Highlights
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Choosing wisely initiative to reduce urine cultures for asymptomatic bacteriuria and catheter-associated asymptomatic bacteriuria in an 11-hospital safety net system
Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harms, including adverse antibiotic effects, antibiotic resistance, and increased length of stay.
This quality improvement initiative focused on inappropriate urine cultures (UC) at 11 hospitals and 70 outpatient clinics in a safety-net setting. A mandatory notice for appropriate indications for UC orders and a best practice notice (BPA) for UC in patients with urinary catheters were created.
Urine culture (UC) ordering was compared pre-intervention (June 2020-October 2021) with post-intervention (December 2021-August 2022). Variation across hospitals and clinics was assessed, as well as BPA responses by physician type and specialty.
Inpatient urine cultures (UC) decreased by 20.9% (p < 0.001), and outpatient UC did not change (2.6% increase, not significant). UC in patients hospitalized with a urinary catheter decreased by 21.6% (p < 0.001).
Temporal trends were also evaluated. A large variation was observed between hospitals and clinics. Low acceptance rates of BPA were observed in internal medicine and family medicine physicians. Attendees showed high acceptance of BPA compared to other clinicians.
This initiative successfully reduced UC in a large safety net system. More studies are needed to evaluate variation between hospitals and clinics, as well as between types of doctors and specialties.
The initiative provides a model for resource-limited institutions to decrease overdiagnosis and overtreatment of asymptomatic bacterial infections.
Clinicians at the largest safety-net hospital system in the United States used two interventions focused on electronic health records (EHRs) to significantly reduce inappropriate urine cultures among hospitalized patients. Their study findings, published in the American Journal of Infection Control (AJIC), suggest that low-resource approaches could help reduce overdiagnosis and overtreatment of asymptomatic bacteriuria.
"This quality improvement initiative revealed that low-effort EHR interventions can successfully reduce unnecessary urine culture orders to create better, more efficient care, particularly for vulnerable patient populations," said Mona Krouss. , MD, AVP, Value and Patient Safety, NYC Health + Hospitals (NYC H+H), and the lead author of the published study. “We believe this successful intervention can be a model for other institutions and may be especially valuable in resource-constrained safety net systems.”
Asymptomatic bacteriuria ( ASB), the isolation of bacteria in the absence of symptoms or signs of a urinary tract infection (UTI), is overdiagnosed and overtreated in the United States. Although the United States Preventive Services Task Force, the Infectious Diseases Society of America, and multiple Choosing Wisely Lists recommend against treating asymptomatic bacteriuria (ASB) given the lack of benefit for all but a few populations, Inappropriate urine culture testing and subsequent treatment are common. Overtreatment of ASB causes harm, including adverse antibiotic effects, antibiotic resistance, and increased length of hospital or facility stay.
Dr. Krouss and his colleagues at NYC H+H implemented a quality improvement project aimed at decreasing unnecessary urine culture orders at their 11 acute care hospitals in an efficient and relatively non-intrusive manner. The intervention consisted of changing the urine culture ordering screen in the electronic medical record (EMR) to require the entry of an indication for the culture , and a Good Practice Notice (GPA) that appeared when urine cultures were requested for patients with urinary catheters. who were hospitalized for more than 48 hours. The researchers then compared urine culture ordering before the intervention (6/2020 to 10/2021) with after the intervention (12/2021 to 8/2022). They also evaluated variation across hospitals and clinics, as well as BPA responses by physician type and specialty.
During the study period, the Good Practice Notice (GPA) was activated 4,822 times, with 552 urine culture requests eliminated, an acceptance rate of 11.4%. All 11 hospitals saw a statistically significant reduction in urine culture testing. Specifically, urine culture orders in the inpatient setting were reduced from 32.68 per 1000 patient-days before the intervention to 25.85 per 1000 patient-days after the intervention, a 20.9% reduction. . The researchers noted that reductions in urine culture ordering rates were highly variable among the 11 hospitals.
For those patients with a urinary catheter tested 48 hours after admission, urine culture rates decreased from 2.36 per 1000 patient-days before the intervention to 1.85 per 1000 patient-days after the intervention, a reduction from 21.6%. Rates of catheter-associated urinary tract infection (CAUTI) did not change before and after the intervention (1.95 and 1.63, respectively, p = 0.1).
“These findings suggest that EHR-based clinical decision support can be effective and scalable to improve the care of patients with indwelling catheters and reduce antibiotic overuse,” said Patricia Jackson, RN, BSN, CIC, FAPIC, president. from APIC 2023. “It is necessary to curb the use of antibiotics to combat the growing threat of antibiotic resistance.”
