| Description |
Background: Urinary tract infections (UTIs) are one of the most common bacterial infections seen in the neonatal intensive care unit (NICU). Widely used laboratory diagnostic criteria stem from recommendations made by the American Academy of Pediatrics (AAP) in their clinical practice guideline for UTI management in infants and children between two and 24 months of age (2016). This criterion includes the presence of at least 50,000 colony forming units (CFUs) per milliliter of a single uropathogen from the quantitative culture of a properly collected urine specimen in conjunction with pyuria on urinalysis (UA). More recent studies question the use of these standards, particularly in the setting of prematurity, where there may be unmeasurable signs of inflammation at the time of evaluation (Lasry et al., 2024; Shaikh et al., 2024). Local Problem: Despite national guidelines, there is no standardized process for UTI diagnosis for clinicians in two NICUs within an integrated hospital system. As a result, infants in the NICU may be getting over- or under- treated with antibiotics. Methods: A needs assessment was conducted to examine the diagnosis and management of UTIs in infants between two and 24 months of age, determine the need for a guideline, and make evidence-based recommendations. Key stakeholders were engaged in planning and designing the needs assessment. A Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was performed to summarize findings and identify barriers to implementation. Interventions: A SWOT analysis was conducted, summarized, and presented to key stakeholders. Providers were surveyed on practices surrounding UTI management and diagnosis. Patient charts were retrospectively reviewed. Discussions were held with nurses regarding barriers and/or facilitators to the specimen collection process. Results: A self-report survey was sent to 122 providers with a response rate of 29% (N=35). Most providers described themselves as "somewhat confident" (n=17, 48.6%) or "not at all confident" (n=2, 5.7%) regarding UTI management and report lack of clinical practice guideline as a barrier (n=19, 54.3%). Of 214 instances of urine culture collection, 52% (N=110) were treated as a UTI. Of these, 44% (n=48) had pyuria and 16% (n=18) met AAP criteria. Qualitative analysis of feedback from bedside nurses (N=27) identified several themes including confusion regarding interpretation of results (n=10, 37%) and how they change the plan of care (n=7, 26%). Conclusion: Clinicians in the NICU are not using AAP guidance to diagnose UTI and have differing opinions on minimal diagnostic laboratory criteria needed to define UTI. Standardizing the diagnosis of UTI in the NICU would be helpful for clinicians and may result in decreased antibiotic use. It is recommended to follow AAP guidance with the following evidence-based considerations: it may be reasonable to consider UTI diagnosis in the absence of pyuria on UA. For premature infants, it may be reasonable to consider a diagnostic threshold of as low as 10,000 CFUs per milliliter of a single uropathogen on a catheterized urine specimen when other signs, such as pyuria or fever, are also present. |
