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Optimizing reflex urine cultures: Using a population-specific approach to diagnostic stewardship

Published online by Cambridge University Press:  10 January 2023

Sonali D. Advani Open the ORCID record for Sonali D. Advani [Opens in a new window] ,
Nicholas A. Turner Open the ORCID record for Nicholas A. Turner [Opens in a new window] ,
Kenneth E. Schmader ,
Rebekah H. Wrenn ,
Rebekah W. Moehring ,
Christopher R. Polage ,
Valerie M. Vaughn  and
Deverick J. Anderson Open the ORCID record for Deverick J. Anderson [Opens in a new window]
Sonali D. Advani*
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
Nicholas A. Turner
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
Kenneth E. Schmader
Affiliation:
Division of Geriatrics, Department of Medicine, Duke and Durham VA Medical Center, Durham, North Carolina
Rebekah H. Wrenn
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
Rebekah W. Moehring
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
Christopher R. Polage
Affiliation:
Department of Pathology, Duke University School of Medicine, Durham, North Carolina
Valerie M. Vaughn
Affiliation:
Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
Deverick J. Anderson
Affiliation:
Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
*
Author for correspondence: Sonali D. Advani, MBBS, MPH, FIDSA, Division of Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710. E-mail: [email protected]
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Abstract

Background:

Clinicians and laboratories routinely use urinalysis (UA) parameters to determine whether antimicrobial treatment and/or urine cultures are needed. Yet the performance of individual UA parameters and common thresholds for action are not well defined and may vary across different patient populations.

Methods:

In this retrospective cohort study, we included all encounters with UAs ordered 24 hours prior to a urine culture between 2015 and 2020 at 3 North Carolina hospitals. We evaluated the performance of relevant UA parameters as potential outcome predictors, including sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also combined 18 different UA criteria and used receiver operating curves to identify the 5 best-performing models for predicting significant bacteriuria (≥100,000 colony-forming units of bacteria/mL).

Results:

In 221,933 encounters during the 6-year study period, no single UA parameter had both high sensitivity and high specificity in predicting bacteriuria. Absence of leukocyte esterase and pyuria had a high NPV for significant bacteriuria. Combined UA parameters did not perform better than pyuria alone with regard to NPV. The high NPV ≥0.90 of pyuria was maintained among most patient subgroups except females aged ≥65 years and patients with indwelling catheters.

Conclusion:

When used as a part of a diagnostic workup, UA parameters should be leveraged for their NPV instead of sensitivity. Because many laboratories and hospitals use reflex urine culture algorithms, their workflow should include clinical decision support and or education to target symptomatic patients and focus on populations where absence of pyuria has high NPV.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 44 , Issue 2 , February 2023 , pp. 206 - 209
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Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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Footnotes

PREVIOUS PRESENTATION: These data were presented as a poster at IDWeek 2022 on October 20, 2022 at Washington, DC (abstract no. 1261422).

References

Advani, SD, Gao, CA, Datta, R, et al. Knowledge and practices of physicians and nurses related to urine cultures in catheterized patients: an assessment of adherence to IDSA guidelines. Open Forum Infect Dis 2019;6:ofz305.CrossRefGoogle ScholarPubMed
Petty, LA, Vaughn, VM, Flanders, SA, et al. Risk factors and outcomes associated with treatment of asymptomatic bacteriuria in hospitalized patients. JAMA Intern Med 2019;179:1519–1527.CrossRefGoogle ScholarPubMed
Fakih, MG, Advani, SD, Vaughn, VM. Diagnosis of urinary tract infections: need for a reflective rather than reflexive approach. Infect Control Hosp Epidemiol 2019;40:834–835.CrossRefGoogle ScholarPubMed
Sullivan, KV, Morgan, DJ, Leekha, S. Use of diagnostic stewardship practices to improve urine culturing among SHEA Research Network hospitals. Infect Control Hosp Epidemiol 2019;40:228–231.CrossRefGoogle ScholarPubMed
Ling, D, Seidelman, J, Dodds-Ashley, E, et al. Navigating reflex urine culture practices in community hospitals: need for a validated approach. Am J Infect Control 2020;48:1549–1551.CrossRefGoogle ScholarPubMed
Humphries, RM, Dien Bard, J. Point-counterpoint: reflex cultures reduce laboratory workload and improve antimicrobial stewardship in patients suspected of having urinary tract infections. J Clin Microbiol 2016;54:254–258.CrossRefGoogle ScholarPubMed
Whelan, P, Nelson, A, Kim, CJ, et al. Investigating risk factors for urine culture contamination in outpatient clinics: a new avenue for diagnostic stewardship. Antimicrob Steward Healthc Epidemiol 2022;2:e29.CrossRefGoogle ScholarPubMed
Advani, SD, Polage, CR, Fakih, MG. Deconstructing the urinalysis: a novel approach to diagnostic and antimicrobial stewardship. Antimicrob Steward Healthc Epidemiol 2021;1:e6.CrossRefGoogle ScholarPubMed
Advani, S, Vaughn, VM. Quality improvement interventions and implementation strategies for urine culture stewardship in the acute care setting: advances and challenges. Curr Infect Dis Rep 2021;23(10):16.CrossRefGoogle ScholarPubMed
Advani, SD, Lee, RA, Schmitz, M, Camins, BC. Impact of changes to the National Healthcare Safety Network (NHSN) definition on catheter-associated urinary tract infection (CAUTI) rates in intensive care units at an academic medical center. Infect Control Hosp Epidemiol 2017;38:621–623.CrossRefGoogle Scholar
Trautner, BW. Urinary Tract infections as a continuum: implications for diagnostic and antibiotic stewardship. Clin Infect Dis 2021;72:1339–1341.CrossRefGoogle ScholarPubMed
National Healthcare Safety Network (NHSN) patient safety component manual. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. Published January 2017. Accessed January 1, 2017.Google Scholar
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