Strategize Initiatives You Can Incorporate into Your Program

Urine Culture Stewardship in Hospitalized Patients

What to know

• Prior to developing and employing specific strategies, it may be useful to define facility specific criteria or protocols for the following: indication for urine cultures and urine sample collection.
• These can be used as the basis for a number of the strategies described below.

Use of urine cultures in patients with indwelling urinary catheters

Here are some examples of appropriate and inappropriate uses of urine cultures that you can consider when drafting your list of facility-approved indications, other indications might exist at your facility:

Examples of appropriate & inappropriate use

These examples are not meant to replace the clinical judgement of an individual treating provider.

Appropriate uses of urine cultures

• Presence of symptoms suggestive of a urinary tract infection (UTI). For example;Flank pain or costovertebral angle tenderness,
• acute hematuria,
• new pelvic discomfort
• New onset or worsening sepsis without evidence of another source on history, physical examination, or laboratory testing
• Fever or altered mental status without evidence of another source on history, physical examination, or laboratory testing
• In spinal cord injury patients: increased spasticity, autonomic dysreflexia, sense of unease

Inappropriate uses of urine cultures

• Odorous, cloudy, or discolored urine in the absence of other localizing signs/symptoms
• Reflex urine cultures based on urinalysis results, such as pyuria, in the absence of other indications (Absence of pyuria suggests diagnosis other than CAUTI)
• Urine culture to document response to therapy unless symptoms are fail to resolve

Diagnosing CAUTI vs. CA-ASB

It is important to distinguish between catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CA-ASB) to determine if treatment with antibiotics is required.

Some points to consider and help differentiate CAUTI from CA-ASB:

Key components of urine culture protocols

You can develop a urine culture protocol for providers to follow when collecting urine samples for microbiologic analysis (including culture and urinalysis) to avoid contamination with microorganisms and subsequent misdiagnosis of CAUTI.

Consider the following components when developing a protocol:

Prior to collection

• Determine the number of days the urinary catheter has been in place; if greater than 14 days, consider replacing the catheter prior to specimen collection. Ensure that appropriate indications for culture collection are present.
• Obtain a facility approved urine collection kit.
• Never collect a urine culture from the collection bag.

Collection

• Perform hand hygiene and don gloves.
• Occlude the catheter tubing a minimum of three inches below the collection port.
• When urine is visible under the sampling port scrub the port with a disinfectant wipe.
• Use aseptic technique to collect the specimen using a facility approved collection device.
• If needed, transfer the specimen to a facility approved container and label according to hospital policy. Make sure to indicate the date and time the culture was collected.
• Prepare the specimen for transport per facility policies for specimen handling.
• Doff gloves and perform hand hygiene.

Post collection

• Transport the specimen to the laboratory or refrigerate immediately; follow the manufacturer's instructions for your collection tube regarding the amount of time the specimen is stable when at room temperature or refrigerated.
• If significant delay is anticipated (e.g. regional laboratory) consider using a collection tube that contains a preservative such as boric acid to prevent overgrowth of contaminating organisms or using a collection device that already contains a preservative.

Strategies to support implementation of urine culture stewardship

There are a number of strategies that you can employ in your urine culture stewardship program. You can pick from the strategies detailed below to customize a plan that meets the needs of your facility, staff, and patients or you may develop your own strategies based on unique needs at your facility. Different strategies target different types of providers. For example, a urine culture collection protocol and prepackaged kit provides nurses with tools to support urine culture stewardship. An electronic medical record prompt helps physicians and advanced practice providers adhere to urine culture stewardship by ensuring the appropriate indications for culture are present.

Broadly these strategies encompass 2 areas:

• Educations and training
• Behavior support

Education and training

Educating and training staff are important. Education increases knowledge and awareness of the principles of urine culture stewardship while training helps staff acquire and maintain skills necessary to practice urine culture stewardship. You can use the information gathered from monitoring and audits (discussed in more detail below) to decide where to target education and training initiatives.

Two primary groups to include:

• Nursing staff involved with collecting and storing urine cultures.
• Physicians and other advanced practice providers who order and interpret urine cultures.

Education and training can be provided on a group or individual level and can range from live presentations and webinars to resources such as pocket cards that can be used to reinforce concepts in real time.

Education and training tools

• How and when nurses collect urine cultures on catheterized patients: A survey of 5 hospitals. Survey of nurses showing a significant opportunity to improve nursing knowledge about urine culture stewardship
• A survey of resident physicians' knowledge regarding urine testing and subsequent antimicrobial treatment. Survey of physicians showing a significant opportunity to improve nursing knowledge about urine culture stewardship
• Pocket cards for staff; includes indications for urine culture collection.Pages 28-29 of the Supplementary Online Content for Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter–Associated Asymptomatic Bacteriuria.
• Mayo Clinic Reduces Catheter-Associated Urinary Tract Infections Through a Bundled 6-C Approach. Pages AP1-AP4 at the end of the article.
• Posters that can be displayed in units to remind staff of the key elements of urine culture stewardship.Symptom-free Pee: Let It Be

Behavior support

A number of different strategies can be used to guide behavior and reinforce the concepts of urine culture stewardship.

Laboratory-based

For example, a laboratory might only process a urine culture if specific findings are present on urinalysis or an indication for culture is included. Or urine culture results may only be provided if an ordering provider contacts the microbiology laboratory requesting the result.

Collection

Ensure the appropriate equipment is in stock and easily accessible by staff. For example, urine culture collection kits contain the equipment needed for as well as step-by-step instructions on appropriately collecting urine cultures.

Appropriate indications

The electronic medical record (EMR) can help confirm an appropriate indication is present before a provider orders a urine culture. For example, a mandatory stop can be inserted into the electronic medical record and a provider must select an appropriate indication before a urine culture can be ordered.

Examples of urine culture stewardship initiatives

These include strategies to guide and support healthcare personnel behavior.

• The Story of Kicking CAUTI: Achieving Clinical Impact through Interdisciplinary Team Work. The VA "Kicking CAUTI" Campaign was implemented at VA medical centers to improve antibiotic stewardship for CA-ASB.
• Achieving Clinical Impact Through Interdisciplinary Teamwork
• Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter–Associated Asymptomatic Bacteriuria
• Mayo Clinic Reduces Catheter-Associated Urinary Tract Infections Through a Bundled 6-C Approach. Mayo Clinic Bundled 6-C Approach was implemented at Mayo Clinic in Rochester, Minnesota and involved a bundle of six elements to reduce CAUTIs.
• A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit With an Emphasis on "Stewardship of Culturing". An intervention that involved aligning urine culturing practice among Intensive Care units at a single institution resulted in improved CAUTI rates.

Resources

• Diagnosis, Prevention, and Treatment of CAUTI in Adults: 2009 International Clinical Practice Guidelines (IDSA)
• Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults (IDSA)
• Guidelines for evaluation of new fever in critically ill adult patients: 2008 update (American College of Critical Care Medicine and IDSA)
• Guideline for Prevention of Catheter-Associated Urinary Tract Infections—2009 (CDC)
• Clinician Guide for Collecting Cultures – Urine (CDC)

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