References
- Advani S, et al. Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges. Curr Infect Dis Rep 2021.
- The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting.
- Claeys K, et al. Optimal Urine Culture Diagnostic Stewardship Practice - Results from an Expert Modified-Delphi Procedure. Clin Infect Dis 2022.
- A multidisciplinary expert panel utilized a RAND-modified Delphi approach to ascertain diagnostic stewardship best practices. The panel reached a conclusion and provided 18 guidance statements to optimize use of urine cultures for better patient outcomes.
- Daniel M, et al. An Implementation Guide to Reducing Overtreatment of Asymptomatic Bacteriuria. JAMA Intern Med 2017.
- Review of different approaches used in prior studies to decrease treatment of ASB, with recommendations on steps to take to improve use in your own hospital
- Drekonja D, et al. Teamwork and Safety Climate Affect Antimicrobial Stewardship for Asymptomatic Bacteriuria. Infect Con Hosp Epi 2019.
- Revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.
- Jones CW, et al. Reflect urine culture cancellation in the emergency department. J Emerg Med 2014
- In the ED, authors estimate a 40% reduction in urine cultures if a culture was cancelled when urinalysis did not meet criteria (one of the following: white blood cell >10, + leukocyte esterase, + nitrites, + bacteria)
- Krouss M, et al. Choosing Wisely Initiative for Reducing Urine Cultures for Asymptomatic Bacteriuria and Catheter-Associated Asymptomatic Bacteriuria in an 11-Hospital Safety Net System. Am Journ Inf Con 2023.
- 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.
- Leis JA, et al. Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among noncatheterized inpatients: a proof of concept study. Clin Infect Dis 2014.
- This proof-of-concept study demonstrates that no longer routinely reporting urine culture results from noncatheterized medical and surgical inpatients can greatly reduce unnecessary antimicrobial therapy for ASB without additional workload for the laboratory.
- Morgan DJ, et al. Diagnostic Stewardship - Leveraging the Laboratory to Improve Antimicrobial Use. JAMA 2017.
- Suggests that implementing stewardship practices in the diagnostic testing process could positively impact the reliability of antibiotic use, reduce unintended harms, and improve the safety of care.
- Munigala S, et al. Impact of order set design on urine culturing practices at an academic medical center emergency department. BMJ Qual Saf 2017.
- Removing all urine culture orders except “urinalysis with reflex to microscopy” from frequently ordered list of tests for the ED resulting in decreasing daily urine culture rate by about half
- O'Brien WJ, et al. Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture. JAMA Netw Open 2024.
- This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.
- Petty LA, et al. Risk Factors and Outcomes Associated with Treatment of Asymptomatic Bacteriuria in Hospitalized Patients. JAMA IM 2019.
- Cohort study of ~2700 ASB patients revealed that ~83% received inappropriate antibiotic treatment, which was associated with longer lengths of hospital stays without improvements in outcomes.
- Petty LA, et al. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020.
- Cohort study of ~2400 ASB patients who received antibiotics which found that ED physicians commonly initiated urine testing and antibiotic treatment, with most antibiotics continued by inpatient providers. Antibiotic treatment in these patients was not associated with an improvement in clinical outcomes; however, it was associated with a longer length of inpatient stay and C.diff infections.
- Salazar JG, et al. Association of Screening and Treatment for Preoperative Asymptomatic Bacteriuria with Postoperative Outcomes Among US Veterans. JAMA Surg 2018.
- A national study of ~68,000 veterans showing that screening patient urine cultures for ASB prior to major surgical procedures, and subsequently treating with antibiotics, did not reduce the incidence of post-op infections and, thus, should not be continued as part of routine practice.
- Schulz L, et al. Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections. J Emerg Med 2016
- Asymptomatic bacteriuria is common in all age groups and is frequently over-treated. A UTI diagnosis should be based on a cominbation of clinical symptoms and supportive laboratory information. This review will assist providers in navigating common pitfalls in the diagnosis of UTI.
- Stagg A, et al. Impact of two-step urine culture ordering in the emergency department: a time series analysis. BMJ Qual Saf 2017.
- In the ED, urine samples collected by nurses, then saved for 48 hours, and not processed without additional physician order
- Resulted in a decrease of urine cultures processed, decreased need for patient callbacks for positive cultures, and decrease in antibiotics prescribed for a urinary indication for those admitted
- Trautner B, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter–Associated Asymptomatic Bacteriuria. JAMA 2015.
- A multifaceted educational implementation strategy in the VA to reduce urine culture ordering and inappropriate antibiotic prescribing in catheterized patients
- See Supplement- CAUTI Diagnostic Algorithm and Audit and Feedback Script
- Vaughn V, et al. Revisiting the panculture. BMJ Qual Saf 2016.
- Pan culturing for fever is costly and contributes to unnecessary cultures and inappropriate antibiotic use
- Vaughn V, et al. Addressing the Overuse of Cultures to Optimize Patient Care. Annals of Int Med 2019.
- Exploration of the mental models and social contexts that influence overuse of microbiological testing in order to help reduce over-diagnosis and over-treatment of infections.
- Vaughn V, et al. SHEA Featured Oral Abstract: Reducing Unnecessary Antibiotic Treatment for Asymptomatic Bacteriuria: A Statewide Collaborative Quality Initiative. Open Forum Inf Dis 2022.
- Across 46 hospitals within the HMS Collaborative, there was a decrease over time in unnecessary treatment for ASB with independent hospitals improving most. Diagnostic stewardship appeared responsible for nearly all improvement.
- Vaughn V, et al. A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria. JAMA IM 2023.
- Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize diagnostic stewardship to reduce antibiotic treatment related to ASB.
Click Here to Return to - Reduce Testing and Treatment of Asymptomatic Bacteriuria (ASB) Recommendation
