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circumstances (eg, pregnancy, neutropenia, neonates, renal transplantation, and screening prior to urologic procedures). Only 1 respondent reported that all urine cultures had to be coupled with a UA. Also, 24 of 26 respondents (92%) indicated that UA could be ordered alone, and 1 respondent stated that all positive UAs proceed to urine culture at that institution. Most respondents (21 of 26, 81%) stated that their laboratory accepts urine from all sources (eg, clean-catch, indwelling catheter, other) for reflex urine culturing but 2 of 26 (8%) reported restriction to urine from indwelling urinary catheters. Most respondents (22 of 26, 85%) indicated that reflex urine cultures were available to all patients. The remainder reported restriction to inpatients, out- patients, and/or the emergency department. In reflex urine cultures, the criteria used to designate a uri-
nalysis as “positive” varied. Almost all respondents (25 of 26, 96%) reported the inclusion of white blood cells per high-power field (with a variety of WBC cutoffs), and most (19 of 26, 76%) reported inclusion of leukocyte esterase and nitrite status. Following implementation of reflex urine culturing, 7 respondents (27%) perceived a decrease in their CAUTI rates; 7 (27%) perceived no change; 3 (11%) perceived an increase; and 9 (35%) were uncertain. Of the 10 institutions reporting no change or an increase, 3 restricted reflex urine culturing to emergency department patients and outpatients.
Urine collection and laboratory processing
Most respondents (50 of 52, 96%) reported that their nurses receive training on appropriate urine collection technique, and 39% reported that their laboratory proceeds with urine culture even when there is a delay in transporting the urine to the laboratory. Only 35% of respondents reported that their institu- tion encourages submission of urine in transport devices con- taining boric acid preservative.
Urine culture reporting
Moreover, 90% of respondents reported that their laboratory reports a “mixed” urine culture with no further organism workup when 3 or more uropathogens are recovered. In positive urine cultures, 23 of 52 respondents (44%) reported using cascade antibiotic susceptibility reporting; 23 of 52 (44%) reported selectively suppressing reporting of certain antibiotics; and 15 of 52 (29%) indicated reporting of all antibiotics tested.
Discussion
Diagnostic stewardship of urine cultures was common among SRN hospitals. Half of respondents reported that they had implemented reflex urine cultures at their instiution. However, order restriction based on clinical symptoms and interventions aimed at improving the quality of urine specimens processed for urine culture was uncommon. Inappropriate urine culturing of asymptomatic patients is
Kaede V. Sullivan et al
practice has gained acceptance. However, the perceived impact of reflex urine culturing was mixed and could be explained by dif- ferences in how institutions defined and implemented reflex urine culturing. When introduced as an alternative to “routine” urine culturing, reflex urine culturing has been found to decrease urine culturing, reported CAUTI rates, and antibiotic use.4,5 However, when all urine samples with positive urinalysis auto- matically reflex to culture regardless of symptoms, unnecessary urine culturing will occur. Dietz et al6 reported a reduction in urine culture orders and antibiotic use after de-implementing reflex urine culturing; this finding reinforces the importance of ordering reflex urine cultures in symptomatic patients only. Respondents reported a wide range of urinalysis criteria, and
almost all included pyuria. Although the presence of pyuria does not predict UTI, the absence of pyuria can exclude UTI with a high negative predictive value, making it a useful strategy to limit unnecessary urine cultures.7,8 Prolonged transport of urine cul- tures can decrease their accuracy due to bacterial overgrowth. The American Society for Microbiology recommends that laboratories reject urine culture orders when urine is received >2 hours after collection without preservative to avoid reporting false-positive cultures.9 However, 40% of respondents indicated that their laboratories proceed with urine cultures even after prolonged specimen transport, and only 35% reported the use of boric acid preservative. This study has limitations. We had a limited sample with only
52 respondent hospitals overall, and >80% had an academic affiliation, which may limit the generalizability of our findings. In summary, we identified a variety of opportunities for
reduction of unnecessary urine culturing. Requiring (and edu- cating on) symptom-based indications for ordering urine cultures, canceling urine culture orders after prolonged transport without preservative, and reflex urine culturing are all interventions that that can be implemented to reduce unnecessary detection of asymptomatic bacteriuria.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.325
Acknowledgments. We thank Valerie Deloney from SHEA for her con- tribution to the survey, its distribution, and summary of results. All other authors have no conflicts to declare, financial or otherwise.
References
1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.
2. Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other urinary system infection [USI] events. Centers for Disease Control and Prevention website.
https://www.cdc.gov/nhsn/PDFs/pscManual/ 7pscCAUTIcurrent.pdf. Accessed August 22, 2018.
common.1 Only 44% of respondents reported that their institu- tion had written indications for urine culturing, and only 17% required documentation of symptoms to order urine cultures. EMR-based decision support may be an effective way to ensure that clinical symptoms are considered when placing urine culture orders.3
Two-thirds of North American respondents indicated that their laboratory offers reflex urine cultures, suggesting that this
3. Keller SC, Feldman L, Smith J, Pahwa A, Costrove SE, Chida N. The use of clinical decision support in reducing diagnosis of and treatment of asymptomatic bacteriuria. J Hosp Med 2018;13:392–395.
4. Epstein L. Evaluation of a novel intervention to reduce unnecessary urine cultures in intensive care units at a tertiary care hospital in Maryland, 2011–2014. Infect Control Hosp Epidemiol 2016;37:606–609.
5. SargM,Waldrop GE, BeierMA, et al. Impact of changes in urine culture ordering practice on antimicrobial utilization in intensive care units at an academic medical center. Infect Control Hosp Epidemiol 2016;37: 448–454.
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