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Discordance between perception and treatment practices associated with intensive care unit-acquired bacteriuria and funguria: A Canadian physician survey*

Chant, Clarence PharmD, BCPS; Dos Santos, Claudia C. MD; Saccucci, Paola PharmD; Smith, Orla M. RN, MN, CNCC(C); Marshall, John C. MD, FRCS(C); Friedrich, Jan O. MD, DPhil, FRCP(C)

doi: 10.1097/CCM.0b013e3181692af9
Clinical Investigations

Objective: To determine physician practice and perception about the management of intensive care unit (ICU)-acquired bacteriuria and funguria.

Design: Cross-sectional, self-administered, Web-based survey.

Setting: All provinces within Canada.

Participants: Staff ICU physicians who are members of either the Canadian Critical Care Trials Group or the Canadian Critical Care Society.

Interventions: Survey items were developed by four ICU clinicians, and survey sensibility was assessed by five independent intensivists. Nonrespondents received three follow-up reminders. Participants were asked questions about general perceptions and practices regarding the management of ICU-acquired bacteriuria and funguria. Clinical scenarios were used to elicit management strategies, including antimicrobial prescriptions.

Measurements and Main Results: Ninety of 198 physicians (45%) responded. Bacteriuria was perceived by 63% of the respondents to be a frequent but low-morbidity problem. Most intensivists (98%) did not use a protocol for management. Traditional symptoms were rarely used to interpret the significance of bacteriuria. Presence of systemic inflammatory response syndrome (93%), presence of hemodynamic changes (91%), and urinalysis (69%) were used often. Within clinical scenarios, source control via urinary catheter change was not universal, ranging from 44% to 67% in the various scenarios, even in patients presenting with septic shock. Prescription of antimicrobials was common across scenarios despite the low-morbidity perception. In an asymptomatic patient, 19% of respondents would prescribe antimicrobials. Changing the species from fungus to bacteria and the presence of systemic inflammatory response syndrome or shock increased the likelihood of antimicrobial use up to 70% to 80%.

Conclusions: ICU physicians perceive bacteriuria to have low morbidity. However, management approaches vary considerably, and systemic antimicrobials are frequently prescribed. Increased clinical instability and bacterial vs. fungal organisms isolated in urine cultures increased the use of antimicrobials. The considerable variability in practice and discordance between likelihood of urinary tract infection and antimicrobial prescription, highlights the need for additional clinical trials.

From the Pharmacy Department (CC, PS) and Critical Care Department (CCDS, OMS, JCM, JOF); St. Michael’s Hospital; the Interdepartmental Division of Critical Care (CCDS, JCM, JOF); and Leslie Dan Faculty of Pharmacy (CC), University of Toronto; Li Ka Shing Knowledge Translation Institute (JOF), Toronto, Ontario, Canada.

Dr. Friedrich is supported by a Canadian Institutes of Health Research (CIHR) Clinician Scientist Award. This project received no specific funding.

Dr. Marshall has consulted for Becton Dickinson, Takeda, and Pfizer and has received honoraria/speaking fees from Spectral Diagnostics. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: chantc@smh.toronto.on.ca

© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins