Abstract
Objective
To evaluate the impact of an educational intervention on the appropriateness of urine culture indications and overall urine culture trends.
Methods
A quasi-experimental study in six medical wards of an acute care hospital included a pre-intervention phase (Jan 2019–Dec 2021) and an intervention phase (Jan 2022–Dec 2023). The intervention comprised educational sessions, best practice guidelines, and feedback. Urine culture appropriateness was assessed by reviewing a sample of 360 records from both periods. Bivariate and multivariable logistic regression identified predictors of appropriate urine cultures, and time-series analysis assessed trends in culture rates.
Results
The median age of patients was 81 years (IQR 70.1–87.0), with no differences between the two periods in age, sex, residence in long-term care, or comorbidities. The appropriateness of urine cultures increased significantly from 43.9% (79 of 180 patients) in the pre-intervention period to 56.7% (102 of 180 patients) in the post-intervention period (p = 0.015). The intervention period (OR 1.66; 95% CI, 1.07–2.57; p = 0.023) and younger age (OR, 0.97; 95% CI, 0.95–0.99; p < 0.001) were significantly associated with improved appropriateness. Urine culture rates showed no significant pre-intervention trends (p = 0.19) but decreased by 18% post-intervention (p < 0.001).
Conclusions
Younger age and the intervention period were associated with reduced unnecessary urine cultures and improved adherence to appropriate practices. These findings highlight the importance of ongoing educational initiatives and feedback in enhancing diagnostic stewardship.
Keywords: Diagnostic stewardship, Urine cultures
This work was performed in partial fulfillment of the M.D. thesis requirements of the Faculty of Medical and Health Sciences, Tel Aviv university.
Background
Urine cultures are a cornerstone in diagnosing urinary tract infections (UTIs), but their effectiveness is frequently limited by the high prevalence of asymptomatic bacteriuria (ASB), particularly among elderly patients. ASB rates range from 1 to 5% in non-pregnant women to over 15% in elderly community-dwelling women, escalating to 25–50% among long-term care facility residents [1]. For patients with indwelling urinary catheters, the risk of bacteriuria increases daily due to biofilm formation, reaching 100% in patients with long-term catheters [2].
In light of the high prevalence of asymptomatic bacteriuria among the elderly, obtaining urine cultures in the absence of appropriate indication may result in overdiagnosis of UTIs, administration of unnecessary antibiotics, and increased risk of developing antibiotic resistance [3, 4]. Moreover, misdiagnosing UTIs can delay the identification and treatment of other infections [5]. Previous studies indicate that over half of urine culture orders lack appropriate indications [6].
Diagnostic stewardship plays a crucial role in reducing the frequency of urine cultures performed for patients with asymptomatic bacteriuria, thereby decreasing the misdiagnosis of UTIs and associated antibiotic [7–9]A recent statewide quality initiative demonstrated that enhanced diagnostic accuracy and a decrease in unnecessary urine cultures were associated with reductions in antibiotic use for ASB [10].
The diagnostic process encompasses several critical phases: the clinician’s decision to order a urine culture, the collection and transport of specimens to the laboratory, reflex testing and processing, analysis of the specimens, and ultimately the communication dissemination of results to the sender [11]. Reducing unnecessary urine cultures is the first step in reaching any of these end points. This study evaluates the effectiveness of an educational intervention aimed at improving urine culture ordering practices in an acute care setting, intending to reduce unnecessary testing and enhance patient management.
Methods
Hospital setting
Wolfson Medical Center is a 670-bed, secondary-care teaching hospital in central Israel. The facility houses six medical wards with a median patient age of 77 years.
Study design
This study was a quasi-experimental intervention with a pre-post design, conducted in six medical wards. The study consisted of two periods: a pre-intervention periods of 36 months (January 2019–December 2021) and a post intervention period of 24 months (January 2022–December 2023). Beginning in January 2022, an ongoing educational program focusing on the appropriate indications for ordering urine cultures was implemented. To assess the impact of the intervention, we conducted a retrospective analysis of the appropriateness of urine culture orders by reviewing medical records from both pre- and post-intervention periods. Each record was reviewed against predetermined criteria for appropriate urine culture ordering. We selected 180 consecutive patient records from each period, for a total of 360 records. From each ward, the first 15 urine culture orders were chosen during a 2-month period before and after the intervention. For practical purposes, 2021 was designated as the reference year for the pre-intervention period, and 2022 was designated as the reference year for the post-intervention period. Inclusion criteria required patients to be aged ≥ 18 years. Exclusion criteria included pregnancy and duplicate cultures from the same patient, ensuring that each culture represented a unique individual.
Urinalysis and urine cultures processing
Urine cultures and urinalysis are processed in separate laboratory facilities without automated integration between the systems. As a result, negative urinalysis results do not trigger the cancellation of corresponding urine cultures. Laboratory-based urinalysis is restricted to the day shift (07:00–15:00), limiting its availability during other times. Outside these hours, providers depend on point-of-care dipstick urinalysis.
The intervention
The intervention was launched in January 2022 with a series of structured educational meetings held across all medical wards. During these departmental meetings, both physicians and nursing staff were briefed on the updated indications for ordering urine cultures. Accompanying these sessions, comprehensive written materials outlining the best practices were distributed. Following the initial launch, the program continued with periodic educational sessions held every two to three months to reinforce the guidelines. Concurrently, monthly feedback was emailed to medical directors, head nurses and hospital administration, providing updates on urine tract infections and urine culture rates to monitor progress and highlight areas requiring further attention. We did not have access to individual-level data regarding who ordered each test. As a result, feedback was provided in a grouped format.
Definitions
Appropriateness was predefined as urine cultures obtained under any of the following conditions: local urinary symptoms, including dysuria, frequency, urgency, suprapubic pain, or gross hematuria; febrile illness (temperature ≥ 38 °C) with no other identifiable source of infection upon clinical evaluation; or systolic blood pressure ≤ 90 mmHg.
An order for a urine culture was considered inappropriate if none of the above criteria were met.
Outcomes
The primary outcome measure was the appropriateness of urine culture orders, assessed reviewing a consecutive sample of patient records before and after the intervention. Secondary outcome was the urine culture orders rate, defined as the number of urine cultures ordered per 1,000 patient-days.
Data collection
To assess the appropriateness of urine culture orders, comprehensive patient data were compiled by two authors, GF and DBD. The data collected included demographics, sources of admission (home or long-term care facility), presence of comorbidities (based on International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10]), and the use of indwelling urinary catheter. Clinical documentation from the 24-hour period preceding urine collection was reviewed to record local symptoms (such as dysuria, frequency, urgency, and costovertebral angle pain) and systemic signs (including temperature and systolic blood pressure). Laboratory data collected included white blood cell count, C-reactive protein levels (CRP), and urinalysis results. In addition, physician notes were reviewed to evaluate whether the rationale for urine cultures is documented.
Statistical methods
Appropriateness of urine culture collection
Initially, descriptive statistics were performed using medians and interquartile ranges for continuous variables, and frequencies and percentages for categorical variables. Comparisons of appropriateness between the pre-intervention and post-intervention periods were performed using chi-square tests for categorical variables and independent t-tests for continuous variables. Univariate and multivariate regression analyses were performed to identify predictors of appropriate urine culture orders. Variables with a p-value < 0.1 in the univariate analysis were included in the multivariate model. Statistical significance was defined as a p-value < 0.05.
Urine culture rates
Time-series analysis was employed to evaluate temporal shifts in urine culture ordering rates. We utilized an interrupted time series analysis with Prais-Winsten estimators to compare rates before and after the intervention. The Prais-Winsten estimator takes into account serial autocorrelation (AR1) of the errors in a linear regression model. The procedure recursively estimates the coefficients and the error autocorrelation of the specified model until sufficient convergence of the AR(1) coefficient is reached. All estimates are obtained using Ordinary Least Squares (OLS).
The analysis was performed using IBM SPSS software, version 23.0.
Results
Urine culture collection rates
The average number of monthly admissions was 1,117.7 (SD ± 152.9), with no significant change observed between the pre-intervention (1,123.78, SD ± 171.8) and intervention periods (1,111.5, SD ± 133.4; P = 0.37). Over the 3-year pre-intervention period, 15,129 urine cultures were obtained, compared to 6,624 cultures during the 2-year post-intervention period. The monthly average number of urine cultures collected significantly decreased from 1,260.0 (SD ± 93.9) before the intervention to 578.4 (SD ± 50.2) post intervention (P < 0.001). When adjusted for patient-days, the rate of urine cultures per 1,000 patient-days declined significantly, from 72.7 (SD ± 6.3) to 52.7 (SD ± 6.9), reflecting a 20.1% reduction (95% CI, 16.6–23.5).
The interrupted time series analysis revealed no significant trends in urine culture rates prior to the intervention (P = 0.19). Following the intervention, urine culture rates declined sharply by 18% (P < 0.001). No additional changes in trends were observed during the intervention period (P = 0.59). This is depicted in Fig. 1, which illustrates the time series analysis of urine culture rates over the study period.
Fig. 1.
Time series analysis of monthly admissions and urine culture collection before and after the intervention
Clinical and demographic characteristics
A total of 360 patient records were reviewed, with 180 records analyzed before and 180 after the intervention. The median age of patients was 81 years (IQR, 70.1–87.3), with no significant differences observed between the two periods (p = 0.35). Analysis of gender distribution, functional status prior to hospitalization, residence in long-term care facilities, and Charlson Comorbidity Index showed no significant differences between the groups (Table 1). The prevalence of chronic heart failure increased significantly post-intervention, from 13.9% (25 of 180 patients) before to 24.4% (44 of 180 patients) after (p = 0.011). The proportion of patients with indwelling urinary catheters was also higher post-intervention, at 16.7% (30 of 180 patients) compared to 6.7% (12 of 180 patients) pre-intervention (p = 0.003).
Table 1.
Comparison of patient demographics and comorbidities between pre- and intervention periods
| Variable | Pre-intervention period (n = 180) | Intervention period (n = 180) |
P value | ||
|---|---|---|---|---|---|
| Demographics | |||||
| Age, years, median [IQR] | 80.9 [70.9–87.8] | 81.0 [68.6–86.8] | 0.35 | ||
| Male, n (%) | 78 (43.3) | 92 (51.1) | 0.14 | ||
| Living status, n (%) | Home | 134 (74.4) | 144 (80) | 0.90 | |
| LTCF | 37 (20.6) | 36 (20) | |||
| Comorbidities | |||||
| Diabetes mellitus, n (%) | 81 (45) | 73 (40.6) | 0.39 | ||
| CHF, n (%) | 25 (13.9) | 44 (24.4) | 0.01 | ||
| Dementia, n (%) | 79 (43.9) | 73 (40.6) | 0.52 | ||
| COPD, n (%) | 24 (13.3) | 28 (15.6) | 0.55 | ||
| Renal disease, n (%) | 42 (23.3) | 48 (26.7) | 0.47 | ||
| Decubitus wound, n (%) | 26 (14.4) | 25 (13.9) | 0.88 | ||
| IHD, n (%) | 48 (26.7) | 43 (23.9) | 0.54 | ||
| Urologic disease, n (%) | 27 (15) | 39 (21.7) | 0.10 | ||
| Charlson Comorbidity Index, median [IQR] | 2 [1–4] | 3 [1–4.75.75] | 0.23 | ||
| Dependent functional status, n (%) | 82 (45.6) | 90 (50) | 0.50 | ||
| Indwelling urinary catheter before admission, n (%) | 12 (6.7) | 30 (16.7) | 0.003 | ||
| Admission diagnosis, n (%) | Infection | 76 (42.2) | 71 (39.4) | 0.008 | |
| Pulmonary | 12 (6.7) | 30 (16.7) | |||
| General deterioration | 26 (14.4) | 32 (17.8) | |||
| Other | 66 (36.7) | 47 (26.1) | |||
Note: CHF congestive heart failure, COPD chronic obstructive pulmonary disease, IHD ischemic heart disease, IQR interquartile range, LTCF long-term care facility
Urine culture appropriateness and associated clinical indicators and laboratory findings
Table 2 summarizes the clinical signs, laboratory results, and the presence of indwelling urinary catheters within 24 h prior to urine culture collection. Fever was the predominant reason for urine culture, affecting 136 of 360 patients (37.8%); of these, 76 of 136 patients (55.9%) had fever with no identifiable source. Local urinary symptoms were observed in only 74 of 360 cases (20.6%), with consistent findings across both study periods. Dysuria was documented in 45 of 360 patients (12.5%), followed by suprapubic pain in 36 of 360 patients (10.0%). Elevated white blood cell counts (≥ 12,000 × 10^6/L) occurred in 167 of 360 patients (46.4%), and raised CRP levels (≥ 10 mg/dL) were noted in 175 of 360 patients (48.6%), with no significant differences between the periods. The median duration of indwelling catheter use before obtaining urine cultures was 2 days (IQR, 1–4).
Table 2.
Comparison of clinical and laboratory parameters 24 h before urine culture in pre- and intervention periods
| Variable | Pre-intervention period (n = 180) |
Intervention period (n = 180) |
P value |
|---|---|---|---|
| Signs and symptoms | |||
| Local symptoms, n (%) | 35 (19.4) | 39 (21.7) | 0.60 |
| Fever ≥ 38, n (%) | 64 (35.6) | 72 (40.0) | 0.38 |
| Isolated fever with no identifiable source, n (%) | 34 (18.9) | 42(23.3) | 0.37 |
| Systolic blood pressures less than 90 mm Hg, n (%) | 16 (8.9) | 27 (15.0) | 0.15 |
| Another infectious source, n (%) | 39 (21.7) | 43(23.9) | 0.62 |
| Urinary culture obtained > 2 days of hospitalization or more, n (%) | 58 (32.2) | 62 (34.4) | 0.67 |
| Urinalysis | |||
| Performed urinalysis, n (%) | 96 (53.3) | 71 (39.4) | 0.012 |
| Abnormal urinalysis, n (%) | 81 (45.0) | 60 (33.3) | 0.23 |
| Invasive devices | |||
| Indwelling urinary catheter on day of urine culture, n (%) | 107 (59.4) | 119 (66.1) | 0.19 |
| Duration of indwelling urinary catheter, days, median [IQR] | 2 [2–3] | 2 [2–4] | 0.98 |
| Mechanical ventilation on day of urine culture, n (%) | 13 (7.2) | 19 (10.6) | 0.27 |
| Laboratory | |||
| WBC ≥ 12,000 × 106/L, n (%) | 89 (49.4) | 78 (43.3) | 0.25 |
| CRP ≥ 10 mg/dL, n (%) | 87 (48.3) | 88 (48.9) | 0.96 |
| Appropriateness | |||
| Appropriate indication ^, n (%) | 79 (43.9) | 102 (56.7) | 0.015 |
| Documentation of obtaining urine culture, n (%) | 108 (60) | 112 (62.2) | 0.67 |
Note: CRP C-reactive protein IQR interquartile range, UTI urinary tract infection, WBC white blood cells
^ Appropriate Indication Calculation: defined as the sum of cases presenting with local symptoms, systolic blood pressures below 90 mm Hg, or isolated fever with no identifiable source
The proportion of urine cultures ordered for appropriate indications increased significantly from 43.9% (79 of 180 patients) pre-intervention to 56.7% (102 of 180 patients) post-intervention (p = 0.015). Urinalysis was conducted in 96 of 180 patients (53.3%) in 2021 compared to 71 of 180 patients (39.4%) in 2022 (p = 0.012). The documentation of culture collection in medical records remained stable at 61.1% (220 of 360 patients), showing no significant variation over time.
Demographic and clinical comparison by urine culture appropriateness
Table 3 summarizes the comparison between patients with appropriately indicated urine cultures (n = 181) and those lacking appropriate indications (n = 179). Patients lacking proper indications were significantly older, with a median age of 81.8 years (interquartile range [IQR], 73.1–87.9), compared with 79.4 years (IQR, 66.7–86.7) for those with appropriate indications (p = 0.005). Renal disease was significantly more common among patients with inappropriate indications for urine cultures, occurring in 53 of 179 patients (29.6%) compared to 37 of 181 patients (20.4%) with appropriate indications (p = 0.045). No significant differences were noted in sex distribution or the presence of indwelling urinary catheters. Patients with appropriate indications underwent urinalysis more frequently (104 of 181 patients, 57.5% vs. 63 of 179 patients, 35.2%; p < 0.001). Multivariable analysis revealed that both the intervention period (OR 1.66; 95% CI 1.07–2.57; p = 0.023) and younger age (OR 0.97; 95% CI 0.95–0.99; p < 0.001) were significantly associated with improved appropriateness of urine culture indications (Table 4).
Table 3.
Demographic and clinical comparison by urine culture appropriateness
| Variable | Appropriate indication (n = 181) | Inappropriate indication (n = 179) | P value | |
|---|---|---|---|---|
| Demographics | ||||
| Age, years, median [IQR] | 79.4 [66.7–86.7] | 81.8 [73.1–87.9] | 0.005 | |
| Male, n (%) | 84 (46.9) | 84 (46.9) | 0.91 | |
| Comorbidities | ||||
| Diabetes mellitus, n (%) | 81 (44.8) | 73 (40.8) | 0.45 | |
| CHF, n (%) | 31 (17.1) | 38 (21.2) | 0.32 | |
| Dementia, n (%) | 76 (42) | 76 (42.5) | 0.93 | |
| COPD, n (%) | 24 (13.3) | 28 (15.6) | 0.52 | |
| Renal disease, n (%) | 37 (20.4) | 53 (29.6) | 0.045 | |
| Decubitus wound, n (%) | 24 (13.3) | 27 (15.1) | 0.62 | |
| IHD, n (%) | 41 (22.7) | 50 (27.9) | 0.25 | |
| Urologic disease, n (%) | 33 (18.2) | 33 (18.4) | 0.960 | |
| Charlson Comorbidity Index, median [IQR] | 2 [1–4] | 3 [1–5] | 0.11 | |
| Dependent functional status, n (%) | 86 (47.5) | 86 (48) | 0.96 | |
| Indwelling urinary catheter before admission, n (%) | 27 (14.9) | 15 (8.4) | 0.053 | |
| Living status, n (%) | Home | 141 (77.9) | 146 (81.6) | 0.39 |
| LTCF | 40 (22.1) | 33 (18.4) | ||
| Admission diagnosis, n (%) | Infection | 93 (51.4) | 54 (30.2) | < 0.001 |
| Pulmonary | 13 (7.2) | 29 (16.2) | ||
| General deterioration | 27 (14.9) | 31 (17.3) | ||
| Other | 48 (26.5) | 65 (36.3) | ||
| Urinary catheter on day of urine culture, n (%) | 117 (64.6) | 109 (60.9) | 0.46 | |
| Ventilation on day of urine culture, n (%) | 15 (8.3) | 17 (9.5) | 0.69 | |
| Urinalysis | ||||
| Performed urinalysis, n (%) | 104 (57.5) | 63 (35.2) | < 0.001 | |
| Abnormal urinalysis, n (%) | 90 (49.7) | 51 (28.5) | 0.77 | |
| Laboratory tests | ||||
| Blood WBC (× 106/L), median [IQR] | 11,600 [8600–16200] | 11,500 [8300–16600] | 0.82 | |
| CRP (mg/dL), median [IQR] | 11.26 [4.34–19.76] | 8.52 [3.14–15.83] | 0.020 | |
Note: CHF congestive heart failure, COPD chronic obstructive pulmonary disease, CRP C-reactive protein, IHD ischemic heart disease, IQR Interquartile range, LTCF long-term care facility, WBC white blood cells
Table 4.
Multivariable analysis of factors associated with appropriate urine culture indications
| Variable | OR | 95% CI | P value |
|---|---|---|---|
| Post-intervention | 1.66 | 1.07–2.57 | 0.023 |
| Age (years) | 0.97 | 0.95–0.99 | < 0.001 |
| Sex (female) | 1.05 | 0.65–1.88 | 0.83 |
| Transfer from LTCF | 1.05 | 0.58–1.88 | 0.88 |
| Dementia | 1.37 | 0.78–2.38 | 0.27 |
| Renal disease | 0.65 | 0.37–1.14 | 0.14 |
| Urologic disease | 1.17 | 0.63–2.22 | 0.59 |
| Indwelling urinary catheter | 1.51 | 0.88–2.60 | 0.14 |
| Mechanical ventilation | 0.78 | 0.35 | 0.54 |
| Charlson Comorbidity Index | 0.97 | 0.88 | 0.61 |
Note: CI confidence interval, LTCF long-term care facility OR odds ratio
Discussion
This study evaluated the impact of an educational intervention on the appropriateness of urine culture testing within internal medicine wards. Following the intervention, there was a notable decline in the overall rate of urine cultures and an increase in the proportion of appropriately indicated cultures. This reduction may have contributed to fewer misdiagnoses of ASB as UTIs, potentially leading to a decrease in unnecessary antibiotic treatments.
In the current study, we focused on enhancing the appropriateness of urine culture ordering. Recent consensus achieved through a modified Delphi process advocates for culturing primarily in the presence of localized urinary symptoms [11]. However, the clinical relevance of systemic signs such as fever or leukocytosis as solitary criteria for culturing continues to be uncertain.Some protocols consider fever without an alternate source or delirium in the presence of systemic inflammatory response syndrome (SIRS) as sufficient for obtaining urine cultures [10]. Notably, some hospitals have adopted a stringent approach for evaluating catheterized patients, recommending urine cultures only under specific conditions, such as fever in kidney transplant recipients or febrile episodes following urologic procedures [12]. These stringent criteria, however, may inadvertently overlook patients who genuinely have a UTI. Diagnostic stewardship programs are thus challenged to balance the risks of overdiagnosis and underdiagnosis of UTI. The diversity in these definitions could significantly influence the effectiveness of diagnostic interventions. A marked decrease in permitted indications is anticipated to result in a substantial reduction in urine cultures, compared to protocols that allow for clinical judgment involving nonspecific signs or the presence of inflammatory markers.
Although a significant decrease in inappropriate urine cultures was observed, 43% of cultures were still classified as inappropriate. This could be attributed to the elderly population included in the study, many of which cannot report urinary symptoms due to cognitive decline and dementia. This is also reflected by the fact that most urine cultures were ordered based on non-specific indicators, such as fever or elevated inflammatory markers, with only about 20% of cases displaying distinct signs or symptoms of urinary tract infections. Elderly patients with UTI often present with nonspecific symptoms [13]. Previous studies have indicated that even sepsis in this group may manifest with only a low-grade fever [14]. In the current study, no significant change was observed in the proportion of urine cultures ordered when another source of infection was present. Diagnostic stewardship interventions generally discourage urine cultures if another infection is diagnosed [11]. Yet, bacteremic urinary tract infections may occasionally mimic the clinical presentation of respiratory infections, necessitating careful diagnostic evaluation [15]. Given these complexities, careful revision of the criteria for ordering urine cultures in elderly patients should be considered to ensure accurate diagnosis and appropriate treatment.
Evidence indicates that education and training are essential for driving behavior change in infection control and antibiotic stewardship [16, 17]; However, most studies were limited by a short follow-up period, raising concerns that the long-term efficacy of educational interventions may decline over time [17, 18]. Our findings demonstrate that combining long-term educational sessions with regular feedback can significantly improve diagnostic practices by addressing knowledge gaps and reinforcing behavior change over time. The intervention resulted in an immediate and significant 18% reduction in urine culture rates. However, no additional decreases were seen during the follow-up period, with rates stabilizing at approximately 50 per 1,000 patient-days. This finding suggests that while the intervention achieved an initial decrease in urine culture rates, its impact did not extend beyond this immediate effect. Continuous monitoring and potentially additional or reinforced interventions may be necessary to sustain or further enhance the reduction in urine culture rates.
An effective implementation program is crucial for the success of diagnostic stewardship programs. A recent review has suggested that incorporating multimodal interventions, targeting both systems and individuals, proves most effective [19]. These should include education on local policies, the use of checklists, medical record nudges, routine audits, and both process and outcome feedback. Previous studies have shown that incorporating standardized indications in the electronic medical record for ordering a urine culture, and requiring the selection of an indication, is associated with a decrease in the rate of urine culture ordering [12, 20, 21]. However, order sets are not always being used correctly. A previous study observed a mismatch in selected and actual indications, along with the predominance of nonspecific indications selected [21]. Only 45% of the orders placed following the intervention were appropriate. Thus, comprehensive clinician education and engagement are essential to improve understanding and compliance with urine culture ordering practices among providers.
Conducting a urinalysis before ordering a urine culture has been shown to enhance diagnostic accuracy and reduce unnecessary cultures [22, 23]. However, the accuracy of urine reflex testing may vary across different populations. Implementation of conditional culturing decreased the number of urine cultures performed in acute care settings but not in long-term care settings [24], Similarly, a recent multihospital cohort study found that positive urinalysis parameters had poor positive predictive value for diagnosing UTIs in elderly patients [25]. During the study period, we observed a decrease in the use of urinalysis tests. Currently, we lack 24/7 availability of urinalysis testing in the laboratory, leading providers to rely on dipstick urinalysis. It is possible that tests were conducted but not documented by the medical staff. Additionally, urinalysis and urine cultures are not performed concurrently in the same laboratory. Consequently, urine cultures are not canceled if the urinalysis is negative. Future interventions should incorporate clinical decision support tools with appropriate exclusion criteria based on both signs and symptoms, as well as urinalysis results, to guide the decision of whether to conduct a urine culture.
This study was conducted during the COVID-19 pandemic, a period marked by a significant increase in hospitalizations for acute febrile illnesses [26]. As part of efforts to identify co-infections or other causes of fever, this surge likely led to greater diagnostic testing, including urine cultures. Furthermore, the increased prevalence of critically ill patients requiring indwelling urinary catheters led to increased risk of hospital-acquired urinary tract infections [27], potentially prompting ordering more urine cultures. Despite these factors, no significant changes in urine culture rates were observed in the current study before the implementation of our intervention in early 2022. Nevertheless, to account for potential pandemic-related biases, 2021 and 2022 were selected as comparison periods.
A number of limitations should be considered when interpreting the results of this study Firstly, the single-center design may limit the generalizability of our findings to other
healthcare settings or patient populations. While our baseline rates of inappropriate urine culture collection align with other studies [28, 29], the unique characteristics and practices of our medical center could influence clinical decision-making patterns. Secondly, the retrospective nature of our data collection process may lead to inherent inaccuracies. Relying on existing medical records may result in incomplete or inaccurate documentation of clinical signs and symptoms. For instance, inadequate recording of fever or symptoms could lead to misclassification of the appropriateness of urine culture orders. In addition, the study primarily focused on the appropriateness of urine cultures and did not extensively evaluate clinical outcomes such as infection rates, antibiotic usage and its relationship to ASB.
Conclusions
Our findings demonstrates that that combining long-term educational sessions with regular feedback can significantly improve diagnostic practices by addressing knowledge gaps and reinforcing behavior change over time. The effect of our intervention has proven to be sustainable during long-term follow-up of over two years.
Acknowledgements
Not applicable.
Abbreviations
- ASB
asymptomatic bacteriuria
- CRP
C-reactive protein
- IQR
interquartile range
- UTI
urinary tract infections
Authors’ contributions
G.F. and D.B.D. conceived the study idea, reviewed the charts, retrieved the information,, conducted the data analysis, and drafted the initial manuscript. Y.C., I.Z., and Y.M. made significant contributions to revising the manuscript for critical intellectual content. All authors reviewed and approved the final version of the manuscript prior to submission.
Funding
none.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval
The study was conducted in accordance with the Declaration of Helsinki and national and institutional standards and approved by the Wolfson medical center Ethics Committee—approval number 0028-22-WOMC. Informed consent was waived due to the observational nature of the study and the use of de-identified data.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.