Clinicians' Approach to Positive Urine Culture in the Intensive Care Units

Purpose: To study clinicians' approach to distinguishing urinary tract infection (UTI) with sepsis from inconsequential bacteriuria with fever from other sources in the intensive care units (ICUs). Materials and Methods: The microbiology results (November 1, 2004-March 31, 2005) were retrospectively screened. All adult ICU patients with positive urine culture (>= 10(5) colony-forming unit per milliliter) were identified, and their medical records were reviewed. The following information was recorded: demographics, comorbidity, vital signs, urinary catheter placement, and antibiotic treatment. The incidence of diarrhea was estimated based on the number of stool samples submitted for culture and Clostridium difficile tests. Results: We encountered 90 evaluable cases. Their age was 62.9 +/- 17.6 years; 80 (89%) had indwelling catheters, 66 (73.3%) had leukocytosis (> 11(3) white blood cell counts per microliter), 42 (46.7%) were febrile (>= 38.3 degrees C) or septic, and 5 (5.6%) had urinary symptoms. Other possible causes for fever/sepsis were present in 28 (70.0%) febrile/septic patients. Clinicians opted to initiate antibiotics in 43 (91.5%) of 47 patients with fever/sepsis or urinary symptoms (27 of 30 with other causes, 11 of 12 patients without other causes, and 5 of 5 with urinary symptoms without fever) and 25 (58.1%) of 43 patients without symptoms or fever/sepsis. The majority (86.0%) of asymptomatic patients had indwelling catheters. Antibiotic treatment was associated with higher incidence of diarrhea (relative risk, 2.8; 95% confidence interval, 1.03-7.74; P = 0.04). Conclusions: Clinicians often treat UTI in the ICU in the absence of symptoms and in the presence of infections in other sites. This approach is inappropriate in asymptomatic patients and questionable in patients with other conditions. Urinary tract infection treatment guidelines for ICU patients is urgently needed.