Urine Culture Stewardship in Hospitals: Protocols and Strategies for Catheterized Patients

From CDC's guidance on urine culture stewardship in hospitalized patients.

Start with your own criteria

Before choosing strategies, it helps to define facility-specific criteria for when to order a urine culture and how to collect a sample. Many of the strategies below build on them.

When to culture a catheterized patient

These examples can inform a facility's list of approved reasons; others may apply, and none replace the treating clinician's judgment.

Appropriate:

• symptoms suggesting a urinary tract infection (UTI) — flank pain or tenderness at the costovertebral angle, new blood in the urine, or new pelvic discomfort;
• new or worsening sepsis, or fever or altered mental status, with no other source found on history, exam or lab tests;
• in spinal cord injury: increased spasticity, autonomic dysreflexia, or a sense of unease.

Inappropriate:

• urine that is smelly, cloudy or discolored, without other localizing signs or symptoms;
• reflex cultures triggered by urinalysis results such as pyuria alone (and no pyuria points away from catheter-associated UTI);
• repeat cultures to document response to treatment, unless symptoms fail to resolve.

Infection or harmless bacteria?

Telling catheter-associated urinary tract infection (CAUTI) from catheter-associated asymptomatic bacteriuria (CA-ASB) decides whether antibiotics are needed.

A collection protocol

A standard protocol helps avoid contaminated samples and misdiagnosed CAUTI.

Before collecting

• Check how long the catheter has been in; if more than 14 days, consider replacing it first. Confirm there is an appropriate reason to culture.
• Get a facility-approved collection kit.
• Never take a culture from the collection bag.

Collecting

1. Clean hands and put on gloves.
2. Clamp the catheter tubing at least three inches below the sampling port.
3. When urine is visible under the port, scrub the port with a disinfectant wipe.
4. Collect the specimen with aseptic technique and an approved device.
5. If needed, transfer it to an approved container and label it, including the date and time.
6. Prepare it for transport per facility policy; remove gloves and clean hands.

After collecting

• Send it to the lab or refrigerate it immediately, following the tube maker's limits for room temperature and refrigeration.
• If a long delay is likely (a regional lab, say), use a tube with a preservative such as boric acid to stop contaminants overgrowing.

Strategies that help

Pick and adapt what fits your facility, staff and patients. Different tools reach different people: a collection protocol and kit supports nurses; an electronic record prompt helps physicians and advanced practice providers order cultures only for good reasons. The strategies fall into two groups.

Education and training — education builds knowledge; training builds skills. Use audit and monitoring results to target it. Include:

• nurses who collect and store samples, and
• physicians and advanced practice providers who order and interpret cultures.

It can be group or one-to-one, from live talks and webinars to pocket cards. Surveys have found large gaps in both nurses' and resident physicians' knowledge of urine testing; tools include pocket cards listing culture indications, reminder posters (such as Symptom-free Pee: Let It Be), and materials from published programs.

Behavior support

• Laboratory rules: process a culture only if urinalysis shows specific findings or an indication is given — or report results only when the ordering clinician asks for them.
• Collection: keep kits with everything needed, and step-by-step instructions, stocked and easy to reach.
• Electronic records: a hard stop requiring an appropriate indication before a culture can be ordered.

Programs that worked include the VA's "Kicking CAUTI" campaign across VA medical centers; the Mayo Clinic's bundled "6-C" approach in Rochester, Minnesota, with six elements to reduce CAUTI; a published antimicrobial stewardship approach to catheter-associated asymptomatic bacteriuria; and a single hospital's intensive care units aligning their culturing practice, which lowered CAUTI rates.

Guidelines: CDC's Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) and clinician guide to collecting urine cultures, and the IDSA's guidelines on CAUTI and on asymptomatic bacteriuria.

Sources

Based on "Strategize Initiatives You Can Incorporate into Your Program," Urine Culture Stewardship in Hospitalized Patients, Centers for Disease Control and Prevention; a work of the United States government in the public domain.