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Improving the Culture of Culturing: Critical Asset to Antimicrobial Stewardship

Published online by Cambridge University Press:  29 December 2016

Mohamad G. Fakih*
Affiliation:
Care Excellence, Ascension Health, St Louis, Missouri
Riad Khatib
Affiliation:
Ascension St John Hospital, Detroit, Michigan.
*
Address correspondence to Mohamad G. Fakih, MD, MPH, Senior Medical Director, Ascension Center of Excellence, For Antimicrobial Stewardship and Infection Prevention, 19251 Mack Ave, Suite 190, Grosse Pointe Woods, MI 48236 (Mohamad.Fakih@ascension.org).
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Abstract

Type
Letters to the Editor
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

To the Editor—We read with interest the study by Mullin et alReference Mullin, Kovacs and Fatica 1 to reduce catheter-associated urinary tract infections (CAUTIs) in intensive care units (ICUs). The authors focused on optimizing the use of urine cultures and urinary catheter care. The effort led to a reduction in urine culturing in adult ICUs of 41%–80% and more than one-third in the National Healthcare Safety Network (NHSN) defined CAUTI between 2013 and 2014, without much change in device utilization. Compliance with appropriate testing was not reported. These findings highlight 2 important issues: (1) the link between the NHSN surveillance definition and culturing practices and (2) the importance of appropriate testing for CAUTI as a pillar for antimicrobial stewardship.

Nationally, the NHSN CAUTI definition has been used to evaluate quality initiatives to reduce urinary catheter infectious harm, and these definitions have been linked to financial penalties for underperforming hospitals. However, the reliance of this definition on fever and a positive urine culture makes it susceptible to changes in culturing practices.Reference Fakih, Gould and Trautner 2 The artificial improvements in NHSN-defined events based on reductions in culturing do not necessarily equate to preventing clinical CAUTIs. They may even provide a false sense of success in combatting CAUTI in ICUs where we have seen little movement.Reference Saint, Greene and Krein 3 Other measures such as device utilization are not susceptible to testing practices and may better reflect care.Reference Fakih, Gould and Trautner 2

Asymptomatic bacteriuria is common among catheterized patients.Reference Nicolle, Bradley, Colgan, Rice, Schaeffer and Hooton 4 Orders for obtaining urine cultures are influenced by the clinician’s “practice culture.” Practices that utilize “screening cultures on admission,” “standing orders,” or “reflex” urine cultures based on urinalysis results may lead to inappropriate diagnoses and/or antimicrobial use. In addition, clinicians often order urine cultures in catheterized patients based on pyuria, urine odor, color, or turbidity, actions that are discouraged by the Infectious Diseases Society of America guidelines.Reference Hooton, Bradley and Cardenas 5 Such actions also increase utilization of additional resources (eg, testing, antibiotics, consultations) and adversely expose patients to unnecessary testing and treatments.Reference Cope, Cevallos, Cadle, Darouiche, Musher and Trautner 6 More importantly, inappropriately obtained urine cultures may lead to the wrong diagnosis. Ensuring that frontline physicians and nurses are aware of the indications for testing as well as the risks associated with inappropriate testing are good first steps to improving care (Table 1).Reference Jones, Sibai, Battjes and Fakih 7

TABLE 1 When to Obtain or Not Obtain a Urine Culture in a Patient With an Indwelling Urinary Catheter

We suggest a 2-pronged approach to reducing unnecessary urine cultures in catheterized patients. First, we recommend the establishment of an optimized process for obtaining urinalyses and urine cultures. A thorough review of pathways, order sets, policies, and institutional guidelines is needed to ensure best-practice integration. Such a review must include any orders or testing processes embedded into the electronic medical records. For example, pathways or order sets geared toward specific conditions (eg, pneumonia or congestive heart failure) should avoid incorporating tests such as urine cultures to help curb unnecessary use. Moreover, preoperative urine cultures should be avoided in asymptomatic patients that are not undergoing urologic procedures. Testing in populations with a high prevalence of asymptomatic bacteriuria (eg, the elderly or those with urinary catheters) often results in identifying colonized patients, placing them at risk to be exposed to antibiotics unnecessarily. Reflex cultures in catheterized patients based on abnormal urinalysis results (with no consensus on what constitutes abnormal urinalysis to trigger a culture) are frequently used as a convenience to avoid submitting a second urine sample for culture. However, urinalyses are often performed without clinical suspicion of urinary infection, and discovery of pyuria may lead to unnecessary cultures. Pyuria is a common occurrence in patients with urinary catheters and has a low positive predictive value for bacteriuria.Reference Tambyah and Maki 8 Urine cultures based on urinalysis results should only be pursued in symptomatic patients and when CAUTI is suspected in a sepsis workup with no obvious sources.Reference Humphries and Dien Bard 9 Reflex urine cultures, without clinical assessment, may undermine antimicrobial stewardship efforts. The solution is to integrate only established best practices into the work flow, underscoring “no testing without clinical evaluation.”

Second, clinician engagement is of paramount importance in changing a culture of inappropriate testing. Physicians and nurses should be educated on best practices, and clinical leaders should be role models to their peers.Reference Jones, Sibai, Battjes and Fakih 7 Culturing stewardship needs to be viewed as a necessity by all stakeholders, and the benefits should be relayed in a language that resonates with the different teams.Reference Fakih, Krein, Edson, Watson, Battles and Saint 10 For example, “PAN” culturing is frequently used without understanding that certain sites are colonized and that the value of the cultures depend on the suspected site of infection. Infectious diseases specialists and infection preventionists often focus on the risk of Clostridium difficile infection and multidrug resistance. We must also highlight the risk of misdiagnosis, which may better capture the attention of other stakeholders such as hospitalists and intensivists. Antimicrobial stewardship teams should also consider incorporating testing stewardship in their efforts to achieve the correct diagnosis, the optimal antimicrobial choice, and the appropriate duration of antimicrobial use. Short of establishing benchmarks for culturing stewardship to gauge success, periodic audits of urine culture use are necessary to identify trends and provide feedback on performance.

In summary, “improving the culture of culturing” should be viewed as an integral component of antimicrobial stewardship. Such an approach is likely to encourage clinicians to use their clinical judgment in their patient evaluations and to move from a reflexive process to a more reflective one, leading to better care.

ACKNOWLEDGMENTS

Financial support: No financial support was provided relevant to this article.

Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.

References

REFERENCES

1. Mullin, KM, Kovacs, CS, Fatica, C, et al. A multifaceted approach to reduction of catheter-associated urinary tract infections in the intensive care unit with an emphasis on “stewardship of culturing.” Infect Control Hosp Epidemiol 2016. [Epub November 17, 2016].Google Scholar
2. Fakih, MG, Gould, CV, Trautner, BW, et al. Beyond infection: device utilization ratio as a performance measure for urinary catheter harm. Infect Control Hosp Epidemiol 2016;37:327333.CrossRefGoogle ScholarPubMed
3. Saint, S, Greene, MT, Krein, SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;374:21112119.CrossRefGoogle ScholarPubMed
4. Nicolle, LE, Bradley, S, Colgan, R, Rice, JC, Schaeffer, A, Hooton, TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643654.Google Scholar
5. 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;50:625663.CrossRefGoogle ScholarPubMed
6. 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;48:11821188.Google Scholar
7. Jones, K, Sibai, J, Battjes, R, Fakih, MG. How and when nurses collect urine cultures on catheterized patients: a survey of 5 hospitals. Am J Infect Control 2016;44:173176.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;160:673677.CrossRefGoogle ScholarPubMed
9. Humphries, RM, Dien Bard, J. Point-counterpoint: reflex cultures reduce laboratory workload and improve antimicrobial stewardship in patients suspected of having urinary tract infections. J Clin Microbiol 2016;54:254258.Google Scholar
10. Fakih, MG, Krein, SL, Edson, B, Watson, SR, Battles, JB, Saint, S. Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm. Am J Infect Control 2014;42:S223S229.Google Scholar
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TABLE 1 When to Obtain or Not Obtain a Urine Culture in a Patient With an Indwelling Urinary Catheter