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Urine Trouble: Reducing Midstream Clean Catch Urine Contamination Among Children 3-17 Years Old
Alex C Hoover1, Rachel S Segal1, M Bridget Zimmerman2
1Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa.
Insights
A resident-led initiative successfully reduced pediatric midstream clean catch urine culture contamination by implementing a bundled intervention. However, the contamination reduction and decreased repeat urine cultures diminished over time.
Area of Science:
- Pediatric Medicine
- Clinical Microbiology
- Quality Improvement
Background:
- Midstream clean catch urine culture is preferred over catheterization for pediatric urine samples.
- High contamination rates in midstream clean catch urine cultures can lead to unnecessary medical interventions and increased costs.
- A resident-led initiative aimed to decrease contamination in pediatric midstream clean catch urine cultures.
Purpose of the Study:
- To implement and evaluate a bundled intervention to reduce contamination rates in pediatric midstream clean catch urine cultures.
- To assess the impact of the intervention on repeat urine cultures and catheterization rates.
- To evaluate the sustainability of the intervention's effects over time.
Main Methods:
- A bundled intervention was implemented across emergency, inpatient, and outpatient settings.
- Contamination rates were assessed pre-intervention (April 2016-September 2017), post-intervention (April 2018-September 2018), and during a sustainability period (October 2018-September 2020).
- Balancing measures included repeat urine cultures and contaminated catheterization cultures.
Main Results:
- Midstream clean catch urine culture contamination decreased from 45.3% to 30.9% post-intervention, a 14.7% absolute reduction.
- Repeat urine culture rates significantly decreased from 4.9% to 0.9% six months post-intervention.
- The intervention's impact waned over time, with contamination rates rising to 38.4% and repeat urine culture rates at 3.2% over 30 months post-intervention.
Conclusions:
- A resident-led bundled intervention effectively reduced pediatric midstream clean catch urine culture contamination.
- The positive effects of the intervention, including reduced contamination and repeat cultures, diminished over a 2-year period.
- Sustaining improvements in urine culture collection techniques requires ongoing monitoring and reinforcement.
Background:
Children, caregivers, and clinicians often prefer midstream clean catch technique to urethral catheterization for obtaining urine cultures. However, contamination is common, potentially resulting in unnecessary medical intervention and cost. With this resident-led initiative, we aimed to reduce pediatric midstream clean catch urine culture contamination over 6 months.
Methods:
A bundled intervention was implemented in the emergency department, inpatient units, and outpatient clinics at our institution. Baseline contamination rates were collected April 2016 to September 2017; the intervention was introduced October 2017 to March 2018 and evaluated April 2018 to September 2018. Sustainability was measured October 2018 to September 2020. Balancing measures included rates of repeat urine cultures, positive cultures, and contaminated cultures by urethral catheterization.
Results:
Rates of midstream clean catch urine culture contamination were 45.3% preintervention and 30.9% postintervention, a 14.7% (95% confidence interval: 8.0% to 21.5%) absolute decrease. Before and after intervention, girls and patients 16 to 17 years old had the highest rates of midstream clean catch contamination. Six months postintervention, the rate of repeat urine culture decreased from 4.9% to 0.9% with no change in positive culture results or contaminated cultures by urethral catheterization. Over the subsequent 2 years, the impact of the intervention decreased (rate of contamination over 30 months postintervention: 38.4%, a 7.3% [95% confidence interval: 2.9% to 11.6%] absolute decrease; rate of repeat urine culture: 3.2%).
Conclusions:
An intervention to improve midstream clean catch urine culture collection was associated with a clinically meaningful decrease in contamination. Impact of the resident-led intervention decreased over time.
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