A Culture Of Stewardship: Antibiotic Stewardship Starts .
A Culture of Stewardship:Antibiotic Stewardship Starts withthe Urine Culture1
PresenterBarbara W. Trautner, MD, PhDAssociate ProfessorBaylor College of MedicineContributions byKristi Felix, RN, BSN, CRRN, CIC, FPAICMadonna Rehabilitation HospitalLinda Greene, RN, MPS, CIC, FAPICUniversity of Rochester, Highland HospitalMilisa Manojlovich, PhD, RN, CCRNUniversity of MichiganJennifer Meddings, MD, MScUniversity of MichiganSanjay Saint, MD, MPHUniversity of MichiganKaren Fowler, MPHUniversity of Michigan2
Learning Objectives Discuss the role asymptomatic bacteriuria (ASB) playsin antibiotic stewardship Describe the downstream effect of urine cultures onantimicrobial resistance Identify how to introduce urine testing stewardshipto your facility3
The Rise of Antibiotic Resistance andAntibiotic StewardshipThe White HouseCDCWHO(The White House, 2015; Core Elements of Hospital Antibiotic Stewardship Programs, CDC, 2014;Antibiotic/Antimicrobial Resistance , CDC,2017; WHO, 2015)4
Goals of Antibiotic StewardshipAntibiotic stewardship refers to a set of commitments andactivities designed to “optimize the treatment of infections whilereducing the adverse events associated with antibiotic use.”The Goal is to have the RIGHT DRUG for the RIGHT PERSON over the RIGHT TIME FRAME(Core Elements of Hospital Antibiotic Stewardship Program, CDC, 2014)5
Inappropriate Management of UTI andCAUTI is a Stewardship IssueSuspected urinary tract infection (UTI) is one of the mostcommon causes of inappropriate antibiotic prescribing inthe inpatient setting– Wrong drug Inappropriate choice of first-line therapy– Wrong person Treating patients with asymptomatic bacteriuria (ASB)– Wrong duration Treating UTI/CAUTI too long(Magill SS, JAMA, 2011)6
What are the Signs and Symptoms of CAUTI?YES: CAUTINO: Not CAUTI Fever Change in urine color Rigors Foul smelling urine Altered mental status Cloudy urine Malaise/lethargy Urinary sediment Flank pain Costovertebral angle tenderness Acute hematuria Pelvic discomfort Dysuria, urgency, frequency Suprapubic pain or tendernessWhy?Chronicallycatheterized patientshave bacteriuria 98%of the time(Hooton TM, Clin Infect Dis, 2010)7
Relationship of Bacteriuria toASB and UTIBacteriuria means a positive urine cultureBacteriuriaASBUTI(Warren, J Infect Dis, 1982)8
Downstream Impact of Urine Cultures 20% to 83% of patients with asymptomaticbacteriuria receive un-needed antibiotics totreat their suspected UTI Positive urine cultures lead to inappropriateantibiotics– 57% of asymptomatic patients received antibioticswhen their urine culture results from admissionturned positive(Trautner BW, Infect Dis Clin North Am, 2014; Leis JA, Infect Control Hosp Epidemiol, 2013)9
Urinalysis and Pyuria Over 90% of older adults with positive urine cultures(bacteriuria) have pyuria If leukocyte esterase (LE) and nitrite are bothnegative, it is strongly predictive that a UTI is NOTpresent Urinalysis can rule out UTI but cannot rule in UTI(Mandell GL, Churchill Livingstone Elsevier, 2009)10
What Happens in Real Life*places to interveneDisclaimer: All case studies are hypothetical and not based on any actual patient information. Anysimilarity between a case study and actual patient experience is purely coincidental.11
Technical Strategies for UrineCulture StewardshipDo NOT culture urine unless it is clinically indicated When to obtain a urine culture– Focal symptoms suggestive of a UTI or CAUTI Symptoms include: costovertebral angle tenderness, flank pain, pelvicdiscomfort, acute hematuria, fever, rigors– Signs and symptoms of sepsis in patients with no clear source When to AVOID obtaining a urine culture– Screening on admission without signs and symptoms– Screening for non-urologic surgery– Automatic triggers for cultures Increased temperature White blood cells in the urine12
Socio-Adaptive Strategies for UrineTesting Stewardship Unit and hospital culture Effective communication– Complete, clear, brief and timely– TeamSTEPPS communication tools SBAR, CUS, Two-Challenge Rule, etc.– Joint Commission handoff tool(Sentinel Event Data Root Causes by Event Type, 2004 – 2014, Joint Commission; 8 Tips for High Quality HandOffs, Joint Commission, TeamSTEPPS, AHRQ)13
Additional Resources on Antibiotic andUrine Culture Stewardship IHI Antibiotic Stewardship Driver Diagram andChange Package CDC Clinician Guide to Collecting Cultures AHRQ Urine Culture Practices in the ICU Presentation14
Know When to Obtain a Urine Culture(Preventing CAUTI: Focus on Culturing Stewardship, AHRQ, 2015)15
References Antibiotic/Antimicrobial Resistance. Centers for Disease Control and Prevention, CDC. August 2017. Available athttps://www.cdc.gov/drugresistance/index.html. Accessed October 24, 2017.Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America andthe Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016; 62(10): e51-77. doi: 10.1093/cid/ciw118.Core Elements of Hospital Antibiotic Stewardship Programs. Centers for Disease Control and Prevention (CDC). U.S. Department of Health and HumanServices. Accessible at: tion/core-elements.htmlDrekonia DM, Gnadt C, Kuskowski MA, et al. Urine cultures among hospitalized veterans: casting too broad a new? Infect Control Hosp Epidemiol. 2014;35(5): 574-6.Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009International Clinical Practice Guidelines from the Infectious Diseases Society of American. Clin Infect Dis. 2010; 50(5): 625-63.Irfan N, Brooks A, Mithoowani S, et al. A controlled quasi-experimental study of an educational intervention to reduce the unnecessary use ofantimicrobials for asymptomatic bacteriuria. PLoSOne. 2015; 10(7): e0132071.Leis JA, Gold WL, Daneman N, et al. Downstream impact of urine cultures ordered without indication at two acute care teaching hospitals. Infect ControlHosp Epidemiol. 2013; 34(10):1113-4.Magill SS, Edwards JR, Beldavs ZG, et al. Prevalence of antimicrobial use in US acute care hospitals, May-September 2011. JAMA. 2014; 312(14): 1438-46.Mandell GL, Bennett JE, Dolin R. Mandell, et al. Bennett’s Principles and Practice of Infectious Diseases, 7th Edition. Philadelphia, PA: Churchill LivingstoneElsevier, 2009.National Action Plan for Combatting Antibiotic-Resistant Bacteria. The White House, Office of the Press Secretary. March -national-action-plan-combat-ant. AccessedDecember 23, 2015.Preventing CAUTI: Focus on Culturing Stewardship. Content last reviewed October 2015. Agency for Healthcare Research and Quality, Rockville, n7.htmlTrautner, BW, Grigoryan, L. Approach to a Positive Urine Culture in a Patient Without Urinary Symptoms. Infect Dis Clin North Am. 2014; 28(1): 15–31.Warren JW, Tenney JH, Hoopes JM, et al. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J InfectDis. 1982; 146(6): 719-23.World Health Organization (WHO). Global Action Plan on Antimicrobial Resistance. 2015. WHO, Geneva, Switzerland.16
Speaker Notes17
Speaker Notes: Slide 1Welcome to the final Tier 1 module of the Catheter-AssociatedUrinary Tract Infection (CAUTI) Prevention course. This module,titled “A Culture of Stewardship: Antibiotic Stewardship Startswith the Urine Culture” will explore the connection betweenurine culture practices and antibiotic stewardship.18
Speaker Notes: Slide 2This module was developed by national infection preventionexperts devoted to improving patient safety and infectionprevention efforts.19
Speaker Notes: Slide 3After completing this module you will be able to: Discuss the role asymptomatic bacteriuria (ASB) plays inantibiotic stewardship, Describe the downstream effect of urine cultures onantimicrobial resistance, and Identify how to introduce urine testing stewardship to yourfacility.20
Speaker Notes: Slide 4This module begins with some background information. Hereare three important organizations—the White House, theCenters for Disease Control and Prevention, or CDC, and theWorld Health Organization, WHO, that are all emphasizing theimportance of antibiotic stewardship and combating the growingthreat of antibiotic resistance. Antibiotics are an essential part ofmodern health care, greatly reducing illness and death frominfectious diseases. However, antibiotic resistance is on the rise.The CDC estimates that in the U.S. at least 2 million peoplebecome infected with resistant bacteria every year and about23,000 people die every year from these infections.21
Speaker Notes: Slide 4 ContinuedWidespread use of antibiotics has contributed to increasing ratesof antibiotic resistant bacteria. Recent studies estimate that“between 20-50% of all antibiotics prescribed in U.S. acute carehospitals are either unnecessary or inappropriate.” Health careantibiotic stewardship efforts are a vital element to combat thisgrowing threat of antibiotic resistance. Additionally, antibioticstewardship programs improve patient safety, reduce antibioticharms and reduce rates of Clostridioides difficile infection (whichare intimately tied to antibiotic use).22
Speaker Notes: Slide 4 ContinuedTo read more about the White House National Action Plan forCombatting Antibiotic-Resistant Bacteria, the CDC’s CoreElements of Hospital Antibiotic Stewardship Programs, and/orthe WHO’s Global Action Plan on Antimicrobial Resistance, clickon the corresponding image.23
Speaker Notes: Slide 5Antibiotic stewardship is a set of commitments and activitiesdesigned to “optimize the treatment of infections while reducingthe adverse events associated with antibiotic use.” In essence,antibiotic stewardship is having the right drug, for the rightperson over the right time frame.The remainder of this module discusses how urine culturestewardship is linked to antibiotic stewardship and usingantibiotics appropriately.24
Speaker Notes: Slide 6Suspected urinary tract infection (UTI), including catheterassociated urinary tract infects (CAUTIs), is one of the mostcommon causes of inappropriate antibiotic prescribing in theinpatient setting. Providers often choose a broader spectrumantibiotic for UTI than is necessary, mistakenly treatasymptomatic bacteriuria thinking it is a CAUTI or UTI, andprescribe an unnecessarily long duration of therapy. In essence,treating asymptomatic bacteriuria is a “wrong person” issue instewardship. And it all starts with testing the urine with either aurinalysis or urine culture in a patient without specific symptomsof UTI.25
Speaker Notes: Slide 7This slide reviews the clinical signs and symptoms of a CAUTI.The left-hand side of your screen lists the signs and symptoms asdescribed by the Infectious Diseases Society of America, IDSA, intheir 2009 guidelines. These guidelines were designed to helpguide clinicians in making a decision about whether to test ortreat—so they may differ slightly from surveillance definitions ofCAUTI.The right-hand side of your screen lists the signs and symptomsthat are commonly mistaken as indications of an infection.Change in urine color, foul smelling urine, cloudy urine andurinary sediment are not indicative of a CAUTI.26
Speaker Notes: Slide 7 ContinuedThese are all too non-specific to point towards UTI. The reason ischronically catheterized patients have bacteria their urine 98percent of the time, which will result in cloudy urine that smellsbad. But that doesn’t mean the patient has any symptoms ofUTI. Similarly, certain foods and medications can cause the urinecolor or odor to change, and again these changes don’t mean thepatient has a symptomatic UTI.The point is that urine culture stewardship means only orderingurine cultures when patients have true signs and symptoms of anUTI or CAUTI.27
Speaker Notes: Slide 8Urine cultures test for the presence of bacteria in the urine, orbacteriuria. But bacteriuria is not exclusively indicative of UTIs orCAUTIs. As the graphic on the slide shows, bacteriuria, or apositive urine culture, is a set that includes the two conditions ofasymptomatic bacteriuria (ASB) and UTI. Asymptomaticbacteriuria occurs when patients have a positive urine culture,but lack specific UTI symptoms. Often this will present as cloudyurine or dirty urine, with a “dirty urinalysis.” And as we discussedon the previous slide and in the antibiotic stewardship moduleon urinary tract infections, ASB should not be treated withantibiotics.28
Speaker Notes: Slide 8 ContinuedThe hardest part for most people about dealing with ASB islearning to leave well enough alone. In health care we don’t liketo do that, we see a positive test result or urine culture and wewant to do something about it. We fear that doing “nothing” willhurt our patients. But remember that in this instance you aren’tdoing nothing when you leave asymptomatic bacteriuria alone.In fact, you are protecting your patient from the harms ofunnecessary antibiotics.29
Speaker Notes: Slide 8 ContinuedAdditionally, false positive urine tests can also overly inflate ahospital’s CAUTI rate. Positive urine cultures in a patient with afever and an indwelling urinary catheter have to be counted asCAUTI—even if the patient has pneumonia, or cellulitis, or someother non-urinary cause of fever. So improving your urine culturetesting practices can also help to reduce your hospital’s CAUTIrate.30
Speaker Notes: Slide 9The literature highlights the magnitude of over-treatingasymptomatic bacteriuria. Recent studies document thatbetween 20 to 83 percent of asymptomatic patients withpositive urine cultures were treated with antibiotics. Similarly,the time point when a urine culture result appears in the chart isa period of risk for patients to receive extra and unnecessaryantibiotics. A small study by Leis and colleagues found that 12out of 21 of asymptomatic patients received antibiotics whenthe urine culture result came back positive, usually two days intothe hospital stay.31
Speaker Notes: Slide 10Lastly, it is also important to keep in mind that over 90 percent ofelderly adults with bacteriuria are going to have pyuria. So,testing for pyuria, like bacteriuria, does not help differentiatebetween ASB and UTI or CAUTI. If the leukocyte esterase (LE)and nitrite are both negative on the urine analysis, it is stronglypredictive that a urinary tract infection is not present. But youcannot use the urinalysis to rule in a UTI because pyuria is nonspecific.32
Speaker Notes: Slide 11Here is a sample case that illustrates how inappropriate urinetesting can put patients at risk.Mrs. Jones is an 87-year-old patient at a long-term acute carehospital or LTACH recovering from hip surgery. On Monday sheloses her glasses, and on Wednesday her care nurse notices sheseems confused and a urinalysis was obtained. Her physicianstarts her on ciprofloxacin to “cover all the bases.” However, shesoon becomes nauseated from the Ciprofloxacin anddehydrated. As her condition appears to worsen, she is taken tothe emergency room and a urine culture is obtained and thereshe is placed on ceftriaxone and IV fluids. She begins to improveon the IV fluids.33
Speaker Notes: Slide 11 ContinuedHowever, the results of her urine culture returns several days inhospitalization and now it grows Klebsiella resistant toCeftriaxone. So she starts on cefepime. She begins to haveabdominal pain and diarrhea and is found to have developed aClostridioides difficile infection.This is a classic case of a urinalysis and urine culture beingordered when the patient did not have clear signs or symptomsthat localized to the urinary tract, her confusion in the first placecould be due to the loss of her glasses and subsequent blurredvision. The IDSA guidelines indicate that there is no benefit toscreening and treating older patients for ASB.34
Speaker Notes: Slide 11 ContinuedThe US Preventive Services Task Force and American Board ofInternal Medicine or ABIM foundation also discourage screeningfor and treating ASB.On the slide, the red asterisks indicate where a testingstewardship program could have intervened and prevented theuse of unnecessary antibiotics.35
Speaker Notes: Slide 12In order to achieve urine testing stewardship at your hospital, itis important to not culture the urine unless it is clinicallyindicated. Clinically indicated symptoms include: Focal symptoms suggestive of a UTI, CAUTI or other urinarycomplication, such as costovertebral angle tenderness, flank pain, pelvicdiscomfort, acute hematuria, fever, rigors, etc. Or if the patient is showing signs and symptoms of sepsis with no otherclear source of infection.One easy step you can take to improve urine culture testingstewardship at your facility is to stop automatically screeningpatients for UTI. Many hospitals and units automatically screenpatients on admission, even if they don’t have signs orsymptoms related to the urine.36
Speaker Notes: Slide 12 ContinuedSimilarly, surgical patients should not be screened unless theyare being seen for urologic problems. And finally, some hospitalsor units have automatic triggers for urine cultures, such asincreased temperature or if white blood cells are found in theurine. Such automatic triggers can lead to unnecessary urinecultures and as we have discussed in this module, subsequentantibiotic overuse.37
Speaker Notes: Slide 13It is also important to consider socio-adaptive strategies that canimpact your testing stewardship efforts. As we have discussed inprevious modules, tackling socio-adaptive strategies for improvementare often more challenging. Unit and hospital culture can have a bigimpact on urine testing practices. You should promote a unit andhospital culture where staff are committed to using evidence-basedpractices, working hard to follow and implement best practices.Likewise, staff should be encouraged to be mindful about urineculturing practices, rather than sending cultures reflexively. Considerarming staff with communication tools to help them in theirconversations about if a urine culture is truly necessary and to properlycommunicate patient information so that evidence-based bestpractices are easily followed.38
Speaker Notes: Slide 14In addition to the antibiotic stewardship guides referenced at thebeginning of this module, you may find the resources on thisslide helpful as you begin to implement urine testingstewardship efforts in your hospital or unit.39
Speaker Notes: Slide 15To summarize, urine testing stewardship depends upon knowingwhen to obtain a culture. It is important to provide educationcombined with audit and feedback of appropriate urine testingpractices. Foul smelling or turbid urine, screening urine cultures,standing orders for automatic culturing, pan culturing andculturing of asymptomatic patients should all be discouraged.However, maintaining awareness of a potential urinary tractinfection is also important. CAUTI is often a diagnosis ofexclusion in a sepsis work up. Local findings such a pelvicdiscomfort or flank pain may be indicative of a CAUTI.40
Speaker Notes: Slide 15 ContinuedUrine cultures are also important in urological procedures wheremucosal bleeding is anticipated. It is important to screen for andtreat ASB in early pregnancy – that is one of the situations inwhich treatment for ASB can improve clinical outcomes. Knowingthe indications for urine cultures is an important step indecreasing inappropriate antibiotic usage and the emergence ofresistant organisms.41
Speaker Notes: Slide 16No notes.42
Kristi Felix, RN, BSN, CRRN, CIC, FPAIC Madonna Rehabilitation Hospital. Linda Greene, RN, MPS, CIC, FAPIC. University of Rochester, Highland Hospital. . AHRQ Urine Culture Practices in the ICU Presentation 14. Know When to Obtain a Urine Culture 15 (Preventing CAUT
and the Core Elements of Antibiotic Stewardship for Nursing Homes (23). This 2016 report, Core Elements of Outpatient Antibiotic Stewardship, provides guidance for antibiotic stewardship in outpatient settings and is applicable to any entity interested in improving outpatient antibiotic prescribing and use.
R M AB ARP R R M APP B 3 Completeness of antibiotic prescribing documentation. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing
The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic
and sustainable program. Examples of implementation strategies: Designate a physician (e.g.,CMO) in the C-suite or individual that reports to C-suite to be accountable for the outcomes of the antibiotic stewardship program. Approve a policy for the creation and/or expansion of the antibiotic stewardsh
Guidelines by the Infectious Diseases Society of America . Antibiotic stewardship has been defined in a consensus state-ment from the Infectious Diseases Society of America (IDSA), . Preauthorization and/or prospective audit and feedback improve antibiotic use and are acore component of
Implementation Guide for the Toolkit To Improve Antibiotic Use in Long-Term Care . Introduction. Developing an antibiotic stewardship program (ASP) or improving an existing ASP can take time. If you are starting a stewardship program or growing a nascent program, the resources provided in
A Hospital Pharmacist’s Guide to Antimicrobial Stewardship Programs Greater New York Hospital Association United Hospital Fund — Antimicrobial Stewardship Toolkit - Best Practices from the GNYHA/UHF Antimicrobial Stewardship Collaborative National Quality Pa
Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129
