Abstract
Urine culture is the most common microbiological test in the outpatient setting in the United States.
Unfortunately, contamination during collection is prevalent and undermines test accuracy, leading to incorrect
diagnosis, unnecessary treatment, wasted laboratory resources, and inflated costs. Unnecessary antibiotic
treatment increases the risk of developing antimicrobial resistance, one of the most serious threats to patients
and public health. We previously found that more than half of 1,265 urine cultures collected from women and
men in two primary care clinics were contaminated. Prior trials that attempted to reduce urine contamination
using patient education had mixed results. However, these prior studies did not include stakeholder
engagement and were not preceded by pilot studies, a critical step in the process of intervention development.
Until we have an effective intervention, contaminated samples will continue to give meaningless results, trigger
undue antibiotic use, and inflate costs. The overarching goal of this project is to improve the accuracy of
urinary diagnostic testing, thus furthering antibiotic stewardship in ambulatory care settings. We will create a
novel patient education intervention that incorporates stakeholder input and addresses previously identified
barriers to proper midstream clean-catch urine sample collection. Key barriers include competing nursing
priorities, patient language barriers, poor health literacy, and reticence of nurses and medical assistants to
discuss essential anatomic details. To address these barriers, our animated video and pictorial flyer in English
and Spanish will provide step-by-step guidance for urine collection for women and men. The content and
presentation of our intervention will be developed in collaboration with stakeholders central to this process:
patients, nurses and medical assistants. The overall objective of the proposed project is to design and test a
bilingual educational intervention to reduce urine contamination in a diverse patient population visiting safety
net primary care clinics. In Aim 1 (intervention development), we will iteratively develop an educational
intervention (instructional video and flyer) with input from a patient advisory board, nurses, and medical
assistants. The video and flyer will provide step-by-step guidance to patients for collecting a urine sample. In
Aim 2 (pilot study), we will assess and improve the intervention’s acceptability, appropriateness and feasibility
using a mixed methods approach that includes a quantitative survey and qualitative interviews with
stakeholders. In Aim 3 (randomized controlled trial), we will test the effectiveness of our patient education
intervention at reducing urine contamination and antibiotic use associated with urine cultures. The proposed
research is significant because it will develop an intervention to reduce contamination of urine cultures. The
proposed research is innovative because it uses a stakeholder-centered approach. If successful, this
intervention can be disseminated to other clinical settings in which urine culture contamination drives antibiotic
overuse, including emergency departments and long-term care settings.
