Developing a user-friendly report for electronically assisted surveillance of catheter-associated urinary tract infection.

Catheter-associated urinary tract infection (CAUTI) surveillance is labor intensive, generally involving manual medical record review. We developed a prototype automated report through iterative design. Surveys and qualitative interviews were administered to key stakeholders to assess the report design. We found that different provider types expressed different needs regarding report content and format. Therefore, determining the primary audience for reporting data on CAUTI a priori is critical to developing useful reports, particularly as this process becomes standardized and automated.

Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention.

BACKGROUND: Lack of guideline knowledge and cognitive biases are barriers that drive overtreatment of catheter-associated asymptomatic bacteriuria (ASB). We explored whether providers' knowledge and attitudes toward management of ASB differed before and after a multifaceted guidelines implementation intervention, reported elsewhere. METHODS: We surveyed providers' knowledge of guidelines, cognitive-behavioral constructs, and self-reported familiarity with the relevant Infectious Diseases Society of America guidelines. The survey was administered to providers in the preintervention (n = 169) and postintervention (n = 157) periods at the intervention site and postintervention (n = 65) at the comparison site. RESULTS: At the intervention site, the mean knowledge score increased significantly during the postintervention period (from 57.5%-69.9%; P < .0001) and fewer providers reported following incorrect cognitive cues (pyuria and organism type) for treatment of ASB. The knowledge of guidelines was higher in the postintervention sample after adjusting for provider type in the multiple linear regression analysis. Cognitive behavioral constructs (ie, self-efficacy, behavior, social norms, and risk perceptions) and self-reported familiarity with the guidelines also significantly improved during the postintervention period. CONCLUSIONS: We identified and targeted specific barriers that drive overtreatment of ASB. Guideline implementation interventions targeting cognitive biases are essential for encouraging the application of ASB guidelines into practice.

Decreased microbiota diversity associated with urinary tract infection in a trial of bacterial interference.

BACKGROUND: Patients with long-term indwelling catheters are at high risk of catheter-associated urinary tract infection (CAUTI). We hypothesized that colonizing the bladder with a benign Escherichia coli strain (E. coli HU2117, a derivative of E. coli 83972) would prevent CAUTI in older, catheterized adults. MATERIALS AND METHODS: Adults with chronic, indwelling urinary catheters received study catheters that had been pre-coated with E. coli HU2117. We monitored the cultivatable organisms in the bladder for 28 days or until loss of E. coli HU2117. Urine from 4 subjects was collected longitudinally for 16S rRNA gene profiling. RESULTS: Eight of the ten subjects (average age 70.9 years) became colonized with E. coli HU2117, with a mean duration of 57.7 days (median: 28.5, range 0-266). All subjects also remained colonized by uropathogens. Five subjects suffered invasive UTI, 3 febrile UTI and 2 urosepsis/bacteremia, all associated with overgrowth of a urinary pathogen. Colonization with E. coli HU2117 did not impact bacterial bladder diversity, but subjects who developed infections had less diverse bladder microbiota. CONCLUSIONS: Colonization with E. coli HU2117 did not prevent bladder colonization or subsequent invasive disease by uropathogens. Microbial diversity may play a protective role against invasive infection of the catheterized bladder. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00554996 http://clinicaltrials.gov/ct2/show/NCT00554996.

Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care.

BACKGROUND: Inappropriate use of antibiotics to treat asymptomatic bacteriuria (ASB) is a significant contributor to antibiotic overuse in hospitalized patients despite evidence-based guidelines on ASB management. We surveyed whether accurate knowledge of how to manage catheter-associated urine cultures was associated with level of training, familiarity with ASB guidelines, and various cognitive-behavioral constructs. METHODS: We used a survey to measure respondents' knowledge of how to manage catheter-associated bacteriuria, familiarity with the content of the relevant Infectious Diseases Society of America guidelines, and cognitive-behavioral constructs. The survey was administered to 169 residents and staff providers. RESULTS: The mean knowledge score was 57.5%, or slightly over one-half of the questions answered correctly. The overall knowledge score improved significantly with level of training (P < .0001). Only 42% of respondents reported greater than minimal recall of ASB guideline contents. Self-efficacy, behavior, risk perceptions, social norms, and guideline familiarity were individually correlated with knowledge score (P < .01). In multivariable analysis, behavior, risk perception, and year of training were correlated with knowledge score (P < .05). CONCLUSIONS: Knowledge of how to manage catheter-associated bacteriuria according to evidence-based guidelines increases with experience. Addressing both knowledge gaps and relevant cognitive biases early in training may decrease the inappropriate use of antibiotics to treat ASB.

Quality gaps in documenting urinary catheter use and infectious outcomes.

OBJECTIVE: To describe the frequency of use of all types of urinary catheters, including but not limited to indwelling catheters, as well as positive cultures associated with the various types. We also determined the accuracy of catheter-days reporting at our institution. DESIGN: Prospective, observational trial based on patient-level review of the electronic medical record. Chart review was compared with standard methods of catheter surveillance and reporting by infection control personnel. SETTING: Ten internal medicine and 5 long-term care wards in 2 tertiary care Veterans Affairs hospitals in Texas from July 2010 through June 2011. PARTICIPANTS: The study included 7,866 inpatients. METHODS: Measurements included patient bed-days; days of use of indwelling, external, suprapubic, and intermittent urinary catheters; number of urine cultures obtained and culture results; and infection control reports of indwelling catheter-days. RESULTS: We observed 7,866 inpatients with 128,267 bed-days on acute medicine and extended care wards during the study. A urinary catheter was used on 36.9% of the total bed-days observed. Acute medicine wards collected more urine cultures per 1,000 bed-days than did the extended care wards (75.9 and 10.4 cultures per 1,000 bed-days, respectively; P<.001). Catheter-days were divided among indwelling-catheter-days (47.8%), external-catheter-days (48.4%), and other (intermittent- and suprapubic-catheter-days, 3.8%). External catheters contributed to 376 (37.3%) of the 1,009 catheter-associated positive urine cultures. Urinary-catheter-days reported to the infection control department missed 20.1% of the actual days of indwelling catheter use, whereas 12.0% of their reported catheter-days were false. CONCLUSIONS: Urinary catheter use was extremely common. External catheters accounted for a large portion of catheter-associated bacteriuria, and standard practices for tracking urinary-catheter-days were unreliable. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01052545.

Overtreatment of enterococcal bacteriuria.

BACKGROUND: The purposes of this study were to investigate the clinical outcomes of enterococcal bacteriuria and to determine whether current management is adherent to Infectious Diseases Society of America guidelines. METHODS: We conducted a retrospective medical record review of patients from 2 academic teaching hospitals for 3 months (September 1 through November 30, 2009). Patients were classified as having urinary tract infection (UTI) or asymptomatic bacteriuria (ABU) by applying the guidelines. Antibiotic use was deemed appropriate in patients with UTI and inappropriate in ABU. Medical records were reviewed for Enterococcus cultured from another sterile site within 30 days. RESULTS: A total of 375 urine cultures growing Enterococcus were reviewed, with 339 cultures meeting inclusion criteria. Of these 339 episodes, 183 (54.0%) were classified as ABU and 156 (46.0%) as UTI. In 289 episodes accompanied by urinalysis, pyuria was associated with UTI in 98 of 140 episodes (70.0%) compared with 63 of 149 episodes of ABU (42.3%) (odds ratio, 3.19; 95% CI, 1.96-5.18). Providers inappropriately treated 60 of 183 episodes of ABU (32.8%) with antibiotics. In multivariate analysis, only pyuria was associated with the inappropriate use of antibiotics (odds ratio, 3.27; 95% CI, 1.49-7.18). Only 7 subsequent infections with Enterococcus occurred in the 339 episodes of bacteriuria overall (2.1%), with 2 of the 183 cases of ABU (1.1%) having distant infection. CONCLUSIONS: Providers often overtreat enterococcal ABU with antibiotics, particularly in patients with pyuria. Given the low incidence of infectious complications, efforts should be made to optimize the use of antibiotics in enterococcal bacteriuria.