Highlights
- •Two electronic health record interventions successfully reduced urine cultures by more than 20% in a large safety net system: a mandatory indication on urine culture and a best practice advisory for urine cultures on patients with urinary catheters.
- •No additional education or stewardship was implemented for this initiative.
- •Reductions in urine culture ordering rates and catheter associated urinary tract infection rates were highly variable among 11 different hospitals.
Abstract
Background
Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads
to harm, including adverse effects from antibiotics, antibiotic resistance, and increased
length of stay.
Methods
This quality improvement initiative targeted inappropriate urine cultures (UC) across
11 hospitals and 70 ambulatory clinics in a safety-net setting. A mandatory prompt
for appropriate indications for UC orders and a best practice advisory (BPA) for UC
on patients with urinary catheters were created. UC ordering was compared preintervention
(June 2020-October 2021) to postintervention (December 2021-August 2022). Variation
in hospitals and clinics were assessed, as well as BPA responses by clinician type
and specialty.
Results
Inpatient UCs decreased 20.9% (p < .001), and outpatient UCs was unchanged (2.6% increase, nonsignificant). Inpatient
UCs on patients with urinary catheters decreased 21.6% (p < .001). Temporal trends were also assessed. High variation was seen among hospitals
and clinics. Low BPA acceptance rates were seen in internal medicine and family medicine
clinicians. Attendings showed high acceptance to the BPA compared to other clinicians.
Conclusions
This initiative successfully decreased UCs in a large, safety-net system. Further
study is needed in assessing variation among hospitals and clinics, as well as among
clinician types and specialties.
Keywords
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References
- International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.Clin Infect Dis. 2011; 52: e103-e120
Society AG. Choosing wiselyhttps://www.choosingwisely.org/clinician-lists/american-geriatrics-society-antimicrobials-to-treat-bacteriuria-in-older-adults/. Published 2013. Accessed November 22, 2022.
AMDA. Choosing wisely. https://www.choosingwisely.org/clinician-lists/amda-urine-cultures/. Published 2013. Accessed November 21, 2022.
AUA. Choosing wisely. https://www.choosingwisely.org/societies/american-urological-association/. Published 2013. Accessed November 21, 2022.
USPSTF. Asymptomatic bacteriuria in adults: screening.https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/asymptomatic-bacteriuria-in-adults-screening-:∼:text=The%20USPSTF%20recommends%20screening%20for,urine%20culture%20in%20pregnant%20persons.&text=The%20USPSTF%20recommends%20against%20screening%20for%20asymptomatic%20bacteriuria%20in%20nonpregnant%20adults. Published 2019. Accessed November 21, 2022.
- An implementation guide to reducing overtreatment of asymptomatic bacteriuria.JAMA Intern Med. 2018; 178: 271-276
- Risk Factors and outcomes associated with treatment of asymptomatic bacteriuria in hospitalized patients.JAMA Intern Med. 2019; 179: 1519-1527
- Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: A multicenter experience.Infect Control Hosp Epidemiol. 2020; 41: 564-570
- Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections.Am J Infect Control. 2017; 45: 1143-1153
- Modified reporting of positive urine cultures to reduce inappropriate antibiotic treatment of catheter-associated asymptomatic bacteriuria (CA-ASB) among inpatients, a randomized controlled trial.Infect Control Hosp Epidemiol. 2021; 42: 1221-1227
- A hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of catheter-associated asymptomatic bacteriuria.Implement Sci. 2011; 6: 41
- Safety and efficacy of a novel silver-impregnated urinary catheter system for preventing catheter-associated bacteriuria: a pilot randomized clinical trial.Am J Infect Control. 2015; 43: 260-265
- Knowledge and practices of physicians and nurses related to urine cultures in catheterized patients: an assessment of adherence to IDSA guidelines.Open Forum Infect Dis. 2019; 6ofz305https://doi.org/10.1093/ofid/ofz305
- Quality improvement interventions and implementation strategies for urine culture stewardship in the acute care setting: advances and challenges.Curr Infect Dis Rep. 2021; 23: 16https://doi.org/10.1007/s11908-021-00760-3
- Reducing inappropriate urine cultures through a culture standardization program.Am J Infect Control. 2020; 48: 656-662
- Mayo clinic reduces catheter-associated urinary tract infections through a bundled 6-C approach.Jt Comm J Qual Patient Saf. 2016; 42: 254-261
- Innovative implementation studies conducted in US safety net health care settings: a systematic review.Am J Med Qual. 2019; 34: 293-306
- Systematic review of clinician-directed nudges in healthcare contexts.BMJ Open. 2021; 11e048801
NHSN. Urinary tract infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) events https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf. Published 2022. Accessed November 21, 2022.
- SEE the DIFFerence: reducing unnecessary C. difficile orders through clinical decision support in a large, urban safety-net system.Am J Infect Control. 2022; S0196-6553(22)00783-0https://doi.org/10.1016/j.ajic.2022.11.003
- Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.BMJ Qual Saf. 2017; 26: 475-483
- Free the T3: implementation of best practice advisory to reduce unnecessary orders.Am J Med. 2022; 135: 1437-1442
Article info
Publication history
Published online: March 01, 2023
Publication stage
In Press Journal Pre-ProofFootnotes
.Conflicts of interest: None to report.
Identification
Copyright
© 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
