A proof-of-concept study that used different criteria for urine testing than those outlined by the current Infectious Disease Society of America (IDSA) guidelines, has demonstrated that the new approach cuts down on the testing of urine samples and inappropriate use of antimicrobials. The significant decreases were all the more noteworthy since they were driven by the few clinicians who bought into the program.
“Intervention led to a decrease in urine tests sent. The discussion of testing indications does influence urine testing. While compliance rates of checklist complication were low, we conclude that the decrease in testing was most likely due to the discussion of testing within teams, especially on daily rounds,” wrote poster presenter Corinne Klein, MD, Oregon Health & Science University, Department of Internal Medicine, Portland, Oregon, and her colleagues.
The current IDSA guidelines recommend urine cultures when signs and symptoms of infection are evident. The result, which has been amply documented, is that too many urine cultures are sent too often when these signs and symptoms are not evident, and antimicrobial use begins even before results are back from the lab. In addition, catheter-associated bacteremia that is asymptomatic can be misdiagnosed as catheter-associated urinary tract infection (CAUTI), which also drives the inappropriate use of antimicrobial drugs.
To find a better way of doing things, the researchers explored whether reducing inappropriate urine testing would cut down on these problems. Their approach focused on modifying the behavior of intensive care unit (ICU) clinicians. Essentially, the clinicians had to observe the steps outlined in a form developed by the researchers. The form spelled out the nuts and bolts of urine testing, with clear explanations on how urine should be collected and why it is important to follow the instructions. The clinicians had to sign off on the guidelines, in hopes that it would help them overcome habitual behavior. Findings of a pilot study provided feedback to positively reinforce the new behavior.
Perhaps not surprisingly, compliance was low, ranging from 4.3% of neuroscience ICU clinicians to 43% of medical ICU clinicians. However, even this dismal compliance produced significant savings in lab time and cost, as well as significant savings in charges to patients.
Importantly, despite the less-than-stellar compliance, the study still proved beneficial in terms of the decreased number of urine tests and the actual number of CAUTI in the various ICUs. The number of days without a CAUTI per unit was extended beyond what any unit had accomplished in the past, in the best case by 190 days in the cardiovascular ICU.
Researchers' future aims include increasing the proportion of clinicians buying-in to the initiative; the researchers are confident that having data will encourage more people to get on board. Incorporating the principles of the urine collection checklist into the electronic health record is another goal, as is broadening the dialogue to all units of the hospital, including nurses and physicians-in-training. Assessing the benefits of the approach in preventing antibiotic-resistant Clostridium difficile
is also a goal.
Corinne Klein: None
- IDSA presentation
- Hooten TM et al. Clin Infect Dis 2010 50:625-663
Poster 1871.Decreasing Inappropriate Urine testing to Decrease Cather-Associated UTI: A Provider Behavior Approach; Presenter, Corinne Klein MD, Oregon Health & Science University, Department of Internal Medicine, Portland, Oregon
Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at firstname.lastname@example.org.
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