What Is A Reflexive 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

It is the authors’ pleasure to express their appreciation to the laboratory directors and employees of the Los Angeles County Department of Health Services for the several useful talks that they had regarding reflex urinalysis techniques. A special thanks goes out for the data and data analysis provided by Tam Van, Ph.D. Melanie Yarbrough, PhD, was also thanked for her critical assessment of this essay, which was greatly appreciated by us. Doctor Yi Xiao is a clinical chemistry fellow at Children’s Hospital Los Angeles (CHLA).

Chambliss, PhD, DABCC, FAACC, is an assistant professor of clinical pathology at the Keck School of Medicine at the University of Southern California (USC).

+EMAIL:

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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.

Typology of Specimen (Needs BOTH tubes)

Urinalysis, Complete, with Reflex to Culture

Specimen Characteristics (Needs BOTH tubes)

  • 1 teaspoon of urine in a urine culture tube (gray top)
  • 10 teaspoons of urine in a urine transport tube (yellow top, blue fill line, preservative tube)
  • 4 teaspoons of urine in a urinalysis transport tube

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.

Orange pee can suggest a breakdown of pigments, whereas blood in urine might signal a urinary tract infection (UTI) or kidney stones. Chemical Test- A chemical test may be used to assess many different components of your urine, including the following:

  • An individual who is having symptoms that might indicate a urinary tract infection (UTI) is more likely to have this test performed (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 on. This test has the following components: In a visual test, also known as a macroscopic test, the amount, clarity, color, and cloudiness of the sample will be evaluated. It is necessary that your usual urine be clear and not cloudy. A wide range of disorders can be indicated by abnormal findings, which might include: Urine that is murky or black in color can suggest infection, but urine that is clear or light in color can indicate dehydration In some cases, the presence of tea-colored urine indicates the presence of a liver problem. It is possible to have blood in pee owing to a UTI or stones, whereas having orange urine indicates a breakdown of pigments. In a chemical test, various components of your urine may be identified and analyzed. These components include:

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

When utilized effectively, reflex urine cultures (RUC) can be a useful diagnostic stewardship intervention in the management of infectious diseases. Even while RUC can reduce the detection of bacteriuria, it may not be effective in improving the diagnosis of urinary tract infections unless it is administered to symptomatic individuals. The implementation of RUC at community hospitals brings with it a distinct set of potential as well as problems. RUC techniques should be studied further in the future to determine the optimal urinalysis parameters and the specific patient categories who can safely benefit from them.

We discovered that 28 hospitals utilized a total of 26 different reflexing criteria.

Our findings show that further validation of urinalysis criteria, as well as identification of certain groups in which RUC operates best, are needed for the existing RUC strategy in community hospitals, according to our findings.

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

Implement evidence-based urinalysis (UA) reflex criteria and assess the impact of the intervention on minimizing needless antibiotic use are the objectives of this study.

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.

Interpretation of Urinalysis and Urine Culture for UTI Treatment

United States Pharmacopeia, vol. 38, no. 11, pp. 65-68. ABSTRACT: Outpatient and inpatient populations alike are affected by urinary tract infection (UTI), which is one of the most often diagnosed illnesses. It is critical for practitioners to understand the benefits and limitations of urinalysis and urine culture in order to make an appropriate diagnosis in their patient population. It is possible to diagnose either asymptomaticbacteriuria or asymptomatic urinary tract infection (UTI) using these tests in combination with an evaluation of urine symptoms.

Urinalysis is a powerful diagnostic technique for a wide range of common illness conditions, including diabetes.

Aside from that, it can give valuable information about the screening and diagnosis of various disorders, such as cancer, proteinuria, glycosuria, ketonuria, and renal calculi.

It is the primary emphasis of this article to discuss the interpretation of urinalysis results and the subsequent urine culture results in the diagnosis and management of UTIs.

Overview

A urinary tract infection (UTI) is the second most frequent form of infection in the United States, accounting for around 10 million visits to health-care professionals in the country each year. 2A large number of these visits take place in the emergency room, when urinalysis can offer quick diagnostic findings for many conditions. However, because urinalysis is so often done in the emergency department, there is worry that misunderstanding might result in overtreatment of urinary tract infections (UTIs) and increased antibiotic use.

One study found that, although 43 percent of women over the age of 70 with a diagnosis of urinary tract infection (UTI) in the emergency department had no microbiological evidence of a UTI, nearly all (95 percent) of culture-negative patients got antibiotic treatment.

Clinical Presentation

In order to schedule a urinalysis and urine culture, it is critical to recognize the symptoms of urinary tract infection (UTI). To diagnose UTI, symptoms of the urinary tract should be considered in conjunction with test findings. However, while many of the symptoms remain intuitive, there have been some recent revisions to the definitions of the nonspecific symptoms that many health care practitioners have come to identify with urinary tract infection (UTI). Upper Urinary Tract Infection (UTI) Symptoms: The most common symptoms linked with lower UTI are dysuria or acute discomfort, frequent or urgent urinating, urgency, and incontinence.

  1. 4,5Pyelonephritis/Upper Urinary Tract Infection (UTI) Symptoms: When compared to cystitis, pyelonephritis frequently manifests as a more severe, systemic condition.
  2. 4.
  3. These nonspecific symptoms were included in prior consensus-based criteria for diagnosing urinary tract infection (UTI) in residents of skilled care institutions, which may have contributed to our finding.
  4. Patients with noncatheterized urinary tract infections (UTIs) who have acute mental status change are not included in the most current definitions of UTI in long-term care institutions.

5 Following this criteria, nonspecific symptoms such as fatigue, nausea, and vomiting should be ignored until the patient is catheterized or has unexplained leukocytosis.

Urinalysis Interpretation

In order to schedule a urinalysis and a urine culture, it is critical to recognize the symptoms of UTI that may be present. To diagnose UTI, symptoms of the urinary tract should be considered in combination with laboratory results. However, while many of the symptoms remain intuitive, there have been some recent revisions to the definitions of the nonspecific symptoms that many health care practitioners have come to identify with urinary tract infections. Upper Urinary Tract Infection (UTI) Symptoms: The most common symptoms linked with lower UTI include dysuria or acute discomfort, frequent urination and urgency, and incontinence.

  1. 4,5Pyelonephritis/Upper Urinary Tract Infection (UTI) Signs and symptoms include: The severity and systemic nature of the presentation of pyelonephritis differs from that of cystitis.
  2. 4,5Nonspecific Symptoms: Nonspecific symptoms, most notably changes in mental state, have become connected with a suspicion of UTI in the elderly.
  3. 3 If isolated nonspecific symptoms in the elderly can be linked to UTI, it is still debatable if this is the case.
  4. A change in mental state or sudden functional impairment in the absence of an alternative diagnosis can be used to rule out urinary tract infection in patients who do not have an indwelling catheter, but only if leukocytosis is present in addition.

Approach to the Asymptomatic Patient

In the case of a patient who has urinalysis or culture results that are compatible with UTI but does not have any urinary symptoms, a treatment dilemma arises. Age-related increases in the occurrence of this illness, which is known as symptomatic bacteriuria. 6,7 It has been observed that 50 percent of women in long-term care institutions have asymptomatic bacteriuria, and that the frequency among males over the age of 60 is significantly higher than in the general population. Sixth, routine screening of asymptomatic individuals is not suggested by the Infectious Diseases Society of America, according to their recommendations.

(6) Treatment may also be considered in women who have bacteriuria more than 48 hours after catheter removal have been removed.

Antibiotic therapy should be initiated empirically; however, depending on the organism discovered in the urineculture, it may necessitate adjustment of the first regimen.

Approach to the Symptomatic Patient

If you have been diagnosed with urinary tract infection (UTI) based on your symptoms and urine test results, the next step is to begin empirical antibiotic medication while you await culture and susceptibility findings. As previously noted, urinary tract infection (UTI) symptoms can be classified as lower (cystitis), upper (pyelonephritis), or nonspecific in nature. An additional type of urinary tract infection (UTI) that might influence treatment and therapy duration is simple vs complex. Uncomplicated urinary tract infection (UTI) is described as a UTI that does not have any structural or urologic abnormalities.

  1. The physical characteristic of a longer urethra in men, which defends against the ascending transmission of germs, makes uncomplicated infections unusual in this group.
  2. Despite the fact that there are many different criteria for complicated UTI, the most persistent patient characteristics include the presence of a foreign body, blockage, immunosuppression, renal failure or transplantation, urine retention, and pregnancy.
  3. When it comes to simple infections, Escherichia coli is the most prevalent pathogen, followed by other Enterobacteriaceae such as Proteus mirabilis, Klebsiella pneumoniae, and Staphylococcus saprophyticus, among others.
  4. It is possible that the same infections are present in individuals with complex UTI; however, gram-negative organisms are more resistant to antibiotics.
  5. Several other multidrug-resistant bacteria, including Serratia, Citrobacter, Enterobacter, Pseudomonas, and Acinetobacter species, are becoming increasingly prevalent in health-care–associated illnesses.
  6. In the event that a urinary catheter is in situ, the catheter should be removed and a culture taken from the midstream urine or a new catheter should be used to direct therapy.
  7. In order to avoid excessive antibiotic exposure, urine culture findings should be utilized to de-escalate or adjust therapy as needed.

The specified length of therapy should also be followed to avoid excessive antimicrobial exposure The suggested medicines and treatment durations for symptomatic UTI are shown in TABLE 3 below. 13,14

Conclusion

The clinical interpretation of urinalysis and urine culture data necessitates both a grasp of the relevance of test parameters and the inclusion of patient symptoms into the decision-making process. Antimicrobial stewardship and clinical actions are carried out in conjunction with positiveurinalysis and urine culture findings, with pharmacists playing an important role in many facilities. Although it may be tempting to just prescribe an antibiotic based on test findings, in order to avoid overtreating asymptomatic people, a thorough examination of their symptoms should be carried out.

REFERENCES

1. J.A. Simerville, W.C. Maxted, and J.J. Pahira A complete review of urine analysis. 2005;71(11):1153-1162. American Family Physician. 2. Schappert, S.M., and Burt, C.W. 2. Hospital outpatient departments and the emergency department were the most common destinations for ambulatory care visits in the United States in 2001–2002, according to the National Center for Disease Statistic. VITAL HEALTH STATISTICS (2006) 13 3. Gordon LB, Waxman MJ, Ragsdale L, Mermel LA, Waxman MJ, Waxman MJ, Waxman MJ, Waxman MJ, Waxman MJ When older women go to the emergency department with a suspected urinary tract infection, they are routinely overtreated.

The infectious illnesses of the human body (Smith, CL, ed.).

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Nicolle LE, Bradley S, Colgan R, Nicolle LE, Bradley S, Colgan R, Nicolle LE Clinical Infectious Diseases, Volume 40, Number 6, Pages 643-654, 2005.

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The Journal of Urology 179:1379-1390 (2008).

Letter from the pharmacist/letter from the prescriber 280706 is the month of July in 2012.

Hooton, T.M., Bradley, S.F., Cardenas, D.D., and colleagues The Infectious Diseases Society of America published International Clinical Practice Guidelines in 2009 for the diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults.

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Editors: DiPiro JT, Talbert RL, Yee GC, and colleagues A Pathophysiologic Approach to Pharmacotherapy is in its eighth edition, published by McGraw-Hill Medical in New York City. If you have any comments or questions about this post, please email [email protected]

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