Changes to Order Urinalysis with Reflex to Urine Culture

Starting on October 4, 2016, Providence Regional Laboratory Services will slightly change the criteria that are used to reflex urines to a urine culture “if indicated”. This only concerns the order “URINALYSIS WITH MICROSCOPIC WITH CULTURE IF INDICATED“ (LAB2480). In the future, urine will only be reflexed to a urine culture if

Ø Both WBC are ≥ 10/high power field AND Ø Bacteria are ≥ 1+. Goal is to increase the specificity of the culture reflex criteria and subsequently decrease the number of patients with asymptomatic bacteriuria who are unnecessarily treated with antibiotics. Furthermore, the presence of yeast was removed as reflex criterium because clinical studies have shown that yeast is almost always the result of contamination of urine with commensals. Please use the order CULTURE, YEAST, SMEAR (LAB241) if a fungal UTI is suspected.

These changes and “best practice guidelines” that will appear when you order certain urine tests in Epic are evidence based (Clin Inf Dis;2011;52:e103-e120) and are now standardized across Providence Health & Services. See reverse side for a detailed description of all changes.

The following table contrasts the reflex criteria now and in the future:

Current Reflex Criteria Future Reflex Criteria WBC ≥ 10/high power field ≥ 10/high power field OR AND Bacteria ≥ 2+ ≥ 1+ Yeast Present – Squamous epithelial cells – –

For questions, please contact: Customer Service (503) 215-6660, Dr. Luzzi (503) 893-7649 or Dr. Margret Oethinger (503) 893-7718 Notification: Changes to Urine Culture Criteria Effective: October ECO Release- October 4th, 2016

Situation: Misidentifying asymptomatic bacteriuria results in inappropriate antimicrobial therapy and related side-effects.

Background/ Rationale: • There is substantial variation across PH&S in the criteria that labs use to reflexly culture urine. This variation results in increased recovery of organisms that are by and large treated by clinicians, often inappropriately. In addition, patients may be incorrectly diagnosed/treated with UTI/CAUTI, which results in complications such as C. difficile, as well as adversely affecting enterprise quality measures. • Standardization of reflex criteria (for urinalysis with reflex to culture) has been shown to reduce identification of asymptomatic bacteriuria. o Absence of white cells in urine is the strongest criterion against urinary tract infection and has the highest negative predictive value. • Requiring clinical criteria at the time of clinician ordering should improve the appropriate utilization of urinary tests.

Upcoming Changes: 1. When a urine culture or a urinalysis with reflex to culture is ordered, the following table will appear, reflecting Infectious Diseases Society of America (IDSA) guidelines (Clin Inf Dis;2011;52:e103-e120) for use of diagnostic tests for UTIs: infections: Patient Presents With… Action No symptoms of cystitis (including during routine pre-op screening) Do nothing (see exceptions* below) Cystitis, Uncomplicated (with typical UTI symptoms: dysuria, frequency, urgency, Treat empirically (avoid fluoroquinolones if lower abdominal pain, not including sexually transmitted infections) possible) Cystitis, Complicated (cystitis in patients with high risk factors such as diabetes, Urine culture pregnancy, symptoms for seven or more days before seeking care, hospital acquired infection, renal failure, urinary tract obstruction, presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion, functional or anatomic abnormality of the urinary tract, renal transplantation, immunosuppression) Pyelonephritis, Typical (fever, flank pain, N/V ± bladder symptoms) Urine culture UTI, Atypical symptoms/signs (fever, malaise, mental status changes, abdominal Urinalysis ± reflex to urine culture pain, spasticity/autonomic dysreflexia, malodorous/cloudy urine) *Exceptions: Asymptomatic pregnant women, pre-urologic surgical patients Urine culture

2. Indications will be required when ordering urinalysis with reflex to culture and urine culture alone, as follows: Indications for “urinalysis with reflex to culture” Indications for “urine culture” include: include: • Atypical symptoms of cystitis (see chart above) • Complicated cystitis (see chart above) • Unable to re-collect urine • Pyelonephritis • None of the above • High risk patient (asymptomatic pregnant women, pre- urologic surgical patients) NOTE: Do not order urinalysis with reflex to culture in • Age (pediatrics) restriction patients < 2 yrs of age; order both UA and urine culture • None of the above

3. For patients with catheters in place >14 days, an alert will fire at the time of order advising the clinician that it is preferred to have the catheter replaced before urine is collected for a urine culture. Consider changing a catheter that has been in place >3 days prior to culture. 4. Reflex criteria (for urinalysis with reflex to culture) will be updated to reflect current evidence, to include: 5. Reflex criteria (for urinalysis with reflex to culture) will be updated to reflect current evidence, including: UA with Microscopic UA without Microscopic

Criteria to be • Pyuria (≥ 10 white cells/ high power field) • Leukocyte esterase (positive, 1+ or greater, utilized small or greater) AND OR • Bacteria (positive or 1+ or greater) • Nitrite positive Criteria will NOT • Yeast be utilized • Squamous epithelial cells