What Is A Reflex Urine Culture

Urine Reflex Testing: Why and How?

Dr. Yi Xiao and Dr. Allison B. Chambliss, both of whom have doctorates in biology and chemistry and are FAACC members/Date:SEP.1.2021/ Clinical Laboratory is the source of this information. News Urinalysis (UA) is generally comprised of physical, chemical, and microscopic evaluations, with the complexity, expense, and turnaround time increasing as the number of evaluations increases. As an added bonus, UA is interdisciplinary in that it may be conducted in the core lab or at the point of care, and it can be either a manual or an automated test.

Many laboratories have utilized reflex testing procedures in order to increase efficiency.

There are two types of reflex testing that are often used.

Following an abnormal chemical UA result, a further microscopic UA is performed to examine for cells, bacteria, yeast, casts, and crystals, among other things.

We were interested in implementing a reflex-to-culture approach to reduce the reporting of clinically insignificant catheter-associated urinary tract infections (CAUTI), reduce misinterpretation or overinterpretation of clinically insignificant positive culture results, and support antibiotic stewardship in our hospital system.

Validating Urine Reflex Criteria

A small amount of data has been collected using recent automated UA methods despite the fact that these approaches are now frequently utilized and discussed in the literature. However, whereas the majority of the studies that looked into reflex-to-culture criteria compared manual microscopy findings to urine culture findings, we were interested in using a compounded reflex approach—chemical urine analysis combined with reflex to microbiology for general UA orders, and chemical urine analysis combined with reflex to microbiology followed by reflex to culture for reflex culture UA orders—to see how well it worked.

We also intended to employ an automated user authentication system as the primary user authentication technique.

In order to determine the importance of the diagnoses that would be missed and the number of microscopic UA and cultures that may be avoided by our suggested reflex UA techniques, we conducted a series of simulations.

Six percent of the samples with accessible urine culture findings (n=3,127) were negative for all chemical UA criteria but had clinically significant positive urine cultures, demonstrating that negative chemical UA alone performed rather well in ruling out culture-positive UTIs.

Workflow Challenges and Clinical Considerations

We had many vigorous talks regarding how to standardize the urine reflex testing procedure across our health system, including sample collection and transportation across laboratory sites. The urine specimen container was a key problem that needed to be addressed initially. In fact, some of our institutions were already using a urine collection kit that included a boric acid preservation tube for culture, while others were still using regular urine collection cups for collection. The standard collection kit was used in all of our laboratories since the urine analysis (UA) required to be done and the results obtained before evaluating whether or not the urine culture should be begun in any of our laboratories.

  • We came to the conclusion that having a fresh specimen label for urine culture immediately generated in the microbiology lab upon a positive UA result would be an excellent trigger.
  • The full UA and urine culture should normally be performed at the same time for pregnant women, newborns, and immunocompromised patients regardless of whether the UA was chemical or microscopic.
  • Additionally, if the standalone urine culture order is available to providers, an alert noting that it meets the required requirements may be included.
  • Overall, it is critical to maintain the involvement of key clinical stakeholders, including: Our planning process included constant consultation with leaders in infectious diseases, infection prevention, hospital quality, and patient safety to ensure that we were meeting our objectives.
  • In conclusion, while our laboratories can appreciate the decrease in labor costs, improvements in patient outcomes or reductions in CAUTI incidence have yet to be determined.

Acknowledgements

The authors would like to express their gratitude to the laboratory directors and personnel of the Los Angeles County Department of Health Services for the numerous and useful talks that they had with reflex urinalysis techniques throughout the years. We would like to express our gratitude to Tam Van, PhD, for supplying data and conducting data analysis. We would also want to express our gratitude to Melanie Yarbrough, PhD, for her critical evaluation of this paper. Doctor Yi Xiao is a clinical chemistry fellow at Children’s Hospital Los Angeles, where she has worked for the past year.

Chambliss (dot) com.

Allison B. Chambliss, PhD, DABCC, FAACC is an assistant professor of clinical pathology at the University of Southern California (USC) Keck School of Medicine. She also serves as director of clinical chemistry and point-of-care testing at the Los Angeles County+USC Medical Center. +EMAIL:

Reflex urine culture testing in an ambulatory urology clinic: Implications for antibiotic stewardship in urology

To analyze the performance features of urinalysis and urine microscopy factors for predicting urine culture findings, as well as to develop a reflex urine culture program, the following objectives were established: Patients who were catheter-dependent or who had urine diversions were excluded from the study. We evaluated the files of all patients who presented to our clinic between January and March 2013 and June and August 2014. Our study looked at the relationship between urinalysis and urine microscopy parameters and urine culture outcomes.

  • A logistic regression analysis was performed in order to identify predictors of positive urine cultures in order to inform the development of a reflex urine culture program.
  • Using urinalysis variables as predictors of positive urine culture, a logistic regression analysis revealed that positive nitrites (odds ratio 18.6, P0.001) and large leukocyte esterase (odds ratio 41.8, P0.001) were the most significant predictors of positive urine culture.
  • The odds ratio for 50 white blood cells per high-powered field was 13.6, and the odds ratio for moderate/many bacteria was 16.8, indicating that moderate/many bacteria was the strongest predictor of positive urine culture.
  • Conclusions: A urine positive for nitrites and/or containing less than 50 white blood cells per high powered field with bacteria appears to have a strong correlation with a positive urine culture and the strongest negative predictive value of all the variables studied.
  • Keywords:quality control; quality improvement; urinary tract infection; urine; urine test; urinary tract infection The Japanese Urological Association (JUA) is a non-profit organization that promotes the study of urology in Japan.
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Urinalysis with Culture Reflex

Type of Specimen (Needs BOTH tubes)

Test ID LAB5187
EPIC Order URINALYSIS with Culture Reflex
CPT Code(s) 81001, 87086 (UA, urine culture)
Group/Individual Test Group
Laboratory Core Laboratory/Clinical Microbiology
Tube Station Gray Top Tube (Culture) to 82 Pale Yellow (Urinalysis) to 30 (routine), 888 (STAT)
Specimen Routine: Minimum volume:
NOTE:if Minimum volume cannot be obtained for each tube, send specimen in original collection cup.
Stability Room temperature: Gray Top – YesRefrigerator: DO NOT Refrigerate Gray Top Pale Yellow Tubes stable 8 hours refrigerated, 2 hours room temperature Refrigerate original collection cup stable8 hours.Frozen:NO
Transport Deliver urine to lab within 1 hour of collection
Availability Routine: 24 hrs/day
STAT: YES
Turnaround Time STAT 1 hr., Routine 2.5 hrs.
Reference Range Normal: See Urinalysis (UA) webpage for urinalysis reference ranges.
Comments Criteria for Reflex:Leukocyte esterase: Trace, 1+, 2+Nitrite: PositiveWBC:(greater than) or =(equal to) 5 wbc/hpfBacteria: Rare, Occasional, Few, Moderate, ManyPatients must meet certain criteria in order to have the urinalysis with culture reflex. Excluded patients include:Patients who are5 years old Pregnant womenPatients currently on antibioticsPatients who are neutropenicIt will be the physician’s responsibility to determine if these exclusion criteria apply.The physician will still have the option to order a UA or urine culture separately.

On November 15, 2021, Christopher Parker gave his opinion. Please keep in mind that the reference ranges supplied on this website are for informational purposes only and may not reflect the most recent revisions.

For the most up-to-date reference data, see laboratory reports. The McLendon Clinical Laboratories at UNC Hospitals are located at 101 Manning Drive in Chapel Hill, North Carolina.

Urinalysis, Complete, with Reflex to Culture

Collection Instructions: U03 – UA Tube with a Yellow Cap (Supply) U01 – C S Gray Tube with Straw (Supply:U01 – C S Gray Tube with Straw) Specimen(s) of preference: Two distinct clean capture specimens should be submitted:

  • Guide to the Collection: Product code U03 is an uncoated aluminum tube with a yellow end cap. U01 – C S Gray Tube with Straw is available for purchase. Specimen(s) of preference include the following. Two clean catch specimens should be submitted:

The following pediatric specimen(s) are preferred: refrigerated unpreserved sample Procedure: Clean catch mid-stream samples are taken in order to reduce contamination and enhance accuracy. If a sample is submitted unpreserved, please note that it is from a pediatric patient in the body of the submission (patient is less than or equal to 12 years of age). Label the sample in the proper manner. Only urine from pediatric patients will be received, and it must be unpreserved.

  • Instructions for a female clean catch
  • Instructions for a male clean catch

Instructions for submitting specimens:

  1. Remove the sterile urine cup from the refrigerator
  2. Fill the dropper halfway with urine collected in the sterile cup
  3. Fill the tube up to the fill line (4ML) specified on the tube label using the dropper
  4. And Put the gray cap on the tube. Prior to packing for transportation, double-check the patient’s two IDs on the tube.

Containers for transport include a yellow-top urinalysis transport tube with a blue fill line and a gray-top urine culture tube. Temperature during transportation:

  • Keep preserved at room temperature
  • Keep unpreserved pediatrics refrigerated (in cold packs).

Stability of the specimen:

  • Room temperature: preserved specimen for 72 hours
  • Refrigerator temperature: unpreserved pediatric specimen for 24 hours

Criteria for rejection are as follows:

  • Adult specimens that have not been preserved
  • Conical transport tube with a swirled top in yellow and red and a preservative

Please contact DLO’s Customer Service at (800) 891-2917, option 2 if you require any more information on supply or collection devices. The CPT codes supplied are based on American Medical Association criteria and are provided solely for informative purposes. The billing party is solely responsible for the coding of CPT codes. If you have any queries about coding, please send them to the payor who is being invoiced.

UA with Reflex to Culture

This test is frequently requested when a person is experiencing symptoms that might indicate a urinary tract infection (UTI) (urinary tract infection). These symptoms may include: frequent urination, lower back pain, murky or strongly smelling urine, pain or burning feeling when peeing, and so on and so forth. The following are the components of this test: Visual Examination-A visual examination, also known as a macroscopic examination, will be performed to determine the amount, clarity, color, and cloudiness of the sample.

A variety of illnesses can be indicated by abnormal findings.

In some cases, the presence of tea-colored urine indicates the presence of liver disease.

Chemical Test- A chemical test may be used to assess many different components of your urine, including the following:

  • Specific gravity is a measurement of the concentration of urine that may be used to determine whether or not your kidneys are properly concentrating your urine. It also takes into account the concentration of each and every chemical particle identified in your urine throughout the analysis. As a result, the gravity of the urine would be measured in relation to the gravity of the water. In the normal range, the values are between 1.000 and 1.030. If you consume excessive amounts of alcohol before to the test, typical gravity levels will be about 1.000. If you don’t drink anything before the test, you’ll get a usual result of 1.130
  • Acidity: This test measures the pH values in the urine in order to determine if the urine is acidic or alkaline. Increased risks for kidney stones are typically associated with acidity levels that are either high or too low (upper high or lower low). Proteinuria is a term used to describe the presence of proteins in the urine, primarily albumin levels, which are measured. Normal urine samples have modest quantities of urine proteins, however excessive levels that persist over time might suggest renal disease. Testing for glucose levels in the urine (also known as glycosuria): This test examines for high amounts of sugar in the urine. Our bodies require and utilize sugar as a source of energy, which is accomplished through the conversion of carbs into glucose. When your blood glucose levels are elevated, it is usually a sign that there is a problem with your digestive system (like diabetes). In the absence of medical intervention, this might develop into a dangerous condition (such as renal failure or nerve damage). Test for ketones: This test detects the amount of ketones in the blood, which are the results of fat breakdown and are also referred to as ketonuria. When glucose levels are low, your body will turn to alternative sources of energy for energy. Ketone levels beyond a certain threshold can suggest ketoacidosis, which is a complication of diabetes that can be fatal. Keeping track of your ketone levels might help you avoid a medical emergency in the future. In the presence of blood in the urine, which is caused by broken red blood cells that have not been reabsorbed by the kidneys, hemoglobin can be detected by the presence of hemoglobin. The presence of hemoglobin in the urine will cause it to be dark in hue. Hemoglobin is not seen in the urine of healthy persons. The presence of white blood cells in urine is determined by the enzyme leukocyte esterase. The enzyme leukocyte esterase is produced by leukocytes and is used in the production of leukocytes. The existence of an infection is indicated by a positive test result. A test for the presence of nitrites in the urine, which might indicate the presence of bacteria, is performed using this method. It is possible for nitrates that are ordinarily detected in the urine to be transformed into nitrites when bacteria are present in the urinary system. The results of a positive nitrite test will need to be analyzed further in the lab in order to determine the precise type of bacteria and its responsiveness to the various therapies. Bilirubin: This test identifies elevated amounts of bilirubin, which may indicate liver or gallbladder problems, as well as the destruction of red blood cells. This test can indicate the existence of a possible liver illness since it measures the amount of bilirubin present in bile, which is the consequence of the breakdown of red blood cells
  • Urobilirubin: this test can indicate the presence of a possible liver disease. Urobilirubin is produced as a result of the decrease in bilirubin. Individuals that are in good health have a little level of Urobilirubin in their urine. Positive findings might suggest the presence of liver disorders such as hepatitis, cirrhosis, liver damage, or hemolytic anemia, among others. They can also occur as a result of the use of certain drugs, such as etodolac.

Based on the results of the culture section of this test, it may be necessary to do a sensitivity test. Dr. Kurt Kloss, M.D., has reviewed this document. Date of last review: January 13, 2022

Navigating reflex urine culture practices in community hospitals: Need for a validated approach

Based on the findings of the culture section of this test, a sensitivity test may be done. Dr. Kurt Kloss, M.D., has reviewed this article. Submitted on January 13, 2022; last reviewed on January 14, 2022.

Key Words

Asymptomatic bacteriuria requires a high level of culturing stewardship.

Stewardship of a laboratory Diagnostic stewardship is important. See the full text of this article The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) was founded in 2020. Elsevier Inc. is the publisher. All intellectual property rights are retained.

Evaluation of evidence-based urinalysis reflex to culture criteria: Impact on reducing antimicrobial usage

Open access is granted under a Creative Commons license.

Highlights

Antimicrobial resistance is increasing at a rapid pace, and it is becoming a serious public health concern. The overuse of antibiotics is the most important factor leading to the development of antimicrobial resistance. Many laboratory practices still use old and poor urinalysis protocols, which leads in substandard test results in the majority of cases. The implementation of evidence-based urinalysis reflex criteria has helped our laboratory to enhance practice while also improving test findings.

Abstract

A serious public health concern, antimicrobial resistance is increasing at an alarming rate. Malpractice with antibiotics is the most important factor contributing to the emergence of antibacterial resistance. Many laboratory practices still use old and poor urinalysis protocols, which results in inferior test findings in the majority of circumstances. In order to enhance practice and laboratory findings, our laboratory has introduced evidence-based urinalysis reflex criteria.

Methods

The study had 4130 urine samples that were exposed to UA between March and May 2020. It was a prospective intervention study. A study was conducted to test the usefulness of newly implemented evidence-based criteria in predicting positive urine cultures, and the results were evaluated. The intervention consisted of the implementation of evidence-based UA reflex criteria in order to guarantee that the UA reflex parameters had a high predictive value. It was decided to use multivariable logistic regression to analyze the usefulness of these UA characteristics in predicting positive urine cultures, as well as to examine the influence of the revised UA criteria on antibiotic usage.

Results

A total of 4130 patient samples were included in the study; 60.1 percent (n= 2484) of the samples were from female patients and 39.9 percent (n= 1646) came from male patients, according to the findings. Three thousand eleven hundred and sixty-six negative urine reflex samples were collected, accounting for 75.4 percent of the total number of UA reflex samples. The pee reflex samples produced positive UA values in 24.6 percent of the cases (n= 1014), and the samples were reflexed to the urine culture lab.

Based on the results of the chi-square analysis, it was found that there were highly statistically significant associations between the combination parameters of (5 white blood cells (WBCs) and positive nitrite) and positive urine cultures (Chi-square = 516.428,p0.001), as well as between the combination parameters of (5 WBCs and moderate or large esterase) and positive urine cultures (Chi-square = 503.387,p0.001).

Moreover, the results of the Chi-square test revealed a very statistically significant relationship between the combination parameters of (5 WBCs and 1 bacterium) and positive urine cultures (Chi-square = 434.806, p0.001).

Conclusions

After everything was said and done, the combination of 5 WBCs and positive nitrite had the greatest positive predictive value of 98.00 percent and was found to be associated with positive urine cultures in a highly significant way. In this study, it was discovered that the revised UA reflex criteria are extremely successful at predicting positive urine cultures, perhaps leading to a reduction in the use of unneeded antibiotics.

Keywords

Infections of the urinary tract Antibiotics are used in the urine analysis. Criteria for urinalysis reflexes Antimicrobial resistance in 2020, according to the authors International Society for Infectious Diseases (ISID) is represented by Elsevier Ltd in this publication.

Implementation of Urinalysis with Reflex Urine Culture to Reduce Unnecessary Urine Cultures

Skip nav destinationArticle navigation Skip nav destination Part I: Hospital Medicine|August 1, 2019 Wendi-Jo Wendt, MD, of the University of Michigan in Canton, MI, is a physician. Alternatively, you may look for further publications by this author on the following websites:Shannon Taut, M.D.;(3) Children’s Hospital of Wisconsin, Milwaukee, WI Search for other publications by this author on:Pediatrics(2019) 144 (2 MeetingAbstract): 486 or on PubMed. Purpose: A UTI is diagnosed based on quantitative urine culture findings in addition to evidence of pyuria and/or bacteriuria, as stated in the American Academy of Pediatrics Pediatric Urinary Tract Infection (UTI) Clinical Practice Guidelines Action Statement.

The goal of this study was to alter ordering methods in order to reduce the amount of needless urine cultures that were being conducted on patients.

In partnership with a university-wide committee, an order set for the electronic health record was developed that recommends ordering a urinalysis (UA) with a reflex culture in place of both a urinalysis and a urine culture in the majority of cases.

In order to provide education to pediatric residents, a brief presentation outlining the project and order set was given to them.

Tests done on the same day and on the same patient were omitted if they were performed on two different patients.

Results: 125 UA with reflex cultures were ordered in the six months before to the implementation of the order set, whereas 282 UA with reflex cultures were ordered in the six months following the implementation of the order set.

A decline in the overall number of urine cultures occurred during the same time period, with the total number of urine cultures dropping from 851 to 818.

Conclusion: Increasing the overall quantity of urine cultures requested with reflex culture was sufficient to modify urine culture ordering practice, as demonstrated by simple order set adjustments and resident education.

The next step will be a thorough evaluation of the chart to check that the exclusion criteria were applied correctly and that no harm was done as a result of the delayed diagnosis of UTI.

In February 2017, the order set was put into effect. Figure 1 shows a diagram of a UA with reflex cultures ordered in each month is depicted in Figure 1. In February 2017, the order set was put into effect. The American Academy of Pediatrics has copyright protection for the year 2019.

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