Improving the Culture of Culturing: When Do Resident Physicians Obtain Urine Cultures, and What Do they Do with Them?

Mohamad G Fakih, MD, MPH,1 Karen Jones, RN, BSN,1 Elango Edhayan, MD,1 Ana Cecilia Bardossy, MD,2 Takiah Williams, RN,1 Katherine Reyes, MD, MPH,2 Raymond Hilu, MD,1 Marcus Zervos, MD,2 Mina El-Kateb, MD,1 Susanna Szpunar, PhD,1 Rebecca Battjes, BA,1 Steven Minnick, MD, MBA,1 Louis Saravolatz, MD.1

1St. John Hospital and Medical Center, and 2Henry Ford Hospital, Detroit, Michigan

Introduction Catheter associated urinary tract infections (CAUTIs) account for a large proportion of healthcare associated infections (HAIs). The diagnosis of CAUTI is based on having a positive urine culture in addition to the presence of symptoms and signs of infection without the identification of sources different from the urinary tract. The 1st step to evaluate for CAUTI is to obtain a urine culture. The urine culture collection is often triggered by some misconceptions, such as urine color, sediments, or odor. This leads to an increased unnecessary collection of urine cultures, and consequent inappropriate antimicrobial use.

Results Ø  124 participants [Hospital A, n=63 (50.8%), Hospital B, n=61 (49.2%)] completed the survey.

86 (69.4%) were from Internal Medicine, and 38 (30.6%) from surgery. Postgraduate year of training: PGY1: 30 (24.2%), PGY2: 44 (35.5%), PGY3: 36 (29%); PGY4: 14 (11.3%).

Ø  58 (46.8%) felt their knowledge is above average or excellent, and 85 (68.5%) received lectures addressing appropriate indications for urinary catheter use. In addition 89 (71.8%) reported being aware of guidelines to diagnosis and treatment of CAUTI.

ID Week 2015 Session 50; Presentation #294

Question (correct answer) Medicine answered

correctly (%)

Surgery answered

correctly (%)

Foul smelling urine (no) 31 (37.3%) 10 (27%)

Hematuria (no) 49 (59%) 26 (70.3%)

Cloudy urine (no) 34 (41.5%) 12 (32.4%)

Urine Sediment (no) 43 (53.8%) 20 (54.1%)

Dark urine (no) 55 (66.2%) 27 (73%)

Urgency (no) 34 (41%) 17 (36%)

Post Catheter insertion routinely (no) 56 (68.3%) 29 (80.6%)

Catheter present more than 3 days (no) 56 (67.5%) 29 (78.4%)

Chronic urinary catheter on admission (no) 57 (70.4%) 22 (59.5%)

New onset abdominal pain (yes) 56 (67.5%) 21 (56.8%)

New onset confusion (yes) 68 (82.9%) 25 (67.6%)

Patient going for bladder tumor resection (yes) 45 (54.9%) 16 (43.2%)

Patient going for colon surgery (no) 47 (57.3%) 25 (69.4%)

Temp >38, hypotension, no clear source of infection (yes) 68 (81.9%) 29 (78.4%)

Temp>38, hypotension with pneumonia (no) 50 (61%) 22 (59.5%)

UA WBC is 25 cells (no) 29 (34.9%) 14 (37.8%)

UA WBC is 100 cells (no) 10 (12%) 7 (18.9%)

UA WBC is 500 cells (no) 6 (7.2%) 3 (8.1%)

Methods We conducted a survey of internal medicine and surgery resident physicians (RPs) at 2 large teaching hospitals. The surveys addressed when and how to obtain a urine culture, and management of catheterized patients with positive urine cultures using multiple patient scenarios. Survey was web-based and each resident physician was given a personal code to perform the survey. RP responses were evaluated based on specialty, year of training, and hospital.

Table 1. When to Obtain a Urine Culture in Catheterized Patients Comparing Medicine to Surgery

Abstract Background: The diagnosis and management of catheter associated urinary tract infections (CAUTIs) starts by obtaining a urine culture, often triggered by subjective observations that may not relate to infection.

Methods: We surveyed medicine and surgery resident physicians (RPs) in 2 large teaching hospitals on what triggers a urine culture in a catheterized patient and when to administer antimicrobials for a positive urine culture result. Results: 124 RPs participated in the survey. About half of the RPs (58/124; 46.8%) felt their knowledge about the diagnosis of CAUTI is above average or excellent, and 68.5% received lectures addressing appropriate indications for urine cultures within the last year. RPs showed less than optimal knowledge on what triggers ordering a urine culture in patients with an indwelling catheter with RPs obtaining urine cultures for foul smelling urine (45%), cloudy urine (42%), sediments in urine (26.5%), hematuria (16.6%), chronic urinary catheter on admission (16.1%), and darker looking urine (15%). Residents tended to order more urine cultures the higher the urine analysis white cell counts: for 25 cells (33.3%), for 100 cells (67.5%), and for 500 cells (82.5%). For asymptomatic bacteriuria, 58.3% would change the catheter, 24.2% would treat bacteriuria for a patient going for a non-urologic surgery, and 17.5% will administer antibiotics. Conclusion: There are significant opportunities for improvement in training the resident physicians regarding the appropriate reasons for collecting urine cultures, the clinical diagnosis of CAUTI, and management. We suggest programs to evaluate their residents’ knowledge and practice, and implement educational interventions if needed.

Management Answered correctly (%)

Treat if they have neutropenia (yes?) 84 (70%)

Evaluate catheter need and discontinue if possible (yes) 111 (92.5%)

Treat if they had renal transplant 2 weeks prior (yes?) 91 (76.5%)

Change the catheter (no) 13 (10.8%)

Treat if they are going for urological surgery (yes) 90 (75%)

Treat if they are going for non urological surgery (no) 61 (50.8%)

Treat with Antibiotics to reduce risk of infection (no) 24 (20%)

Watch without Antibiotics (yes) 81 (67.5%)

Mohamad Fakih, MD, MPH Infection Prevention & Control St John Hospital & Medical Center 19251 Mack Ave., Suite 190 Grosse Pointe Woods, MI 48236 Mohamad.fakih@stjohn.org

Table 2. Management of catheterized patients with asymptomatic bacteriuria (>105)

Management of Symptomatic CAUTI: Ø  For patients with positive urine cultures, fever,

chills and suspecting CAUTI, RPs would change the catheter (112; 93.3%), evaluate discontinuation of catheter (112; 94.1%), and treat with antibiotics for 2 weeks (85; 70.8%), and would treat based on susceptibilities (113; 94.2%).

Conclusions Ø  There are significant opportunities for

improvement in training RPs regarding the appropriate reasons for collecting urine cultures, diagnosis and management of CAUTI.

Ø  Training programs may consider integrating such a training in their Clinical Learning Environment Review activities.

Funding Support: Supported by a contract from the Agency for

Healthcare Research and Quality HHSA290201000025I/HHSA29032001T,

under a subcontract with the Health Research & Educational Trust.

Discussion §  RPs often considered obtaining urine

cultures in catheterized patients based on findings that are not related to infection.

§  This was seen for both medical and surgical residents in both hospitals and the different years of training.

§  In addition, the more the pyuria, the more likely that RPs would order urine cultures in catheterized asymptomatic patients.

§  This practice may lead to more asymptomatic bacteriuria patients being inappropriately treated with antibiotics, leading to increase resistance and Clostridium difficile infection.

§  Half of the RPs would do urine cultures prior to nonurologic surgery and 20% would treat catheter-associated asymptomatic bacteriuria.

§  Areas for potential improvement were also noted in the treatment of symptomatic CAUTI, where 70% would treat patients for up to 2 weeks with antibiotics.