Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.
Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
Clin Infect Dis. 2022 Aug 31;75(3):382-389. doi: 10.1093/cid/ciab987.
Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.
A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.
One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.
These 18 guidance statements can optimize use of urine cultures for better patient outcomes.
尿液培养是非特异性的，往往导致尿路感染的误诊和不必要的抗生素使用。诊断管理是一组程序，用于修改测试的订购、处理和报告，以优化诊断和下游治疗。在这项研究中，我们旨在制定关于尿液培养诊断管理最佳实践的专家指南。
采用 RAND 改良 Delphi 方法和多学科专家小组，确定诊断管理的最佳实践。指导建议的临床问题分为三个主题领域（订购、处理、报告），在急诊、住院、门诊和长期护理的实践环境中进行。15 名专家对建议进行了 9 分制的 Likert 量表评分。小组未达成一致的建议在一次虚拟会议上进行讨论，然后通过电子邮件进行第二轮排名。在对结果进行二次审查和小组讨论后，制定了一系列指导声明。
审查了 165 个问题。专家组对 104 个问题达成一致，提出了 18 项总体指导声明。为了优化尿液培养的订购，建议采取以下策略：要求记录症状，发送警报以阻止在没有症状的情况下订购，以及取消重复培养。对于尿液培养处理，支持条件性尿液培养和尿液白细胞计数作为标准。对于尿液培养报告，适当的做法包括在特定条件下劝阻治疗的提示以及选择性报告抗生素以指导治疗决策。
这 18 项指导声明可以优化尿液培养的使用，以改善患者的治疗效果。
