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Impact of Changes in Urine Culture Ordering Practice on Antimicrobial Utilization in Intensive Care Units at an Academic Medical Center

Published online by Cambridge University Press:  18 January 2016

Mohamed Sarg ,
Greer E. Waldrop ,
Mona A. Beier ,
Emily L. Heil ,
Kerri A. Thom ,
Michael Anne Preas ,
J. Kristie Johnson ,
Anthony D. Harris  and
Surbhi Leekha
Mohamed Sarg
Affiliation:
Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
Greer E. Waldrop
Affiliation:
University of Maryland School of Medicine, Baltimore, Maryland
Mona A. Beier
Affiliation:
Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Emily L. Heil
Affiliation:
Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
Kerri A. Thom
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Michael Anne Preas
Affiliation:
Department of Infection Prevention, University of Maryland Medical Center, Baltimore, Maryland
J. Kristie Johnson
Affiliation:
Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
Anthony D. Harris
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Surbhi Leekha*
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
*
Address correspondence to Surbhi Leekha, MBBS, MPH, 110 S. Paca St, 6th Floor, Baltimore MD 21201 (sleekha@epi.umaryland.edu).
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Abstract

OBJECTIVE

To assess antimicrobial utilization before and after a change in urine culture ordering practice in adult intensive care units (ICUs) whereby urine cultures were only performed when pyuria was detected.

DESIGN

Quasi-experimental study

SETTING

A 700-bed academic medical center

PATIENTS

Patients admitted to any adult ICU

METHODS

Aggregate data for all adult ICUs were obtained for population-level antimicrobial use (days of therapy [DOT]), urine cultures performed, and bacteriuria, all measured per 1,000 patient days before the intervention (January–December 2012) and after the intervention (January–December 2013). These data were compared using interrupted time series negative binomial regression. Randomly selected patient charts from the population of adult ICU patients with orders for urine culture in the presence of indwelling or recently removed urinary catheters were reviewed for demographic, clinical, and antimicrobial use characteristics, and pre- and post-intervention data were compared.

RESULTS

Statistically significant reductions were observed in aggregate monthly rates of urine cultures performed and bacteriuria detected but not in DOT. At the patient level, compared with the pre-intervention group (n=250), in the post-intervention group (n=250), fewer patients started a new antimicrobial therapy based on urine culture results (23% vs 41%, P=.002), but no difference in the mean total DOT was observed.

CONCLUSION

A change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.

Infect. Control Hosp. Epidemiol. 2016;37(4):448–454

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 37 , Issue 4 , April 2016 , pp. 448 - 454
Copyright
© 2016 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

a

Authors with equal contribution; co-first authors.

References

REFERENCES

1. Hooton, TM, Bradley, SF, Cardenas, DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625–663.CrossRefGoogle ScholarPubMed
2. Kwon, JH, Fausone, MK, Du, H, Robicsek, A, Peterson, LR. Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients. Am J Clin Pathol 2012;137:778–784.CrossRefGoogle ScholarPubMed
3. Tambyah, PA, Maki, DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000;160:678–682.Google Scholar
4. Cope, M, Cevallos, ME, Cadle, RM, Darouiche, RO, Musher, DM, Trautner, BW. Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital. Clin Infect Dis 2009;48:1182–1188.Google Scholar
5. Dellit, TH, Owens, RC, McGowan, JE Jr., et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.Google Scholar
6. Hartley, S, Valley, S, Kuhn, L, et al. Overtreatment of asymptomatic bacteriuria: identifying targets for improvement. Infect Control Hosp Epidemiol 2015;36:470–473.CrossRefGoogle ScholarPubMed
7. Silver, SA, Baillie, L, Simor, AE. Positive urine cultures: a major cause of inappropriate antimicrobial use in hospitals? Can J Infect Dis Med Microbiol 2009;20:107–111.Google Scholar
8. Tambyah, PA, Maki, DG. The relationship between pyuria and infection in patients with indwelling urinary catheters: a prospective study of 761 patients. Arch Intern Med 2000;160:673–677.Google Scholar
9. Stovall, RT, Haenal, JB, Jenkins, TC, et al. A negative urinalysis rules out catheter-associated urinary tract infection in trauma patients in the intensive care unit. J Am Coll Surg 2013;217:162–166.Google Scholar
10. Polk, RE, Hohmann, SF, Medvedev, S, Ibrahim, O. Benchmarking risk-adjusted adult antibacterial drug use in 70 US academic medical center hospitals. Clin Infect Dis 2011;53:1100–1110.CrossRefGoogle ScholarPubMed
11. Healthcare-associated Infections (HAIs)/Catheter-associated Urinary Tract Infections (CAUTI). Centers for Disease Control and Prevention website. http://www.cdc.gov/HAI/ca_uti/uti.html. Published 2015. Accessed May 12, 2015.Google Scholar
12. Deyo, RA, Cherkin, DC, Ciol, MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–619.Google Scholar
13. Bonnal, C, Baune, B, Mion, M, et al. Bacteriuria in a geriatric hospital: impact of an antibiotic improvement program. J Am Med Dir Assoc 2008;9:605–609.Google Scholar
14. Leis, JA, Rebick, GW, Daneman, N, et al. Reducing antimicrobial therapy for asymptomatic bacteriuria among noncatheterized inpatients: a proof-of-concept study. Clin Infect Dis 2014;58:980–983.Google Scholar
15. Linares, LA, Thornton, DJ, Strymish, J, Baker, E, Gupta, K. Electronic memorandum decreases unnecessary antimicrobial use for asymptomatic bacteriuria and culture-negative pyuria. Infect Control Hosp Epidemiol 2011;32:644–648.CrossRefGoogle ScholarPubMed
16. Loeb, M, Brazil, K, Lohfeld, L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ 2005;331:669.CrossRefGoogle ScholarPubMed
17. Leis, JA, Gold, WL, Daneman, N, Shojania, K, McGeer, A. Downstream impact of urine cultures ordered without indication at two acute care teaching hospitals. Infect Control Hosp Epidemiol 2013;34:1113–1114.Google Scholar
18. Walker, S, McGeer, A, Simor, AE, Armstrong-Evans, M, Loeb, M. Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions. CMAJ 2000;163:273–277.Google Scholar
19. Vaisman, A, Gold, WL, Leis, JA. Interpreting positive urine cultures. The authors respond. CMAJ 2013;185:1527.CrossRefGoogle Scholar
20. Ackerman, MJ, Worster, A, Lin, D. Interpreting positive urine cultures. CMAJ 2013;185:1526–1527.Google Scholar
21. Dellinger, RP, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med 2013;41:580.Google Scholar
22. Aarts, MA, Granton, J, Cook, DJ, Bohnen, JM, Marshall, JC. Empiric antimicrobial therapy in critical illness: results of a surgical infection society survey. Surg Infect (Larchmt) 2007;8:329–336.Google Scholar