Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines

Sonali D Advani; Catherine A Gao; Rupak Datta; Lawrence Sann; Cindy Smith; Michael S Leapman; Adam B Hittelman; James Sabetta; Louise-Marie Dembry; Richard A Martinello; Manisha Juthani-Mehta

doi:10.1093/ofid/ofz305

Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines

Open Forum Infect Dis. 2019 Aug 1;6(8):ofz305. doi: 10.1093/ofid/ofz305.

Authors

Sonali D Advani^{1

2}, Catherine A Gao³, Rupak Datta¹, Lawrence Sann⁴, Cindy Smith², Michael S Leapman⁵, Adam B Hittelman^{5

6}, James Sabetta⁷, Louise-Marie Dembry^{1

8

9}, Richard A Martinello^{1

2

6}, Manisha Juthani-Mehta^{1

9}

Affiliations

¹ Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
² Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut.
³ Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
⁴ Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
⁵ Department of Urology, Yale School of Medicine, New Haven, Connecticut.
⁶ Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut.
⁷ Greenwich Hospital, Greenwich, Connecticut.
⁸ VA Connecticut Healthcare System, West Haven, Connecticut.
⁹ Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut.

Abstract

Background: A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters.

Methods: We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines.

Results: On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by "pan-culturing" rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures.

Conclusions: Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.

Keywords: catheter-associated urinary tract infections; diagnostic stewardship; nurses; urinary catheter; urine cultures.

Grants and funding

UL1 TR001863/TR/NCATS NIH HHS/United States