The Culture of Culturing—The Importance of Knowing When To Order Urine Cultures
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Slide 1: The Culture of Culturing—The Importance of Knowing When To Order Urine Cultures
Welcome to today's educational session on The Culture of Culturing: The Importance of Knowing When to Order Urine Cultures for the residents we serve. This module is part of the Agency for Healthcare Research and Quality's (or AHRQ's) Safety Program for Long-Term Care that addresses Healthcare-Associated Infections (or HAIs) and Catheter-Associated Urinary Tract Infections (or CAUTI).
This education session was designed specifically for any staff member who works in a long-term care facility. Every team member is important in helping make our long-term care facility a safe place to live and work! Believe it or not, even a test as simple as a urine culture can cause resident harm if used incorrectly.
Slide 2: Objectives
Upon completion of this training, participants will be able to—
- Explain why unnecessary urine cultures can lead to increases in catheter-associated urinary tract infection (CAUTI) reporting and resident harms.
- Determine when (or not) to order urine cultures.
- Utilize evidence-based communication strategies to more effectively communicate urine culture practices.
Slide 3: How Can Ordering Urine Cultures Lead To Resident Harms?
Image: Flow chart showing how urinary catheters and unnecessary urine cultures can lead to resident harms.
Residents with urinary catheters have bacteria in their bladders—usually just colonizing the bladder or "hanging out" there. However, bacteria can make the urine smell bad, look cloudy, or even have some sediment. But these conditions aren't necessarily harmful, and they certainly aren't a reason to send a urine culture, particularly if the resident doesn't have any specific symptoms of a UTI.
If a urine culture is sent, and bacteria are found (in other words, a positive urine culture), that resident is almost certainly going to get antibiotics to treat the urine. But the bacteria in the urine may not be causing any actual harm! Meanwhile, the real problem that is causing the resident to have fever, or confusion, or malaise, may actually be missed, because we are "covering the urine."
Also, if you have a positive urine culture in a resident with fever, then you may end up reporting that as a CAUTI—even if the resident clearly has another source of the fever. To make this really clear with a simple example, if your resident has obvious gangrene of the leg, and a fever, but you send a urine culture and that comes back positive— it may accidently get reported as a CAUTI.
Similarly, inappropriate ordering of urine cultures can lead to improper use of antibiotics. Thus inappropriate urine culturing can put residents at increased chances of developing drug-resistant bacteria and infections like C diff.
Slide 4: Bacteriuria Is Not the Same as CAUTI1
- What is Bacteriuria?
- Bacteria in the urine
- Bacteriuria means the resident has a positive urine culture
- Bacteria in the urine
- What is the main difference between bacteriuria and CAUTI?
- Bacteriuria can be symptomatic or asymptomatic
- Asymptomatic bacteriuria (ASB)
- CAUTI requires presence of symptoms consistent with UTI
- Bacteriuria can be symptomatic or asymptomatic
Image: Bacteriuria Venn diagram showing that ASB and CAUTI are different
1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
Slide 5: Common Signs That Are Inappropriate Triggers for Urine Cultures1
Chronically catheterized patients have bacteriuria 99% of the time.
- Bacteriuria signs
- Urine color
- Urine smell
- Urine sediment
- Cloudy urine
- Pyuria (white blood cells or WBC in the urine)
- Positive dipstick
- Bacteriuria is not the same as CAUTI
1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
Slide 6: Pyuria Is Not Diagnostic of CAUTI2
Pyuria, like bacteriuria, does not help differentiate asymptomatic bacteriuria from CAUTI.
- Why?
- Pyuria in the urine is nonspecific
- Pyuria can be from—
- The catheter itself
- Bladder distension
- Asymptomatic bacteriuria
- Generally avoid dipsticks in catheterized residents
2. Gould CV, Umscheid CA, Agarwal RK, et al. Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections 2009. Centers for Disease Control and Prevention.
Slide 7: What Are the Signs and Symptoms of a CAUTI?3
ONE or MORE of the following:
CAUTIs are indicated by the presence of one or more of the following:
- Fever
- Rigors
- New confusion or functional decline (without alternative diagnosis AND increased WBC count in the blood)—in older adults you have to meet all these criteria to say that CAUTI is the cause of confusion or decline.
- New pain or tenderness in the suprapubic region (above the pubic bone in the abdomen) or costovertebral angle (in the angle between the bottom of the ribs and the spine)—now this is really pretty specific for CAUTI.
- New onset of hypotension with no alternative non-infectious cause (e.g., i.e., medications, trauma).
- Acute pain, swelling or tenderness of the testes, epididymis or prostate.
- Pus discharge from around the catheter.
Image: The table lists the signs and symptoms that can be associated with a CAUTI
3. Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance.
Slide 8: CAUTI Criteria NSHN* Definitions Pocket Card
A really helpful tool that can be used at the bedside for all staff is the NHSN Definitions Pocket Card, found on the AHRQ website. This card is worth printing out and distributing, as it can help guide your decision-making.
It provides detailed definitions for the constitutional criteria for long-term residents; for example fever, leukocytosis, mental status change and functional decline. It also provides clinical decision guidance to define CAUTI.
Images: Front of NHSN Definitions CAUTI Criteria pocket card
Back of NHSN Definitions CAUTI Criteria pocket card with a list of constitutional criteria.
*National Healthcare Safety Network
Slide 9: Case Scenario: Mrs. Bell
Mrs. Bell is an 86-year-old resident of your facility. She is being transferred back from a weeklong stay in the hospital. She has an indwelling urinary catheter, but you are unsure why the catheter has been placed. Yesterday her urine was clear and yellow, but today her urine is cloudy and smells bad.
What should be done next?
- Urinalysis
- Urine culture
- Urinalysis and antibiotics
- Culture and antibiotics
- Nothing
Slide 10: Answer to Mrs. Bell's Case
Nothing!
- At least, don't send urine for urinalysis or culture.
- Definitely don't start antibiotics!
You wouldn't really do nothing
- Ask about what she ate.
- Look at her medications.
- Assess for catheter trauma.
- Assess to ensure she is at her baseline.
- Offer fluids; often a better initial step.
Slide 11: SBAR for Health Care Communication4,5
- SBAR is a TeamSTEPPs framework for team members to effectively communicate information to one another
- Communicate the following information:
- Situation―What is going on with the resident?
- Background―What is the clinical background or context?
- Assessment―What do I think the problem is?
- Recommendation―What would I recommend?
- SBAR can be used with clinicians and with residents and families
4. Team Formation Success Video - Sub-Acute Care. TeamSTEPPS® Long-Term Care Version. Rockville, MD: Agency for Healthcare Research and Quality; April 2013.
5. Communication: Instructor's Slides. TeamSTEPPS® Long-Term Care Version: Module 6. Rockville, MD: Agency for Healthcare Research and Quality; November 2012. Accessed October 1, 2015.
Slide 12: Using SBAR To Communicate With Residents and Families
- Sometimes, residents and families push for urine cultures and antibiotics.
- SBAR can be used to improve communication with residents and families.
- When forming your SBAR make sure to consider
- What residents and their families are really asking for.
- Alternatives to ordering cultures and using antibiotics.
- Possible side effects of antibiotic use.
- Promote shared decision making.
Slide 13: References
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
- Gould CV, Umscheid CA, Agarwal RK, et al. Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections 2009. Centers for Disease Control and Prevention.
- Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance.
- Team Formation Success Video - Sub-Acute Care. TeamSTEPPS® Long-Term Care Version. Rockville, MD: Agency for Healthcare Research and Quality; April 2013.
- Communication: Instructor's Slides. TeamSTEPPS® Long-Term Care Version: Module 6. Rockville, MD: Agency for Healthcare Research and Quality; November 2012. Accessed October 1, 2015.
