Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines

Abstract

Background A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters. Methods We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines. Results On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures. Conclusions Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.

Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges

“…Diagnosis of UTI is often a clinical challenge due to the high prevalence of asymptomatic bacteriuria, presence of non-specific symptoms, and lack of knowledge about appropriate indications for urine testing [15]. Surveillance criteria and clinical definitions have been used to diagnose UTI [16,17], but even these definitions overcall many cases of ASB as UTI [18].…”

“…Overdiagnosis occurs because UTI is not a dichotomous outcome [9] but rather exists on a continuum spanning no detectable bacteriuria or pyuria, asymptomatic bacteriuria with or without pyuria, probable UTI, and clinical UTI (see Table 1). High incidence of ASB coupled with non-specific findings such as confusion, fever, or hypotension leads many clinicians to lean on laboratory findings to diagnose UTI [15,19]. Increasing reliance on urine testing leads to overdiagnosis of UTI and antibiotic overuse, because a positive urine culture has a poor positive predictive value for diagnosing a UTI, in contrast to blood where pathogen detection equates to infection for most pathogens.…”

“…Overdiagnosis of UTI also may cause alternative or true diagnoses to be missed. Advani et al found that catheterized patients treated for a positive urine culture experienced a delay in other diagnoses likely due to anchoring to positive urine cultures [15].…”

“…Pan-culturing is a deep-rooted practice in medicine [20,21], driven by fear of missing an infection combined with increasing reliance on laboratory tests over clinical findings. "Pan-culturing" usually provides instant gratification as it often yields positive results, albeit these results may be due to detecting colonization and contamination more often than true infection [15]. Testing may also be influenced by the convenience of sampling site.…”

“…For example, clinicians order urine cultures as a part of initial workup of confusion more often than ordering a lumbar puncture [20]. Misuse of urine cultures also occurs in response to subjective findings such as change in color or odor of urine, change in mental status, positive urinalysis parameters, and initial workup of fever in patients without genitourinary symptoms [15]. In addition, urine cultures and urinalyses are often included as pre-selected tests in many order sets (e.g., pre-operative, admission).…”