clinical factors rather than customary and default decision errors. Finally, any large-scale intervention Received 13 December 2013; accepted 29 December 2013; electronically published 26 February 2014. Correspondence: Barbara Trautner, MD, PhD, Houston Health Services Research and Development Center of Excellence (152), Michael E. DeBakey VAMC, 2002 Holcombe Blvd, Houston, TX 77030 (trautner@bcm.edu). Clinical Infectious Diseases 2014;58(7):984–5 Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. Thiswork iswritten by (a) US Government employee(s) and is in the public domain in the US. DOI: 10.1093/cid/ciu011

Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention

In long-term care facilities, treatment of asymptomatic bacteriuria (ASB) is common. However, randomized, controlled trials suggest that such treatment offers no benefit and may promote antimicrobial resistance. For 3 months before and 30 months after instituting an educational intervention, we monitored the appropriateness of urine culture collection and antibiotic treatment based on published guidelines and examined the effect on total antimicrobial use. The intervention included education of nursing staff to discourage the collection of urine cultures in the absence of symptoms suggestive of urinary tract infection and of primary care practitioners to not treat ASB. In preintervention period, 23 of 38 (61%) antibiotic regimens prescribed for urinary tract indications were for ASB. In the 6 months after the intervention, inappropriate submission of urine cultures decreased from 2.6 to 0.9 per 1000 patient-days (P < .0001), overall rate of treatment of ASB was reduced from 1.7 to 0.6 per 1000 patient-days (P = .0017), and total antimicrobial days of therapy were reduced from 167.7 to 117.4 per 1000 patient-days (P < .001). These reductions were maintained for 30 months after beginning the intervention. Educational interventions requiring minimal resources can result in sustained reductions in inappropriate treatment of ASB in long-term care and decreased total antimicrobial use. Education of the nursing staff regarding appropriate criteria for requesting urine cultures should be a component of such interventions.

Urine Culture Contamination: A College of American Pathologists Q-Probes Study of 127 Laboratories

While urine culture contamination may not be completely avoidable, some laboratories have lower contamination rates than others. A College of American Pathologists (CAP) 1998 Q-Probes study showed that many interventions commonly assumed to reduce contamination were not demonstrably effective. This article revisits the issue. To examine the frequency of urine culture contamination, review current laboratory practices in the collection of urine culture specimens, and determine practice characteristics that may be associated with the contamination rate. Laboratories participating in a CAP Q-Probes study were required to prospectively collect data on 120 consecutive urine culture specimens and provide information on the patient's demographics (age and sex), the location where the specimen was collected, how the specimen was handled, the number of isolates in quantities greater than or equal to 10,000 colony-forming units (CFU)/mL, and whether the laboratory considered the specimen to be contaminated. Specific inclusion and exclusion criteria were provided to the participants. Each laboratory completed a supplemental questionnaire that probed for specific laboratory urine culture collection practices. One hundred twenty-seven laboratories participated in the study. Results from a total of 14,739 urine specimens were received. For the purpose of this study, a urine specimen was determined to be contaminated if the culture yielded more than 2 isolates in quantities greater than or equal to 10,000 CFU/mL. Using these criteria the median institution had a contamination rate of 15.0%. Laboratories in the 10th percentile (low performance) had an average contamination rate of 41.7%, while laboratories in the 90th percentile had an average rate of 0.8%. The collection site had no influence on the contamination rate, but postcollection processing, especially refrigeration of the specimen, had a substantial effect. Providing instruction to patients produced a statistically significant lowering of contamination rates for specimens from male patients (P = .006) but not for female patients, except when written instructions were provided in the emergency room, in which case specimen contamination rates for both male and female patients dropped (P = .01). The median contamination rates remain at a level comparable to the results seen in a previous Q-Probes study, and some laboratories have very high contamination rates. Specimen refrigeration is associated with lower overall urine culture specimen contamination rate. Providing patient instruction is also associated with lower contamination rates under specific circumstances.