Unnecessary Testing for UTIs Significantly Reduced

Tests to detect urinary tract infections (UTI) often are performed routinely in hospitals, even when patients do not have symptoms. Such testing "just to be safe" can return results that lead doctors to prescribe antibiotics when there is little to no evidence to warrant such treatment.

A new study indicates that making a simple change to the electronic system used by doctors to order urine tests can cut by nearly half the number of bacterial culture tests ordered without compromising the ability to identify people who need treatment for UTIs. The change encouraged doctors to first look for signs of a UTI before testing a patient's urine for bacteria.

Medical scientists at the Washington University School of Medicine (St Louis, MO, USA) and their colleagues evaluated the impact of changes to urine testing ordered in computerized physician order entry (CPOE) system on urine culturing practices. The team made two changes to encourage more informative urine testing among their colleagues at Barnes-Jewish Hospital (St. Louis, MO, USA).

First, they sent an email to all clinicians explaining the rationale behind ordering a urine dipstick test for signs of infection before ordering a bacterial culture test. Then, they changed the electronic ordering system. They set the default to a urine dipstick test followed by a bacterial culture test, rather than a culture test alone, which had previously been the first option. Clinicians who wished to order a culture test alone could still do so, but they had to open an additional screen on their computers.

The investigators compared all urine culture tests ordered at Barnes-Jewish Hospital in the 15 months before the intervention, staged in April 2016, to the 15 months after. Before the intervention, doctors ordered 15,746 urine cultures, or 38 orders per 1,000 patient-days. After the intervention, they ordered 45% fewer: a total of 8,823, or 21 orders per 1,000 patient-days. In particular, the number of urine cultures from people with catheters, who are at high risk of UTIs, dropped from 7.8 to 1.9 per 1000 patient-days while the number of catheter-associated UTIs did not change at all. There were 125 diagnosed catheter-associated UTIs in each time period.

Since it costs about USD 15 to perform a urine culture, the intervention saved approximately USD 104,000 in laboratory costs alone over the 15-month period. The team was unable to obtain pharmacy records to determine whether more careful testing decreased antibiotic prescriptions, but previous studies have shown that minimizing unwarranted testing does reduce antibiotic overuse.

David K. Warren, MD, a professor of medicine and the senior author of the study, said, “Over-testing for UTIs drives up health-care costs and leads to unnecessary antibiotic use which spreads antibiotic resistance. Ordering tests when the patient needs them is a good thing. But ordering tests when it's not indicated wastes resources and can subject patients to unnecessary treatment. We were able to reduce the number of tests ordered substantially without diminishing the quality of care at all, and at a substantial cost savings.” The study was published on February 21, 2019, in the journal Infection Control and Hospital Epidemiology.

Related Links:
Washington University School of Medicine
Barnes-Jewish Hospital