Reducing unnecessary urine culture testing in residents of long term care facilities

Piggott, Katrina; Trimble, Johanna; Leis, Jerome A

doi:10.1136/bmj-2023-075566

Cited by 4 publications

(4 citation statements)

References 44 publications

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“…Specifically, older age, AMS, dementia, and change in urine character were not associated with bacteremia. These data reinforce prior evidence highlighting the poor yield of urine and blood cultures among hospitalized patients without systemic signs of infection and support not empirically treating patients with AMS and no systemic signs of infection …”

Section: Discussionsupporting

confidence: 85%

“…These data reinforce prior evidence highlighting the poor yield of urine and blood cultures among hospitalized patients without systemic signs of infection and support not empirically treating patients with AMS and no systemic signs of infection. [23][24][25] Our study highlights that bacteremia in adult inpatients with ASB is rare, compared with estimates as high as in 24% to 56% in symptomatic patients. 26,27 The probability of bacteremia varies widely based on individual risk factors, clinical presentation, and laboratory findings.…”

Section: Discussionmentioning

confidence: 68%

Section: Discussionmentioning

confidence: 99%

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Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Advani,

Ratz,

Horowitz

et al. 2024

JAMA Netw Open

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ImportanceGuidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common.ObjectivesTo determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB.Design, Setting, and ParticipantsThis cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023.Main Outcomes and MeasuresThe primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient’s risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia.ResultsOf 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia.Conclusions and RelevanceIn patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.

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Section: Discussionsupporting

confidence: 85%

Section: Discussionmentioning

confidence: 68%

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Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Advani,

Ratz,

Horowitz

et al. 2024

JAMA Netw Open

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“…We thank Zhang for comments regarding our article 1. Urinary tract infections are overdiagnosed among older adults and judicious antimicrobial use to prevent patient harms and antimicrobial resistance is needed 2…”

mentioning

confidence: 99%