Podkovik Stacey, Toor Harjyot, Gattupalli Maya, Kashyap Samir, Brazdzionis James, Patchana Tye, Bonda Sruthi, Wong Serena, Kang Christine, Mo Kevin, Wacker Margaret Rose, Miulli Dan E, Wang Sharon
Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA.
Neurosurgery, Touro University College of Osteopathic Medicine California, Vallejo, USA.
Cureus. 2019 Aug 26;11(8):e5494. doi: 10.7759/cureus.5494.
Hospital-acquired infections (HAIs) are profound causes of prolonged hospital stay and worse patient outcomes. HAIs pose serious risks, particularly in neurosurgical patients in the intensive care unit, as these patients are seldom able to express symptoms of infection, with only elevated temperatures as the initial symptom. Data from Center for Disease Control (CDC) and the Infectious Disease Society of America (IDSA) have shown that of all HAIs, urinary tract infections (UTIs) have been grossly over-reported, resulting in excessive and unnecessary antibiotic usage.
We conducted a retrospective analysis of 686 adult patients that were evaluated by the neurosurgery service at Arrowhead Regional Medical Center between July 2018 and March 2019. Inclusion criteria were adults greater than 18 years of age with neurosurgical pathology requiring a minimum of one full day admission to the intensive care unit (ICU), and an indwelling urinary catheter. Exclusion criteria were patients under the age of 18, those who did not spend any time in the ICU, or with renal pathologies such as renal failure.
We reviewed 686 patients from the neurosurgical census. In total, 146 adult patients with indwelling urinary catheters were selected into the statistical analysis. Most individuals spent an average of 8.91 ± 9.70 days in the ICU and had an indwelling catheter for approximately 8.14 ± 7.95 days. Forty-two out of the 146 individuals were found to have a temperature of 100.4°F or higher. Majority of the patients with an elevated temperature had an infectious source other than urine, such as sputum (22 out of 42, 52.38%), blood (three out of 42, 7.14%) or CSF (one out of 42, 2.38%). We were able to find only two individuals (4.76%) with a positive urine culture and no evidence of other positive cultures or deep vein thrombosis.
Our analysis shows evidence to support the newest IDSA guidelines that patients with elevated temperatures should have a clinical workup of all alternative etiologies prior to testing for a urinary source unless the clinical suspicion is high. This will help reduce the rate of unnecessary urine cultures, the over-diagnosis of asymptomatic bacteriuria, and the overuse of antibiotics. Based on our current findings, all potential sources of fever should be ruled out prior to obtaining urinalysis, and catheters should be removed as soon as they are not needed. Urinalysis with reflex to urine culture should be reserved for those cases where there remains a high index of clinical suspicion for a urinary source.
医院获得性感染（HAIs）是导致住院时间延长和患者预后变差的重要原因。HAIs带来严重风险，尤其是对重症监护病房的神经外科患者而言，因为这些患者很少能够表达感染症状，仅以体温升高作为初始症状。美国疾病控制中心（CDC）和美国传染病学会（IDSA）的数据表明，在所有HAIs中，尿路感染（UTIs）被严重高估，导致抗生素过度且不必要的使用。
我们对2018年7月至2019年3月期间在箭头区域医疗中心接受神经外科评估的686例成年患者进行了回顾性分析。纳入标准为年龄大于18岁、患有神经外科疾病且至少需要在重症监护病房（ICU）住院一整天并留置导尿管的成年人。排除标准为18岁以下患者、未在ICU停留过的患者或患有肾衰竭等肾脏疾病的患者。
我们查阅了神经外科普查中的686例患者。总共146例留置导尿管的成年患者被纳入统计分析。大多数患者在ICU平均停留8.91±9.70天，留置导尿管约8.14±7.95天。在146例患者中，42例体温达到或高于100.4°F。大多数体温升高的患者有尿液以外的感染源，如痰液（42例中的22例，52.38%）、血液（42例中的3例，7.14%）或脑脊液（42例中的1例，2.38%）。我们仅发现2例（4.76%）尿液培养呈阳性且无其他阳性培养或深静脉血栓形成证据的患者。
我们的分析显示有证据支持IDSA的最新指南，即除非临床高度怀疑，体温升高的患者在检测尿液来源之前应进行所有其他病因的临床检查。这将有助于降低不必要的尿液培养率、无症状菌尿的过度诊断以及抗生素的过度使用。根据我们目前的研究结果，在进行尿液分析之前应排除所有潜在的发热源，并且一旦不需要应立即拔除导尿管。对于临床高度怀疑尿液来源的病例，应保留尿液分析及反射性尿液培养。
