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Urinalysis and Urinary Tract Infection: Update for Clinicians

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Urinalysis and Urinary Tract Infection: Update for Clinicians Infect Dis Obstet Gynecol 2001;9:249–255 Urinalysis and urinary tract infection: update for clinicians Jennifer L. Young and David E. Soper Medical University of South Carolina, Charleston, SC Dysuriais a common presentingcomplaint of women andurinalysis is a valuable tool inthe initial evaluationof this presentation.Clinicians need to beaware that pyuriais the bestdeterminate of bacteriuriarequiring therapy and that valuessignificant for infection differ dependingon the method of analysis.A hemocytometer yieldsa valueof ³ 10 WBC/mm3 significantfor bacteriuria, while manual microscopystudies show ³ 8 WBC/high-power field reliably predictsa positiveurine culture. In cases of uncomplicatedsymptomatic urinarytract infection, a positive valuefor nitrites and leukocyte esterase by urine dipstick can be treatedwithout the needfor a urineculture. Auto- mated urinalysisused widely inlarge volume laboratoriesprovides more sensitivedetection of leukocytesand bacteria inthe urine.With automated microscopy,a valueof > 2WBC/hpf issignificant pyuria indicative of inflam- mation ofthe urinarytract. In complicated casessuch as pregnancy, recurrent infection or renal involvement, further evaluation is necessary including manual microscopy and urine culture with sensitivities. Key words: D YSURIA; PYURIA; BACTERIURIA; URINE CULTURE; AUTOMATED URINALYSIS Asmany as oneinfour women experience anepi- bringthe clinician upto date on automated sodeof dysuriaeach year, makingthis oneof the urinalysis procedures. most commonpresenting complaints of women seen byclinicians 1.Dysuria suggests thediagnosis BACTERIURIA IN DIAGNOSIS ofcystitis butmay bepresentin other conditions suchas vaginitis, chlamydial urethritis orpyelo- While aurineculture is thegold standard in the nephritis2.Urinalysis is valued as aquickand in- diagnosis ofaUTI, thelimitations ofthis test have expensive screening methodfor the presence ofa led many physiciansto use urinalysis asaninitial lowerurinary tract infection (UTI). Oftenthis test step inthe evaluation ofdysuria. Bacteriuria is is usedin conjunction with or inplace ofaurine classically definedas aurineculture with greater culturein the diagnosis ofa UTI. However, a than100 000 cfu/ mlofa single microorganism 4. recentstudy found many practicingclinicians use Thisvalue distinguishes patients withasymptom- differentstandards to determine thepresence or atic bacteriuria fromthose with a contaminated absence ofa UTI, most notupdated on current specimen. However, Stamm andcolleagues 5 literature3.Tofurthercomplicate matters, thelevel foundthat this culturecount was insufficientto ofautomation in urinalysis is increasing and includealmost halfof patients withsymptoms of acceptedcut-off values differfor these more sensi- dysuriaand frequency. In a studyof 181women tive methods.This article will review thecompo- withsymptoms ofdysuriaand frequency, 102 had nentsof a standardurinalysis, examine the ³ 105 cfu/ml but79 had < 10 5 cfu/ml andwould usefulness ofeach in the diagnosis ofUTI, and nothave yielded apositive cultureby thestandard Correspondenceto: David E.Soper,MD, Medical Universityof SouthCarolina, Gynecology& Obstetrics,96 JonathanLucas St. Suite 634, P.O. Box 250619, Charleston, SC 29425, USA. Email: [email protected] Review article 249 Urinalysis and UTI Young and Soper criterion. Furtherstudy demonstrated that women However, some hospitals andmany clinicians in withdysuria, pyuriaand a colonycount of practiceonly perform microscopy if there are any ³ 103 cfu/ml have alowerUTI 1,5.Theadditional abnormalities foundwith dipstick analysis. Aurine problemof urinesample contaminationclouds the dipsticktests forspecific gravity andpH, as well as already muddypicture surrounding urine culture. thepresence ofurobilinogen, ketones, glucose, Several studies found29– 32% of urine cultures hemoglobin,leukocyte esterase andnitrite. The were contaminatedand concluded that the determinationof apositive result is basedon com- methodologyused in collection does not alter this parisonof color development with the standard value6,7.Because ofthese difficulties withurine strip providedby themanufacturer. The urinedip- culture,in addition to the fact that it is slowand stickis valued as aquickand inexpensive test that expensive, physicianshave turnedto urinalysis to requires little expertise toperformcorrectly. The give aquickanalysis ofelements inthe urine. Of results canprove useful in determining whether to these components,leukocytes in the urinedemon- treat empirically orto order a urineculture for strate inflammation andtissue invasion ofthe definitive determinationof bacteriuria. Themost urinarytract, distinguishinginfection from coloni- usefulanalytes forUTI diagnosis are leukocyte zationor contamination 8.Pyuriais valued asthe esterase and nitrite. single best indicatorof bacteriuria thatwill resolve Leukocyteesterase is anenzyme foundin withantimicrobial therapy.If pyuriais absent, anti- neutrophilgranules thatreacts withagents onthe biotic therapy is not indicated 9. dipstickto produce a bluecolor in 1– 2 min. Specificpositive values vary fromtrace tomany, correlatingwith a minimum numberof PYURIA IN DIAGNOSIS WBC/hpf.For the Chemstrip (Boehringer Pyuriais thereforethe most usefulanalyte fordiag- Mannheim,IN) L/Nthis minimum thresholdis nosis ofinfection and the clinician has achoice > 5 WBC/hpf 13,butthis value may vary depend- betweenmultiple laboratorytests. Thegold stan- ingon thetest strip. While trace orsmall leukocyte dardfor the definition of pyuria is theleukocyte esterase activity may beconsidereda positive result excretionrate. Aleukocyteexcretion rate of forthis analyte, this result is notvery specific fora >400000 cells/ hcorrelates well withsymptoms UTIas many otherconditions can cause pyuria. ofdysuriaand frequency as well as thepresence of White bloodcells canbe foundin the urine in a bacteriuria 10.Research demonstratedthat all variety ofconditionsranging from chlamydial ure- abacteriuricpatients hadan excretion rate of thritis topyelonephritis. For this reason, theposi- <400000 cells/ hand144 of 152 bacteriuric tive predictive value ofleukocyte esterase has been patients hada rate of ³ 400000 cells/ h,yielding shownto vary between19 and 88% 14,15. The asensitivity of95% and specificity of100% 11. absence ofleukocyteesterase activity has anegative Collectionof a 24-hurine is notfeasible forthe predictive value of97– 99% indicating that the clinicsetting. Forthis reason, thechamber count urineculture will be<10 3 cfu/ml14.Thisdiscrep- methodis usedin the literature foraccurate deter- ancyis basedon the fact that if theurinary tract minationof pyuriain place of theleukocyteexcre- is infected,the significant inflammation ofthe tionrate. Avalue of> 10cell/ mm 3 of unspun mucosashould produce pyuria. In the absence of urineis always associated witha leukocyteexcre- pyuria, the diagnosis of a UTI is unlikely. tionrate >400000 cells/ h 12.Formost physicians, Nitrite is producedfrom dietary nitrate by these values are onlyimportant in determining the bacteria containingnitrate reductase. Theamine in accuracy of urinalysis in the detection of pyuria. thedipstick reacts withthe nitrite andproduces a bluecolor in 60 s. Thepresence ofnitrites is highly specific forbacteriuria (96.6–97.5%), buthas alow URINALYSIS PART 1: URINE DIPSTICK sensitivity of0– 44% for bacteriuria between10 3 Aurinalysis withmanual dipstickand manual and 105 cfu/ml13,14.False negatives may bethe microscopyis commonlyordered on all patients result ofa lackof dietary nitrate, dilutionof withthe presenting symptom of dysuria. thenitrite inthe urine (such as withdiuretics), or 250 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY Urinalysis and UTI Young and Soper non-nitrate-reducingbacteria including Staphylo- suggesting centrifuging10– 20 ml urineat varying coccus, Enterococcus , or Pseudomonas 16.VanNostrand speeds forapproximately5 min, thenresuspending andcolleagues 17 foundthat 78.9% of samples thesediment ina dropup to 0.2 ml super- containingnitrate-reducing bacteria were actually natant16,24,25.Thetechnician places thesediment negative fornitrite onthe urine dipstick. There- onthe slide andviews between5 and15 fields forethe presence ofnitrite has ahighpositive pre- beforereporting an average value ofWBC/ hpf. dictive value of94% 18,butin the absence of Visualization oftheformed elements inthe urineis urinary nitrite a UTI cannot be ruled out. thegreatest benefitof microscopy. Microscopic Takingthe leukocyte esterase andnitrite evaluation ofleukocyteshas apositive predictive togetherproves muchmore useful. Ifboth tests are value of100%for the presence ofpyuria(defined as positive, thespecificity increases to98– 99.5%, > 8 WBC/mm3)butdoes not correlate as clearly indicatinga highlikelihood of aUTI 14,19. Several withthe presence ofbacteriuria. However, as the studies concludethat from this informationalone a numberof cells/hpfincreases, thepositive predic- diagnosis ofa UTIcan be made andtreatment tive value forbacteriuria increases 26.Microscopy initiated2,18,20,21.Thisclinical conclusionhas canalso beused to visualize bacteria inthe recentlybeen called intoquestion by a study urine. Using acountingchamber, Hiraoka and demonstratinga lowsensitivity forboth leukocyte colleagues27 foundthat the presence ofboth esterase andnitrite butdid not take into account bacteriuria andpyuria had a positive predictive theclinical presentationof the patients inthe value of100% compared with the urine culture study17.Ina lowprevalence population,such as in while
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