Infection Control & Hospital Epidemiology


culture growth without any UTI-associated clinical features independent of additional clinical features. Wedetermined whether patients met 2017 National Healthcare


Safety Network (NHSN) symptomatic UTI criteria, defined as urine culture growth of ≤2 organisms including 1 bacterium with ≥100,000CFU/mL plus≥1 UTI-associated clinical feature within a 7-day infection window encompassing the 3 calendar days before and after urine culture collection.7 Among patients without NHSN-defined symptomatic UTI, we determined whether UTI- specific antimicrobial therapy was administered and the duration of therapy in antimicrobial days. UTI-specific antimicrobial therapy was defined as antimicrobials prescribed for potential UTI according to physician documentation and continued for ≥1 calendar day after speciation data were reported. Characteristics were provided as proportions with the specified


attribute. Among patients without NHSN-defined symptomatic UTI, we determined the proportion that received UTI-specific antimicrobial therapy. To evaluate factors associated with UTI- specific antimicrobial therapy among patients without NHSN- defined symptomatic UTI, we used a modified Poisson regression model with antimicrobial administration as a binary outcome and length-of-stay as an offset variable. Potential risk factors included gender, cancer type, urine culture growth (no growth; 10,000 to <100,000 CFU/mL; or ≥100,000 CFU/mL), and UTI-associated clinical features. Given the high death rate, we accounted for time at risk and used robust variance estimators to estimate the adjusted incidence rate ratio (IRR) for each factor. All analyses were per- formed using SAS version 9.4 software (SAS Institute, Cary, NC).


Results


We identified 300 advanced cancer patients with potential UTI who were transitioned to comfort measures. Median age was 74 years (range, 65–99), 162 (54.0%) were female, and 66 (22.0%) had liquid tumors (Table 1). Median length-of-stay was 9 days (range, 2–138), and 173 patients (57.7%) patients died during hospitalization. Overall, 536 urine cultures were collected, and 76.9% (n=412)


had no growth. Among the remaining 124 cultures, the most common organisms were Escherichia coli (n=25), Candida albi- cans (n=21), and Klebsiella pneumoniae (n=14). Among 300 patients with potential UTI, 19 had NHSN-defined


symptomatic UTI. Among the 281 patients without NHSN- defined symptomatic UTI, 21% (n=59) had asymptomatic bacte- riuria or candiduria, and 14.2% (n=40) received inappropriate UTI-specific antimicrobial therapy for 279 antimicrobial days. Of these 40 patients, 35 had bacteriuria or candiduria, and 35 lacked UTI-associated clinical features (Table 2). The most com- monly prescribed antimicrobials included ciprofloxacin (n=12), fluconazole (n=8), and piperacillin/tazobactam (n=4). In a multivariable model, administration of UTI-specific anti-


microbial therapy was associated with bacteriuria or candiduria. For 10,000 to <100,000 CFU/mL, the IRR was 16.9 (95% confi- dence interval [CI], 6.0–47.2); for ≥100,000 CFU/mL, the IRR was 27.9 (95% CI, 10.9–71.2). However, UTI-specific antimicrobial therapy was not associated with gender (IRR, 1.0; 95%CI, 0.6–1.8), cancer type (IRR, 0.7; 95% CI, 0.4–1.4), or UTI-associated clinical features (IRR, 1.3; 95% CI, 0.7–2.7).


Discussion


We show that most advanced cancer patients with potential UTI lack evidence of NHSN-defined symptomatic UTI. Moreover, 21%


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Table 1. Characteristics of Hospitalized Advanced Cancer Patients With Potential Urinary Tract Infection Who Were Transitioned to Comfort Measures at a Tertiary-Care Medical Center (n = 300)


Characteristic


Age 65–74 y 75–84 y ≥85 y


Gender Female Male


Race


White Black Other


Cancer type Nonliquid tumora Liquid tumorb


Selected comorbidities Cardiovascularc Diabetes


Pulmonary disease


Code status on admission Full code


No resuscitation, no intubation, or both Comfort measuresd


Hospital interventions Intensive care unit admission Vasopressor support Mechanical ventilation Tube feeding Hemodialysis


Length of stay 1to <3 d 3to <7 d ≥7 d


227 (75.7) 41 (13.7) 32 (10.7)


234 (78.0) 66 (22.0)


52 (17.3) 56 (18.7) 32 (10.7)


253 (84.3) 45 (15.0) 2 (0.7)


191 (63.7) 89 (29.7) 22 (7.3) 78 (26.0) 4 (1.3)


10 (3.3) 85 (28.3) 205 (68.3)


aIncludes lung tumor, gastrointestinal tumor and other solid tumor including genitourinary cancer, breast cancer, female reproductive cancer, melanoma, head and neck cancer,


connective tissue cancer, central nervous system cancer, thyroid, and unknown primary. bIncludes lymphoma, myeloid malignancy, plasma cell malignancy, and lymphoid


malignancy. cIncludes myocardial infarction, congestive heart failure, and peripheral vascular disease. dThese 2 patients changed to a non–comfort-measures code status during admission and subsequently transitioned to comfort measures prior to discharge.


of patients without NHSN-defined symptomatic UTI had asymp- tomatic bacteriuria or candiduria. Patients withoutNHSN-defined symptomatic UTI were nevertheless treated for UTI, often with broad-spectrum antimicrobials associated with adverse effects,8 for 279 antimicrobial days after urine culture speciation data were reported. Such inappropriate antimicrobial therapy was independ- ently associated with bacteriuria or candiduria rather than UTI- associated clinical features. Collectively, this study highlights a


No. (%)


159 (53.0) 105 (35.0) 36 (12.0)


162 (54.0) 138 (46.0)


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