As infection prevention
By Barbara DeBaun , MSN , RN , CIC
Urine Culture Practices : Playing Better Defense
an infection preventionist , it is not uncommon to review the medical record of a patient who developed a hospital-onset urinary tract infection and then ask the question , “ why did they culture this ?” We might see a urine culture result in a patient who had no obvious source of a urinary tract infection ( UTI ). Or one in a patient who was ‘ pan-cultured ’ when appearing septic even though the source of the sepsis was obviously something other than the urinary tract . It is also not unusual for a clinician to order a urine culture on a patient who is clearly at the end of life , yet all sources of fluids and body substances were cultured at the end even though the results were not going to be acted upon .
Hospital electronic medical records have made it easy to order a urine culture . It can be as simple as clicking a box .
When a patient ’ s urine culture is reported as positive , it may be difficult for the clinician to ignore it . The clinician will weigh the risks and benefits of treating versus not treating . If the culture result suggests true infection , treatment is indicated . However , if the culture is interpreted as positive despite the patient lacking symptoms of a UTI , the patient will receive unnecessary antibiotics . We all know how that can end .
Culturing patients that do not have clinical symptoms or a potential to be treated for a urinary tract infection is an avoidable medical error . Unnecessary treatment with antibiotics harms patients . It can result in drug-drug interactions , C . difficile infection , multidrug-resistant bacteria , renal damage , allergies , increased length of stay and other complications .
Multiple myths have perpetuated the knee-jerk ordering of urine cultures in the absence of clinical indications . Some myth-busting facts are as follows :
●An abnormal urinalysis does not necessarily indicate a UTI . Asymptomatic bacteriuria is quite common , and we also know that collection and transportation of urine specimens can be problematic when not done correctly or timely .
●Smelly , cloudy urine is a common finding in patients who are dehydrated .
●Elderly or otherwise deconditioned patients can have asymptomatic bacteriuria , therefore symptoms such as weakness , fatigue or mental status changes are not necessarily a reason to suspect UTI .
●Screening patients with no symptoms of a UTI is a recipe for failure and patient harm . We should screen patients for dietary and hydration habits and address those issues before assuming the patient has a UTI when dehydration is much more likely to be the reason for the concentrated , smelly urine .
How do we make it easier to do the right thing , and harder to do the wrong thing ? Diagnostic stewardship or leveraging the clinical laboratory to improve antimicrobial stewardship is key . Our microbiology partners are highly trained to report what they see . If white blood cells are observed in the urinalysis , these will be reported . Unfortunately , white blood cells in the urine ( pyuria ) can ’ t differentiate asymptomatic bacteriuria from a true urinary tract infection . So , there is the conundrum .
Keys to success include :
●Ordering : Test urine only when clinical symptoms suggest a UTI or if testing syncs with current guidance to screen patients scheduled for urologic surgery or those who are pregnant .
●Collection : Go to Gemba and observe how and why urine specimens are being collected ; we often make assumptions about how things are done and there is no better way to know the truth than to go look .
●Processing : Determine criteria for advancing a urinalysis to culture based upon criteria established by your facility .
A recent study by Dougherty , et al ., reported the impact of a urine culture standardization program that included order indications and urinalysis ( U / A ) with reflexive culture . The team determined that 64 percent of urine cultures ordered using the reflexive test did not reflex to culture by U / A criteria .
●Reporting : Provide clear guidance to clinicians to make it easier for them to make the best decision ( e . g ., to not treat a patient who has an unlikely probability of having a UTI ). Clinicians want to do the right thing , but they are easily tempted to treat a patient because a positive test is hard to ignore .
So , perhaps we should think of diagnostic stewardship using a sports analogy . Soccer teams have five defensive players . The sweeper , fullback , center back and wing back are tasked with preventing the soccer ball from entering the goal ( i . e ., avoid sending urine specimens that don ’ t make clinical sense ). The goalie is the person who can put a stop to the score when the other four defensive players can ’ t get the job done ( i . e ., prevent the processing and reporting of a urine culture that has a low probability of being ‘ real ’). Ideally , processes need to be in place to prevent urine specimens from being collected and sent to the laboratory in the first place . When they are clinically indicated , do it right . But we know that sometimes our defense fails us , and we need our goalie ( i . e ., urinalysis with reflexive culture ) to prevent a score for the opposing team .
It takes a team whether it ’ s a sport or healthcare , so explore strategies for practice change that make it easy to do the right thing , and hard to do the wrong thing .
Barbara DeBaun , MSN , RN , CIC , is improvement advisor for Cynosure Health , where she provides vision and leadership in the development , implementation and facilitation of infection prevention and quality improvement initiatives for healthcare organizations . She has 40-plus years of experience in infection prevention and quality improvement .
Reference :
Dougherty DF , Rickwa J , Guy D , Keesee K , Martin BJ , Smith J , Talbot TR . Reducing inappropriate urine cultures through a culture standardization program . Am J Infect Control 2020 ; 48:656-662 .