Opinion
emia varies widely based on the clinical condition, ranging from 2% for cellulitis to 69% for septic shock. In terms of clinical predictors of bacteremia, elevated temperature (for ⱖ38.3°, likelihood ratio [LR], 1.2) or leukocytosis (LR, 1.4) in isolation do not accurately predict bacteremia. The presence of chills is a more useful predictor with a positive LR of 2.2, increasing to 4.7 for “shaking chills.” The systemic inflammatory response syndrome (defined as ⱖ2: temperature 38°C, heart rate >90 beats/min, respiratory rate >20 breaths/min or P CO 2 10% immature neutrophils) is a very sensitive tool for predicting bacteremia, with absence significantly lowering the probability (LR, 0.09). Preexisting antibiotic use also decreases the pretest probability of bacteremia (LR, 0.63). In a retPublished Online: August 11, 2014. doi:10.1001/jamainternmed.2014.3687. Conflict of Interest Disclosures: None reported. 1. Aronson MD, Bor DH. Blood cultures. Ann Intern Med. 1987;106(2):246-253. 2. Coburn B, Morris AM, Tomlinson G, Detsky AS. Does this adult patient with suspected bacteremia require blood cultures? JAMA. 2012;308(5):502-511.
rospective study of 139 inpatients with community-acquired infections or fever, only 1 patient (0.72%) had a new pathogen isolated on blood culture while receiving antibiotic therapy.5 It is common for an immunocompetent inpatient who presented with fever due to an infectious source to have persistent fever during the initial 72 hours of treatment. In response, physicians may reflexively order blood cultures. Our patient’s presenting condition (community-acquired pneumonia: pretest probability of bacteremia approximately 5%-10%), current use of antibiotics, and absence of useful clinical predictors of bacteremia make the use of blood cultures in this setting inappropriate.2 Avoidable diagnostic and therapeutic interventions continue to occur because of reflexive ordering of blood cultures for inpatients with fever, at a high cost.
3. Baron EJ, Miller JM, Weinstein MP, et al. Executive summary: a guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis. 2013;57(4):485-488.
4. Hall KK, Lyman JA. Updated review of blood culture contamination. Clin Microbiol Rev. 2006;19 (4):788-802. 5. Grace CJ, Lieberman J, Pierce K, Littenberg B. Usefulness of blood culture for hospitalized patients who are receiving antibiotic therapy. Clin Infect Dis. 2001;32(11):1651-1655.
LESS IS MORE PERSPECTIVE
Rajat Kalra, MBChB Division of Internal Medicine, University of Alabama at Birmingham, Birmingham. Ryan R. Kraemer, MD Division of Internal Medicine, University of Alabama at Birmingham, Birmingham; and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama. Corresponding Author: Rajat Kalra, MBChB, Tinsley Harrison Internal Medicine Residency Program, Division of Internal Medicine, University of Alabama at Birmingham, 1720 Second Ave S, Boshell Diabetes Building 327, Birmingham, AL 35294-0012 (rkalra @uabmc.edu). jamainternalmedicine.com
Urinary Catheterization—When Good Intentions Go Awry A Teachable Moment Story From the Front Lines
For these reasons, preventing inappropriate urinary catheterization was recently cited in the “Top 5 List” of the Society of Hospital Medicine’s recommendations in the AmericanBoardofInternalMedicineFoundation’s“Choosing Wisely” campaign. Current guidelines recommend urinary catheterization for acute urinary retention, intraoperative urinary measurement for selected surgical patients, and monitoring of urinary output in critically ill patients to aid healing of sacral wounds or decubitus ulcers in patients with incontinence, and to improve comfort in end-of-life care as needed.1,2 Physicians’ orders are required prior to the placement of an indwelling Foley catheter at our medical center. Nursing staff at our medical center are then required to fill out a care bundle in the patient’s medical chart detailing the indication for catheterization. This bundle details the indication and type of catheter used as well as acting as a procedure note, similar to templates used elsewhere in the Veterans Affairs system and those recommended by national guidelines.1,3 Despite this narrow range of indications and standard procedure technique, it has long been known (through both anecdote and research) that urinary catheters are often inserted far more frequently in clinical practice than indicated.4
A man in his 80s with a history of mild dementia and peripheral vascular disease with left below the knee amputation presented to our general medicine service with several weeks of fatigue and worsening lower extremity edema. He was found to have acute kidney injury and nephrotic range proteinuria. He did not have his prosthesis in the hospital and was unable to ambulate to the bathroom without it. A urinary catheter was placed to monitor urinary output while he received diuretics. After several days of diuresis, his symptoms were much improved, and he was discharged home. Five days after discharge, the patient was readmitted to the medical intensive care unit with severe sepsis due to a lower urinary tract infection (UTI). His sepsis was almost certainly due to the urinary catheter our medical team had inserted during his prior admission. With treatment, he recovered and was discharged home, but the hospitalization and its risks could probably have been avoided had he not been catheterized.
Teachable Moment Urinarytractinfectionsareoneofthemostcommonnosocomial infections, and urinary catheterization is thought to be the etiology of 70% to 80% of these infections.1,2
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/24/2015
1547
Opinion
External catheters have been proposed as a potential alternative to indwelling urinary catheters, and there is some evidence that elderly male patients find external catheters to be more comfortable and less painful.5 External catheters, however, are not without their own risks. This includes skin damage in the genital area as well as UTIs. Saint et al5 published a small randomized clinical trial in 2006 comparing external catheters and indwelling catheters using the composite outcome of bacteriuria, symptomatic UTI, and death. This suggested only a small increase in the incidence of composite outcome (mostly owing to the incidence of bacteriuria) in patients who had indwellingcatheterscomparedwiththosewithexternalcatheters.There was no difference between the 2 devices in patients with dementia. Hence, external catheters can still pose substantial risks. Given the known risks of urinary catheterization, why are patients, especially elderly patients, catheterized so frequently? There is a perception that in immobile elderly patients urinary catheterization is a convenient method for managing incontinence for both the patient and hospital staff. However, in such cases, diapers are a viable alternative for managing incontinence. Saint et al5 previPublished Online: August 18, 2014. doi:10.1001/jamainternmed.2014.3806. Conflict of Interest Disclosures: None reported. Correction: This article was corrected on October 16, 2014, to update the authors’ affiliations. 1. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(5):464-479.
ously showed that there is a sizeable portion of men who actually prefer diapers to external and indwelling catheters.3 Moreover, elderly, immunocompromised, and female patients are at an increased risk for catheter-associated UTIs. Accordingly, national guidelines recommend against catheterization for management of incontinence in these populations.1,2 Indwelling catheters are also thought to prevent patients from soiling themselves and decrease the risk of skin breakdown. However, there is no clear evidence about whether urinary catheterization offers primary prevention against skin breakdown. Ultimately, this patient’s catheterization led to a major complication. Had we explored alternate options, such as urinals or toilet collection of urine while letting him use his prosthesis, we might have been able to avoid his repeated admission with severe sepsis. In summary, this patient is a strong reminder that our first job is to do no harm. In his case, we were so focused on monitoring and treating the potentially life-threatening nephrotic syndrome that we missed the fact that our “low-risk” intervention actually led to a more disastrous effect.
2. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-326. 3. Miller BL, Krein SL, Fowler KE, et al. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infect Control Hosp Epidemiol. 2013; 34(6):631-633.
4. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155(13): 1425-1429. 5. Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006;54(7):1055-1061.
LESS IS MORE PERSPECTIVE
Mysha K. Mason, MD Department of Medicine, University of Colorado Denver School of Medicine, Aurora.
Corresponding Author: Mysha K. Mason, MD, Department of Medicine, University of Colorado Denver School of Medicine, 12631 E 17th Ave, PO Box B177, Academic Office 1, Aurora, CO 80045 (mysha.mason @ucdenver.edu).
1548
Looking for Trouble—Patient Preference Misdiagnosis and Overtesting A Teachable Moment Story From the Front Lines A 74-year-old woman with systemic sclerosis was referred to a rheumatology clinic to reestablish care after a 5-year hiatus. Diagnosed as having scleroderma 30 years earlier, her disease manifestations of sclerodactyly, Raynaud phenomenon, gastroesophageal reflux, and calcinosis were consistent with the limited cutaneous subtype of systemic sclerosis, and she had never required anything more than a proton pump inhibitor to control her symptoms. Over the course of the visit, she made it clear that as long as she felt well enough to spend time with her family and tend to her garden, she wished to avoid invasive medical testing. She mentioned that she discontinued routine cancer screening several years earlier because, “At this stage in my life, I don’t want any more uncomfortable tests if I don’t really need them. No point in looking for trouble if I feel good.”
Although she had no symptoms of cardiopulmonary disease, after learning that pulmonary hypertension and interstitial lung disease are leading causes of death in patients with systemic sclerosis and that it is common practice to screen for these complications at regular intervals,1 she agreed to undergo an echocardiogram and high-resolution computed tomography (CT) of the chest. These would not be invasive tests, she reasoned, and she did not recall being screened for these conditions previously. There was very little discussion of the potential risks of screening or alternatives. Her echocardiogram was unremarkable, and high-resolution CT did not show evidence of interstitial lung disease; however, it did reveal esophageal dilation and several small pulmonary nodules. Her primary care physician subsequently referred her for upper endoscopy and follow-up chest CT; esophageal biopsy results
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/24/2015
jamainternalmedicine.com
emia varies widely based on the clinical condition, ranging from 2% for cellulitis to 69% for septic shock. In terms of clinical predictors of bacteremia, elevated temperature (for ⱖ38.3°, likelihood ratio [LR], 1.2) or leukocytosis (LR, 1.4) in isolation do not accurately predict bacteremia. The presence of chills is a more useful predictor with a positive LR of 2.2, increasing to 4.7 for “shaking chills.” The systemic inflammatory response syndrome (defined as ⱖ2: temperature 38°C, heart rate >90 beats/min, respiratory rate >20 breaths/min or P CO 2 10% immature neutrophils) is a very sensitive tool for predicting bacteremia, with absence significantly lowering the probability (LR, 0.09). Preexisting antibiotic use also decreases the pretest probability of bacteremia (LR, 0.63). In a retPublished Online: August 11, 2014. doi:10.1001/jamainternmed.2014.3687. Conflict of Interest Disclosures: None reported. 1. Aronson MD, Bor DH. Blood cultures. Ann Intern Med. 1987;106(2):246-253. 2. Coburn B, Morris AM, Tomlinson G, Detsky AS. Does this adult patient with suspected bacteremia require blood cultures? JAMA. 2012;308(5):502-511.
rospective study of 139 inpatients with community-acquired infections or fever, only 1 patient (0.72%) had a new pathogen isolated on blood culture while receiving antibiotic therapy.5 It is common for an immunocompetent inpatient who presented with fever due to an infectious source to have persistent fever during the initial 72 hours of treatment. In response, physicians may reflexively order blood cultures. Our patient’s presenting condition (community-acquired pneumonia: pretest probability of bacteremia approximately 5%-10%), current use of antibiotics, and absence of useful clinical predictors of bacteremia make the use of blood cultures in this setting inappropriate.2 Avoidable diagnostic and therapeutic interventions continue to occur because of reflexive ordering of blood cultures for inpatients with fever, at a high cost.
3. Baron EJ, Miller JM, Weinstein MP, et al. Executive summary: a guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis. 2013;57(4):485-488.
4. Hall KK, Lyman JA. Updated review of blood culture contamination. Clin Microbiol Rev. 2006;19 (4):788-802. 5. Grace CJ, Lieberman J, Pierce K, Littenberg B. Usefulness of blood culture for hospitalized patients who are receiving antibiotic therapy. Clin Infect Dis. 2001;32(11):1651-1655.
LESS IS MORE PERSPECTIVE
Rajat Kalra, MBChB Division of Internal Medicine, University of Alabama at Birmingham, Birmingham. Ryan R. Kraemer, MD Division of Internal Medicine, University of Alabama at Birmingham, Birmingham; and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama. Corresponding Author: Rajat Kalra, MBChB, Tinsley Harrison Internal Medicine Residency Program, Division of Internal Medicine, University of Alabama at Birmingham, 1720 Second Ave S, Boshell Diabetes Building 327, Birmingham, AL 35294-0012 (rkalra @uabmc.edu). jamainternalmedicine.com
Urinary Catheterization—When Good Intentions Go Awry A Teachable Moment Story From the Front Lines
For these reasons, preventing inappropriate urinary catheterization was recently cited in the “Top 5 List” of the Society of Hospital Medicine’s recommendations in the AmericanBoardofInternalMedicineFoundation’s“Choosing Wisely” campaign. Current guidelines recommend urinary catheterization for acute urinary retention, intraoperative urinary measurement for selected surgical patients, and monitoring of urinary output in critically ill patients to aid healing of sacral wounds or decubitus ulcers in patients with incontinence, and to improve comfort in end-of-life care as needed.1,2 Physicians’ orders are required prior to the placement of an indwelling Foley catheter at our medical center. Nursing staff at our medical center are then required to fill out a care bundle in the patient’s medical chart detailing the indication for catheterization. This bundle details the indication and type of catheter used as well as acting as a procedure note, similar to templates used elsewhere in the Veterans Affairs system and those recommended by national guidelines.1,3 Despite this narrow range of indications and standard procedure technique, it has long been known (through both anecdote and research) that urinary catheters are often inserted far more frequently in clinical practice than indicated.4
A man in his 80s with a history of mild dementia and peripheral vascular disease with left below the knee amputation presented to our general medicine service with several weeks of fatigue and worsening lower extremity edema. He was found to have acute kidney injury and nephrotic range proteinuria. He did not have his prosthesis in the hospital and was unable to ambulate to the bathroom without it. A urinary catheter was placed to monitor urinary output while he received diuretics. After several days of diuresis, his symptoms were much improved, and he was discharged home. Five days after discharge, the patient was readmitted to the medical intensive care unit with severe sepsis due to a lower urinary tract infection (UTI). His sepsis was almost certainly due to the urinary catheter our medical team had inserted during his prior admission. With treatment, he recovered and was discharged home, but the hospitalization and its risks could probably have been avoided had he not been catheterized.
Teachable Moment Urinarytractinfectionsareoneofthemostcommonnosocomial infections, and urinary catheterization is thought to be the etiology of 70% to 80% of these infections.1,2
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/24/2015
1547
Opinion
External catheters have been proposed as a potential alternative to indwelling urinary catheters, and there is some evidence that elderly male patients find external catheters to be more comfortable and less painful.5 External catheters, however, are not without their own risks. This includes skin damage in the genital area as well as UTIs. Saint et al5 published a small randomized clinical trial in 2006 comparing external catheters and indwelling catheters using the composite outcome of bacteriuria, symptomatic UTI, and death. This suggested only a small increase in the incidence of composite outcome (mostly owing to the incidence of bacteriuria) in patients who had indwellingcatheterscomparedwiththosewithexternalcatheters.There was no difference between the 2 devices in patients with dementia. Hence, external catheters can still pose substantial risks. Given the known risks of urinary catheterization, why are patients, especially elderly patients, catheterized so frequently? There is a perception that in immobile elderly patients urinary catheterization is a convenient method for managing incontinence for both the patient and hospital staff. However, in such cases, diapers are a viable alternative for managing incontinence. Saint et al5 previPublished Online: August 18, 2014. doi:10.1001/jamainternmed.2014.3806. Conflict of Interest Disclosures: None reported. Correction: This article was corrected on October 16, 2014, to update the authors’ affiliations. 1. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(5):464-479.
ously showed that there is a sizeable portion of men who actually prefer diapers to external and indwelling catheters.3 Moreover, elderly, immunocompromised, and female patients are at an increased risk for catheter-associated UTIs. Accordingly, national guidelines recommend against catheterization for management of incontinence in these populations.1,2 Indwelling catheters are also thought to prevent patients from soiling themselves and decrease the risk of skin breakdown. However, there is no clear evidence about whether urinary catheterization offers primary prevention against skin breakdown. Ultimately, this patient’s catheterization led to a major complication. Had we explored alternate options, such as urinals or toilet collection of urine while letting him use his prosthesis, we might have been able to avoid his repeated admission with severe sepsis. In summary, this patient is a strong reminder that our first job is to do no harm. In his case, we were so focused on monitoring and treating the potentially life-threatening nephrotic syndrome that we missed the fact that our “low-risk” intervention actually led to a more disastrous effect.
2. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-326. 3. Miller BL, Krein SL, Fowler KE, et al. A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center. Infect Control Hosp Epidemiol. 2013; 34(6):631-633.
4. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155(13): 1425-1429. 5. Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006;54(7):1055-1061.
LESS IS MORE PERSPECTIVE
Mysha K. Mason, MD Department of Medicine, University of Colorado Denver School of Medicine, Aurora.
Corresponding Author: Mysha K. Mason, MD, Department of Medicine, University of Colorado Denver School of Medicine, 12631 E 17th Ave, PO Box B177, Academic Office 1, Aurora, CO 80045 (mysha.mason @ucdenver.edu).
1548
Looking for Trouble—Patient Preference Misdiagnosis and Overtesting A Teachable Moment Story From the Front Lines A 74-year-old woman with systemic sclerosis was referred to a rheumatology clinic to reestablish care after a 5-year hiatus. Diagnosed as having scleroderma 30 years earlier, her disease manifestations of sclerodactyly, Raynaud phenomenon, gastroesophageal reflux, and calcinosis were consistent with the limited cutaneous subtype of systemic sclerosis, and she had never required anything more than a proton pump inhibitor to control her symptoms. Over the course of the visit, she made it clear that as long as she felt well enough to spend time with her family and tend to her garden, she wished to avoid invasive medical testing. She mentioned that she discontinued routine cancer screening several years earlier because, “At this stage in my life, I don’t want any more uncomfortable tests if I don’t really need them. No point in looking for trouble if I feel good.”
Although she had no symptoms of cardiopulmonary disease, after learning that pulmonary hypertension and interstitial lung disease are leading causes of death in patients with systemic sclerosis and that it is common practice to screen for these complications at regular intervals,1 she agreed to undergo an echocardiogram and high-resolution computed tomography (CT) of the chest. These would not be invasive tests, she reasoned, and she did not recall being screened for these conditions previously. There was very little discussion of the potential risks of screening or alternatives. Her echocardiogram was unremarkable, and high-resolution CT did not show evidence of interstitial lung disease; however, it did reveal esophageal dilation and several small pulmonary nodules. Her primary care physician subsequently referred her for upper endoscopy and follow-up chest CT; esophageal biopsy results
JAMA Internal Medicine October 2014 Volume 174, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/24/2015
jamainternalmedicine.com
