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Fig. 2. Inpatient urine culturing practices from January 1, 2015 to August 31, 2017. The intervention time point is noted by a dashed line. P < .001 for urine cultures and cath- eterized cultures; P=.027 for isolated cultures, using interrupted time series analysis.
(75.6%) in the rate of catheterized urine cultures per 1,000 patient days, there was no significant change in the CAUTI rate postinter- vention. Given that we previously reported that isolated urine cul- tures were more likely to be ordered on catheterized patients and patients with prolonged hospital stays,32 we evaluated the propor- tion of CAUTIs associated with isolated urine cultures. We found no significant difference between study periods in the proportion of CAUTIs that were identified based on isolated urine cultures (39 of 125 [31.2%] preintervention vs 26 of 125 [20.8%] postinterven- tion; P=.06). These findings suggest that for patients in whom a clinical suspicion of CAUTI existed, clinicians were ordering diagnostic tests and detecting it in both intervention periods. Therefore, additional infection prevention efforts may be required in this study cohort to prevent CAUTIs. Our intervention resulted in an estimated cost savings of
~$104,000 for inpatient laboratory costs after implementation. This represents a fraction of the total costs and does not reflect the costs saved based on the medical decisions (eg, delayed hospital discharge) and antimicrobial therapy.27 In an era of reducing reim- bursement for clinical laboratory testing,33 the prudent use of common diagnostic tests in patient care is increasingly important. The limitations of our study include a retrospective design,
the absence of chart review for test indication, and lack of data on antibiotic use for assessment of antimicrobial therapy.We were unable to assess asymptomatic bacteriuria because data on clinical symptoms or signs were not collected. In addition, this is a single academic medical center and may not be generalizable to other settings. Our medical informatics database does not include orders; therefore, we were unable to directly evaluate the frequency of urinalysis reflex to microscopy with culture and types of urine cul- ture orders. We attempted to address this limitation by examining urine cultures that were performed along with urinalysis and/or microscopy, but we would not be able to identify how much our intervention reduced the proportion of urinalysis that reflexed to culture. The median number of urine cultures for the preinter- vention and postintervention periods were the same (including demographic characteristics patients who had >1 urine culture); therefore, we did not make any adjustments for the repeat obser- vations. We were unable to directly assess whether antibiotic use changed in patients with urinary testing because of the interven- tion, and its subsequent effect on antimicrobial resistance among urinary pathogens. Strengths of our study include using data from
a large academic medical center and electronic order sets for the intervention. The use of CPOE for such intervention requires relatively little ongoing intervention effort compared with other diagnostic stewardship efforts, which require constant monitoring. Our study results complement a similar CPOE intervention con- ducted in the emergency department of the same hospital, where we observed a 47% decrease in urine cultures ordered when only “urinalysis with reflex to microscopy” was retained in the frequently ordered list of laboratory tests.34Asimilar study of urine diagnostics reported that the elimination of reflexed microscopy examination for inpatient locations resulted in a 95% reduction in the urine microscopy performed.35 In summary, a staged intervention to clarify test names and
inclusion of new reflex tests resulted in a 45%reduction in the urine cultures ordered with an estimated cost savings of $104,000. Further studies are needed to evaluate the role of CPOE in combination with education sessions for ordering physicians and antimicrobial stewardship efforts in reducing the incidence of unnecessary urine cultures. Future research should also focus on reducing isolated urine cultures and CAUTIs.
Author ORCIDs. David K. Warren, Acknowledgements. None.
0000-0001-8679-8241
Financial support. This study was funded in part by Centers for Disease Control and Prevention Epicenters Program (grant no. 1U54CK000482-01).
Conflicts of interest. All authors report no conflict of interest related to this manuscript.
References
1. Trautner BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol 2011;9:85–93.
2. McMaster-Baxter NL, Musher DM. Clostridium difficile: recent epidemio- logic findings and advances in therapy. Pharmacotherapy 2007;27: 1029–1039.
3. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:68–75.
4. Hartley SE, Kuhn L, Valley S, et al. Evaluating a hospitalist-based interven- tion to decrease unnecessary antimicrobial use in patients with asympto- matic bacteriuria. Infect Control Hosp Epidemiol 2016;37:1044–1051.
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