472
Table 2. Antimicrobial Use According to Urine Culture Results and Clinical Features in Hospitalized Advanced Cancer Patients Transitioned to Comfort Measures With Potential Urinary Tract Infection (UTI) who Lack National Healthcare Safety Network-Defined Symptomatic UTI
Urine Culture
Bacteriuria or Candiduria (≥100,000 CFU/mL)
Bacteriuria or Candiduria (≥100,000 CFU/mL)
Bacteriuria or Candiduria (≥10,000 CFU/mL, <100,000 CFU/mL)
Bacteriuria or Candiduria (≥10,000 CFU/mL, <100,000 CFU/mL)
No growth No growth
UTI-Associated Clinical Featuresa (Total No. Patients)
Present (1) Absent (29) Present (5)
Antimicrobial Use, Yes
1b 18c 3
Antimicrobial Use, No
0 11 Author ORCIDs. Rupak Datta, 2 0000-0003-2281-7508
Acknowledgements. We thank the Joint Data Analytics Team at Yale School of Medicine for their support of this study.
Absent (30) 13d 17
Present (25) Absent (191)
1 4
24 187 aUTI-associated clinical features were defined as fever (>38°C), suprapubic tenderness,
costovertebral angle pain or tenderness, urinary urgency, urinary frequency, or dysuria. bThis patient had candiduria alone and therefore did not meet National Healthcare Safety
Network criteria for symptomatic urinary tract infection. cAdditional clinical features were present in 13 total patients, including 10 with leukocytosis
(>14,000 leukocytes/mm3) and 7 with worsening mental status. dAdditional clinical features were present in 6 total patients, including 3 with leukocytosis (>14,000 leukocytes/mm3), 4 with worsening mental status, and 1 with urinary incontinence.
potential target of antimicrobial stewardship, namely, restricting urine culture orders in advanced cancer patients transitioning to comfort measures. Our work confirms published findings9 and supports guidelines
recommending urine culture evaluation only in the presence of UTI-associated clinical features.10 Few studies have examined inappropriate urine cultures in end-of-life advanced cancer patients, a population in whom unnecessary antimicrobials may cause harm and conflict with comfort-oriented goals of care. We show that advanced cancer patients with bacteriuria or candiduria were 17–28 times more likely to receive UTI-specific antimicrobial therapy per patient day when compared to those without bacteri- uria or candiduria. Our data further suggest that nonspecific addi- tional clinical features such as leukocytosis may drive antimicrobial administration in those without UTI-associated clinical features. Future studies should evaluate the impact of urine culture order restrictions in end-of-life advanced cancer patients. This study has limitations. First, the sample size precluded
evaluation of other factors predisposing to antimicrobial therapy such as family preferences. However, the strength of the observed adjusted association suggests bacteriuria and candiduria will remain associated with UTI-specific antimicrobial therapy. Second, NHSN definitions may lack sensitivity for symptomatic
Conflicts of interest. All authors report no conflicts of interest relevant to this work.
References
1. Thompson AJ, Silveira MJ, Vitale CA, Malani PN. Antimicrobial use at the end of life among hospitalized patients with advanced cancer. AmJ Hospice Palliat Care 2012;29:599–603.
2. White PH, Kuhlenschmidt HL, Vancura BG, Navari RM. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manag 2003;25:438–443.
3. Reinbolt RE, Shenk AM, White PH, Navari RM. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manag 2005;30:175–182.
4. Datta R, Juthani-Mehta M. Burden and management of multidrug-resistant organisms in palliative care. Palliat Care 2017;10:1–6. doi: 10.1177/ 1178224217749233.
5. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an antimi- crobial stewardship approach for urinary catheter–associated asymptomatic bacteriuria. JAMA Intern Med 2015;175:1120–1127.
6. Nace DA, Drinka PJ, Crnich CJ. Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. J Am Med Dir Asso 2014;15:133–139.
7. Urinary tract infection and other urinary system events. Centers for Disease Control and Prevention website.
https://www.cdc.gov/nhsn/pdfs/pscmanual/ 7psccauticurrent.pdf. Published 2018. Accessed January 27, 2019.
8. Deshpande A, Pasupuleti V, Thota P, et al. Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother 2013;68:1951–1961.
9. Silver SA, Baillie L, Simor AE. Positive urine cultures: a major cause of inappropriate antimicrobial use in hospitals? Can J Infect Dis Med Microbiol 2009;20(4):107–111.
10. Nicolle LE, Bradley S, Colgan R, Rice JC, SchaefferA, HootonTM. Infectious diseases society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.
Financial support. This work was supported by at the Yale School of Medicine, Section of Infectious Diseases (grant no. 2T32AI007517–16) and by the Claude D. Pepper Older Americans Independence Center from the National Institute on Aging, National Institutes of Health (grant no. P30 AG021342). This work was additionally supported by the Yoshikawa-High Award for Excellence in Research from the Infectious Diseases Society of America Infections in Older Adults Interest Group.
Rupak Datta et al
UTI in older adults.6 However, of the 19 patients with additional clinical features in the setting of bacteriuria or candiduria and absent UTI-associated clinical features, none met revised McGeer criteria for UTI.6 Finally, our results may lack generaliz- ability to other institutions. In summary, many advanced cancer patients with potential
UTI have asymptomatic bacteriuria or candiduria for which inap- propriate antimicrobial therapy was administered for extended periods. Bacteriuria or candiduria was associated with UTI-specific antimicrobial therapy, suggesting that stewardship interventions should consider restricting urine cultures in this population.
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