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Conditional reflex to urine culture: Evaluation of a diagnostic stewardship intervention within the Veterans’ Affairs and Centers for Disease Control and Prevention Practice-Based Research Network

Published online by Cambridge University Press:  25 August 2020

Kimberly C. Claeys Open the ORCID record for Kimberly C. Claeys [Opens in a new window] ,
Min Zhan ,
Lisa Pineles ,
Alison Lydecker ,
Gosia Clore ,
Michihiko Goto ,
Surbhi Leekha ,
Darren Linkin ,
Charlesnika T. Evans  and
Barbara W. Trautner
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Kimberly C. Claeys*
Affiliation:
Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
Min Zhan
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Lisa Pineles
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Alison Lydecker
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Gosia Clore
Affiliation:
Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
Michihiko Goto
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
Surbhi Leekha
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Darren Linkin
Affiliation:
Division of Infectious Diseases, Philadelphia Veterans’ Medical Center, Philadelphia, Pennsylvania
Charlesnika T. Evans
Affiliation:
Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans’ Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois Department of Preventive Medicine and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Barbara W. Trautner
Affiliation:
Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans’ Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas
Matthew B. Goetz
Affiliation:
VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, California
Jonathan D. Baghdadi
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland Veterans’ Affairs Maryland Health Care System, Baltimore, Maryland
Eli N. Perencevich
Affiliation:
Department of Internal Medicine, University of Iowa, Iowa City, Iowa Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
Daniel J. Morgan
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland Veterans’ Affairs Maryland Health Care System, Baltimore, Maryland
*
Author for correspondence: Kimberly C. Claeys, E-mail: kclaeys@rx.umaryland.edu
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Abstract

Objective:

In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention.

Design:

We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression.

Setting:

The study included 6 acute-care hospitals within the Veterans’ Health Administration across the United States.

Participants:

Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included.

Methods:

At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days.

Results:

The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49).

Conclusions:

Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 42 , Issue 2 , February 2021 , pp. 176 - 181
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Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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References

Foxman, B. Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin North Am 2014;28:1–13.CrossRefGoogle ScholarPubMed
Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198–1208.CrossRefGoogle ScholarPubMed
Drekonja, DM, Abbo, LM, Kuskowski, MA, Gnadt, C, Shukla, B, Johnson, JR. A survey of resident physicians’ knowledge regarding urine testing and subsequent antimicrobial treatment. Am J Infect Control 2013;41:892–896.CrossRefGoogle ScholarPubMed
Flokas, ME, Andreatos, N, Alevizakos, M, Kalbasi, A, Onur, P, Mylonakis, E. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis 2017;4(4). doi: 10.1093/ofid/ofx207.CrossRefGoogle ScholarPubMed
Nicolle, LE, Gupta, K, Bradley, SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of Americaa. Clin Infect Dis 2019;68(10):e83–e110.Google Scholar
Drekonja, DM, Gnadt, C, Kuskowski, MA, Johnson, JR. Urine cultures among hospitalized veterans: casting too broad a net? Infect Control Hosp Epidemiol 2014;35:574–576.CrossRefGoogle ScholarPubMed
Spivak, ES, Burk, M, Zhang, R, et al. Management of bacteriuria in Veterans’ Affairs hospitals. Clin Infect Dis 2017;65:910–917.CrossRefGoogle Scholar
Trautner, BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol 2011;9:85–93.Google ScholarPubMed
Köves, B, Cai, T, Veeratterapillay, R, et al. Benefits and harms of treatment of asymptomatic bacteriuria: a systematic review and meta-analysis by the European Association of Urology Urological Infection Guidelines Panel. Eur Urol 2017;72:865–868.CrossRefGoogle ScholarPubMed
Morgan, DJ, Malani, P, Diekema, DJ. Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. JAMA 2017;318:607–608.CrossRefGoogle ScholarPubMed
Trautner, BW, Petersen, NJ, Hysong, SJ, Horwitz, D, Kelly, PA, Naik, AD. Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care. Am J Infect Control 2014;42:653–658.Google ScholarPubMed
Claeys, KC, Blanco, N, Morgan, DJ, Leekha, S, Sullivan, KV. Advances and challenges in the diagnosis and treatment of urinary tract infections: the need for diagnostic stewardship. Curr Infect Dis Rep 2019;21(4):11.CrossRefGoogle ScholarPubMed
Sullivan, KV, Morgan, DJ, Leekha, S. Use of diagnostic stewardship practices to improve urine culturing among SHEA Research Network hospitals. Infect Control Hosp Epidemiol 2019;40:228–231.CrossRefGoogle ScholarPubMed
Stagg, A, Lutz, H, Kirpalaney, S, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2018;27:140–147.Google ScholarPubMed
Epstein, L, Edwards, JR, Halpin, AL, et al. Evaluation of a novel intervention to reduce unnecessary urine cultures in intensive care units at a tertiary-care hospital in Maryland, 2011–2014. Infect Control Hosp Epidemiol 2016;37:606–609.CrossRefGoogle Scholar
Sarg, M, Waldrop, GE, Beier, MA, et al. Impact of changes in urine culture ordering practice on antimicrobial utilization in intensive care units at an academic medical center. Infect Control Hosp Epidemiol 2016;37:448–454.CrossRefGoogle ScholarPubMed
Dietz, J, Lo, TS, Hammer, K, Zegarra, M. Impact of eliminating reflex urine cultures on performed urine cultures and antibiotic use. Am J Infect Control 2016;44:1750–1751.CrossRefGoogle ScholarPubMed
Howard-Anderson, JR, Ashraf, S, Overton, EC, Reif, L, Murphy, DJ, Jacob, JT. Sustained decrease in urine culture utilization after implementing a reflex urine culture intervention: a multicenter quasi-experimental study. Infect Control Hosp Epidemiol 2020;41:369–371.CrossRefGoogle ScholarPubMed
Hertz, JT, Lescallette, RD, Barrett, TW, Ward, MJ, Self, WH. External validation of an ED protocol for reflex urine culture cancelation. Am J Emerg Med 2015;33:1838–1839.CrossRefGoogle Scholar
Simerville, JA, Maxted, WC, Pahira, JJ. Urinalysis: a comprehensive review. Am Fam Physician 2005;71:1153–1162.Google ScholarPubMed
Pallin, DJ, Ronan, C, Montazeri, K, et al. Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infect Dis 2014;1(1):ofu019.CrossRefGoogle ScholarPubMed
McBride, JA, Lepak, AJ, Dhaliwal, G, Saint, S, Safdar, N. The wrong frame of mind. N Engl J Med 2018;378:1716–1721.CrossRefGoogle Scholar
Skelton-Dudley, F, Doan, J, Suda, K, Holmes, SA, Evans, C, Trautner, B. Spinal cord injury creates unique challenges in diagnosis and management of catheter-associated urinary tract infection. Top Spinal Cord Inj Rehabil 2019;25:331–339.CrossRefGoogle ScholarPubMed
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