Treatment for Positive Urine Cultures in Hospitalized Adults: A Survey of Prevalence and Risk Factors in 3 Medical Centers

Abstract

OBJECTIVE Antibiotic treatment for asymptomatic bacteriuria (ASB) is prevalent but often in contrast to published guidelines. We evaluated risk factors for treatment of ASB. DESIGN Retrospective observational study SETTING A tertiary academic hospital, county hospital, and community hospital PATIENTS Hospitalized adults with bacteriuria METHODS Patients without documented symptoms of urinary tract infection per Infectious Disease Society of America (IDSA) criteria were classified as ASB. We examined ASB treatment risk factors, broad-spectrum antibiotic usage, and quantified diagnostic concordance between IDSA and National Healthcare Safety Network (NHSN) criteria. RESULTS Among 300 patients with bacteriuria, ASB was present in 71% by IDSA criteria. By NHSN criteria, 71% of patients had ASB; within-patient diagnostic concordance with IDSA was moderate (kappa = 0.52). After excluding those given antibiotics for non-urinary indications, antibiotics were given to 38% (62/164) with ASB. Factors significantly associated with ASB treatment were elevated urine white cell count (65 versus 24 white blood cells per high-powered field, p<0.01), hospital identity (Hospital C vs. A, OR 0.34, 95% CI 0.14–0.80, p=0.01), presence of leukocyte esterase (OR 5.48, 95% CI 2.35–12.79, p<0.01), presence of nitrites (OR 2.45, 95% CI 1.11–5.41, p=0.03), and E. coli on culture (OR 2.4, 95% CI 1.2–4.7, p=0.01). Of patients treated for ASB, broad-spectrum antibiotics were used in 84%. CONCLUSIONS ASB treatment was prevalent across diverse inpatient settings and contributed to broad-spectrum antibiotic use. Associating abnormal urinalysis results with the need for antibiotic treatment, regardless of symptoms, may drive unnecessary antibiotic use and provides an opportunity for antibiotic stewardship interventions.

Antibiotic Resistance in Urinary Isolates of Escherichia coli

“…The guidelines recommend avoiding antibiotic therapy in bacteriuria in the absence of symptoms, with a few exceptions, such as pregnancy. Despite the recommendations, antibiotic treatment is prevalent and every day contributes to increasing antibiotic resistance, increased costs, and antibiotic side effects, such as Clostridium difficile infection (14). …”

Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel

“…17 The gaps in knowledge that we identified around inappropriate screening for ASB are also similar to those previously reported for acute care. 13,18–20 …”

Urine Culture on Admission Impacts Antibiotic Use and Length of Stay: A Retrospective Cohort Study

“…6,7 Positive urine cultures, even in the absence of symptoms, are strongly linked to subsequent inappropriate antibiotic use in hospitalized patients. [7][8][9][10] Inappropriate antibiotic use contributes to antibiotic resistance and is a threat to public health. [11][12][13] For these reasons, the Choosing Wisely campaign and several national guidelines strongly recommend against urine culture testing in the absence of urinary tract symptoms.…”

“…15 Adding to the potential for prolonged hospitalization, patients who receive frequent antibiotics may have urinary colonization by organisms that are resistant to common oral antibiotics. 9 Treatment of asymptomatic bacteriuria in these patients may require broad-spectrum intravenous antibiotics, which may add to discharge delays. 16 Finally, unnecessary antibiotic use contributes to the development of nosocomial infections, such as Clostridium difficile.…”

“…Prior studies examining the effect of inpatient urine culture testing on antibiotic use have been limited to small samples drawn from a few institutions. [6][7][8][9][10] The aims of this study were to examine the impact of inpatient urine culture testing on inpatient antibiotic use and hospital LOS using a national administrative dataset. To guide development of interventions aimed at reducing unnecessary urine testing, we identified the inpatient medical and surgical diagnoses most impacted by urine culture testing on admission.…”