Contents
- 1 Urinalysis, Complete, with Reflex to Culture
- 2 Urine Reflex Testing: Why and How?
- 3 Validating Urine Reflex Criteria
- 4 Workflow Challenges and Clinical Considerations
- 5 Acknowledgements
- 6 UA with Reflex to Culture
- 7 Urinalysis with Reflex to Culture
- 8 377036: Urinalysis, Complete With Microscopic Examination With Reflex to Urine Culture, Routine
- 9 Urinalysis with Culture Reflex
- 10 Evaluation of evidence-based urinalysis reflex to culture criteria: Impact on reducing antimicrobial usage
- 11 Similar articles
- 12 Urinalysis, Automated (with Reflex Microscopy and Culture)
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:
- 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:
- Remove the sterile urine cup from the refrigerator
- Fill the dropper halfway with urine collected in the sterile cup
- Fill the tube up to the fill line (4ML) specified on the tube label using the dropper
- 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.
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.
In the meanwhile, there are no evidence-based guidelines for how to develop UA reflex criteria or how to deploy reflex techniques at this time.
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.
Chambliss, PhD, DABCC, FAACC is an assistant professor of clinical pathology at the University of Southern California (USC) Keck School of Medicine.
+EMAIL:
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 12, 2022
Urinalysis with Reflex to Culture
| Test Description | Urinalysis with Reflex to Culture | |
|---|---|---|
| Test ID | UARC | |
| General Information | Detect abnormalities of urine; diagnose and manage renal diseases, urinary tract infection, urinary tract neoplasms, systemic diseases, and inflammatory or neoplastic diseases adjacent to the urinary tract | |
| Specimen Type | Urine | |
| Specimen Requirements | Urine Cup | |
| Additional Processing Details | If analysis is unable to be performed within one hour of collection, store refrigerated up to 24 hours. | |
| Stability | 1 hour room temperature.24 hours refrigerated.48 hours in BD Vacutainer UA Preservative Tube | |
| Unacceptable Specimen Conditions | Quantity not sufficient; improper labeling; specimen received in inappropriate preservative; specimen received in urine cup stored at room temperature greater than 1 hour old; specimen received in urine cup refrigerated more than 24 hours old; frozen specimens; specimens received in BD Vacutainer UA Preservative Tube more than 48 hours old | |
| Limitations | Metabolites of Pyridium® may interfere with the dipstick reactions by producing color interference. High vitamin C intake may cause an underestimate of glucose, blood, bilirubin, and a false-negative nitrite test. A low ph can also result in a false negative for protein and WBC’s. A false negative for WBC’s also can occur with elevated specific gravity, glucose, and/or protein levels. An increased specific gravity may cause a false negative for blood and/or nitrites. False positives can occure for protein when hemoglobin is present and/or an elevated ph level. | |
| Methodology | Automated | |
| Estimated TAT | 0-2 days | |
| Testing Schedule | Monday-Saturday,STAT | |
| CPT Code(s) | 81003 | |
| Additional Information | Includes: Specific Gravity pH Urine Color Appearance WBC Esterase Protein Glucose Ketones Blood Bilirubin Urobilinogen NitriteMicroscopic examination includes; WBC, RBC, epithelial cells, casts, crystals, mucus, bacteria, yeast, trichomonas, any other abnormality | |
| Minimum Sample Volume | 5 ml of urine | |
| Pediatric Min. Volume (if applicable) | 2 ml of urine | |
| Reference Range |
| Specific Gravity | 1.005 – 1.030 |
| pH | 5.0 – 7.5 |
| Urine Color | Yellow |
| Appearance | Clear |
| WBC Esterase | Negative |
| Protein | Negative |
| Glucose | Normal |
| Ketones | Negative |
| Blood | Negative |
| Bilirubin | Negative |
| Urobilinogen | Normal |
| Nitrite | Negative |
| Microscopic Exam: | |
| WBC | 0 – 5/hpf |
| RBC | 0 – 2/hpf |
| Squamous Epithelial | 0 – 10/hpf |
| Casts | None Seen |
| Mucus | None Seen |
| Crystals with Identification | None seen |
| Bacteria | None seen |
| Yeast | None seen |
| WBC and RBC clumps | None seen |
| Non-squamous Epithelial | None seen |
| Renal Epithelial | None seen |
| Transitional Epithelial | None seen |
| Trichomonas | Not Present |
| Reflex Conditions | Reflex to Culture with any of the following results: Urine dip results are WBC esterase is ≥ 1+ and/or Nitrite is ≥ 1+ Urine microscopic results are WBC5 per/hpf and/or Bacteria ≥ Moderate | |
|---|---|---|
| Performing Lab | Incyte Diagnostics | |
| LOINC Code(s) | 24356-8 |
377036: Urinalysis, Complete With Microscopic Examination With Reflex to Urine Culture, Routine
| 377036 | UA/M w/rflx Culture, Routine | 013060 | Specific Gravity | 2965-2 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013078 | pH | 5803-2 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013045 | Urine-Color | 5778-6 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013052 | Appearance | 5767-9 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013185 | WBC Esterase | 5799-2 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013094 | Protein | 20454-5 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013086 | Glucose | 2349-9 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013110 | Ketones | 2514-8 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013102 | Occult Blood | 5794-3 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013104 | Bilirubin | 5770-3 | ||
| 377036 | UA/M w/rflx Culture, Routine | 013105 | Urobilinogen,Semi-Qn | mg/dL | 20405-7 | |
| 377036 | UA/M w/rflx Culture, Routine | 013106 | Nitrite, Urine | 5802-4 | ||
| 377036 | UA/M w/rflx Culture, Routine | 012237 | Microscopic Examination | 12235-8 | ||
| 377036 | UA/M w/rflx Culture, Routine | 333336 | Microscopic Examination | 12235-8 | ||
| 377036 | UA/M w/rflx Culture, Routine | 377202 | Urinalysis Reflex | n/a |
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: |
| 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.
Evaluation of evidence-based urinalysis reflex to culture criteria: Impact on reducing antimicrobial usage
To adopt evidence-based urinalysis (UA) reflex criteria and evaluate the efficacy of the intervention on minimizing needless antibiotic use, the following objectives were established: The following methods were used: A prospective intervention research was done on 4130 urine samples that were exposed to UA between March and May 2020. 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.
There were 4130 patient samples included in the study, with 60.1 percent (n = 2484) coming from female patients and 39.9 percent (n = 1646) coming from male patients.
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.
It was found that there were highly statistically significant associations between the combination parameters of (5 white blood cells (WBCs) and positive nitrite), as well as between (5 white blood cells (WBCs) and moderate or large esterase), as well as between positive urine cultures (Chi-square = 516.428, p0.001) and positive urine cultures (Chi-square = 503.387, p0.001).
The statistical analysis revealed that the implementation of evidence-based UA reflex criteria resulted in a significant reduction in the number of urine cultures performed, as well as a potential reduction in the number of patients who were inappropriately treated with antibiotics, which decreased from 45.1 percent to 9 percent after implementation.
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.
Urinalysis, Urinalysis reflex criteria, and urinary tract infections are some of the terms used to describe antibiotic use and antimicrobial resistance. The Authors retain ownership of the copyright until 2020. Elsevier Ltd. is the publisher. All intellectual property rights are retained.
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Urinalysis, Automated (with Reflex Microscopy and Culture)
This test involves a chemical (dipstick) assessment and, if certain requirements are satisfied, it includes a microscopic inspection and a urine culture.
- Urinalysis with Micro:20508
- Urinalysis without Micro:20507
- Urinalysis with Micro:20508
the Epic order code for UFHPL is LAB12300016
CPT Code(s):
- Urinalysis with Micro: 81003
- Urinalysis without Micro: 81001
- Urinalysis with Micro: 81003
- Urinalysis without Micro: 81003
- Urina
Specimen Requirements:
In this case, a clean plastic sample cup with a securely attached lid will suffice; alternatively, a BDyellow-topurinalysis collecting tube and a BDgray-topculture tube, both filled to the proper fill level, would suffice. Sample 20 milliliters of liquid inimum 1 mL of liquid reparation:
- There are no preservatives, and the specimen should be refrigerated immediately after collection.
Temperature stability:Specimens will remain stable in storage for up to 24 hours at 2 – 8oC. Conditions that are unacceptable: Urine specimens that have been kept at room temperature for more than 2 hours will be rejected. Time for Specimen Retention: 5 days
Use:
A routine urinalysis is comprised of a number of physical, chemical, and microscopic screening tests that are capable of identifying a range of renal, urinary tract, and systemic disorders. A routine urinalysis is performed on a person who has not had a recent kidney transplant.
Methodology:
Reflectance photometry is used to assess color change in urine in a semi-automated urine chemical analyzer.
Reported:
Immediately (within 24 hours)
Performed:
It is necessary to respond within 24 hours
Interpretation Data:
All normal urinalysis orders are subjected to examination for color, appearance, specific gravity, pH, protein, glucose, ketones, occult blood, leukocyte esterase, nitrite, bilirubin, and urobilinogen, among other things. It is not necessary to do microscopic inspection if all of the tests for protein, leukocyte esterase, occult blood, and nitrites are negative; just the above-mentioned values are reported in this case. If any of the following tests come back positive: protein, blood, leukocyte esterase, or nitrite, a microscopic examination will be performed.