ORIGINAL CONTRIBUTION
Comparison of Test Characteristics of Urine
From the Department of Emergency
Medicine, Michigan State
University/Kalamazoo Center for
Medical Studies, Kalamazoo, MI.
Author contributions are provided
at the end of this article.
Received for publication
February 19, 2001. Revision received
July 9, 2001. Accepted for publication
August 15, 2001.
Presented at the American College of
Emergency Physicians Scientific
Assembly, Philadelphia, PA, October
2000.
Supported by grant No. 016-PIRAP/96
from the Blue Cross/Blue Shield of
Michigan Foundation.
Address for reprints: Richard L.
Lammers, MD, Department of
Emergency Medicine, Michigan State
University/Kalamazoo Center for
Medical Studies, 1000 Oakland Drive,
Kalamazoo, MI 49008;
616-337-6600, fax 616-337-6475;
E-mail Lammers@kcms.msu.edu.
Copyright © 2001 by the American
College of Emergency Physicians.
0196-0644/2001/$35.00 + 0
47/1/119427
doi:10.1067/mem.2001.119427
NOVEMBER 2001 38:5 ANNALS OF EMERGENCY MEDICINE
Dipstick and Urinalysis at Various Test Cutoff
Points
Richard L. Lammers, MD Study objective: We compare the test characteristics of urine
Scott Gibson, MD
dipstick and urinalysis at various test cutoff points in women
Dave Kovacs, MD
presenting to emergency departments and an intermediate care
Wade Sears, MD
center with symptoms of urinary tract infection.
Gary Strachan, MD
Methods: This was a prospective, observational study of adult
women presenting to 1 of 2 community hospital EDs or an inter-
mediate care center with dysuria, urgency, or urinary frequency
on history, or suprapubic or costovertebral angle tenderness on
examination. Patients who had taken antibiotics in the past 72
hours, had indwelling Foley catheters, symptomatic vaginal dis-
charge, diabetes mellitus, immunodeficiency disorders, or were
unable to provide a reliable history were excluded. The patient’s
clean-catch or catheterized urine specimen was tested immedi-
ately by a nurse using a Multistix 9 SG reagent strip. A second
aliquot was sent within 1 hour of collection to the hospital lab-
oratory, where a semiautomated microscopic urinalysis and a
urine culture were performed. A positive urine culture was de-
fined as more than 100,000 colonies of 1 or 2 uropathogenic
bacteria per mL of urine at 48 hours. Dipstick and urinalysis
data were compared with urine culture results. Sensitivity,
specificity, and predictive values were calculated at various
definitions of a positive test, or “test cutoff points,” for combi-
nations of leukocyte esterase, nitrite, and blood on dipstick and
for RBCs and WBCs on urinalyses. The probability of an erro-
neous decision to withhold treatment on the basis of a nega-
tive test result was defined as “undertreatment,” or 1 minus
the negative predictive value. “Overtreatment” was defined as
1 minus the positive predictive value.
Results: Three hundred forty-three patients were enrolled in
this study. Twelve patients were withdrawn because of missing
laboratory results. Forty-six percent (152/331) of patients had
positive urine cultures. If urine dipstick results are defined as
positive when leukocyte esterase or nitrite is positive or blood
is more than trace, the overtreatment rate is 47% (156/331) and
the undertreatment rate is 13% (43/331). If urinalysis results
5 0 5
URINE DIPSTICK VERSUS URINALYSIS
Lammers et al
are defined as positive when WBCs are more than 3 per high-
power field or RBCs are more than 5 per high-power field, the
overtreatment rate is 44% (146/331) and the undertreatment
rate is 11% (36/331). Matched pairs of test characteristics were
identified when the analysis was repeated using more than 10,000
colonies per mL as a positive culture.
Conclusion: In this patient population, similar overtreatment
and undertreatment rates were identified for various test cutoff
points for urine dipstick tests and urinalysis. Although a urine
dipstick may be equivalent to a urinalysis for the diagnosis of
urinary tract infection, the limitations in the diagnostic accuracy
of both tests should be incorporated into medical decisionmaking.
[Lammers RL, Gibson S, Kovacs D, Sears W, Strachan G.
Comparison of test characteristics of urine dipstick and
urinalysis at various test cutoff points. Ann Emerg Med.
November 2001;38:505-512.]
INTRODUCTION
Urinalysis is the most commonly used test for evaluation
of emergency department patients with potential urinary
tract infections. Unfortunately, in cases in which no other
diagnostic studies are needed, urinalysis can significantly
increase a patient’s time in the ED. Substituting a urine
dipstick test for a hospital laboratory urinalysis may be
less time-consuming and less expensive, but the dipstick
may not be as accurate.
Diagnostic accuracy of urine dipsticks is unclear be-
cause methodologies, such as definitions of a positive
urine culture and thresholds for test positivity, vary
among published studies.1-4 Blum and Wright1 used only
dipstick leukocyte esterase and nitrite as variables in
examining diagnostic performance. Bonnardeaux et al3
studied 5 variables: leukocyte esterase, nitrite, protein,
glucose, and ketones. Christenson et al2 looked at all 9
variables from the Chemstrip 9 dipstick (Boehringer
Mannheim Corporation, Indianapolis, IN). Most studies
were conducted in populations that were not typical of
ED patients.2,3,5 Consequently, some authors recom-
mend confirmatory urinalyses if the urine dipstick results
are negative,1,6 and others if results are positive.2,3,6-11 If
the definitions of positive test results, or “test cutoff point,”
for urine dipstick and for urinalysis are adjusted, these 2
tests may prove to have comparable sensitivities, speci-
ficities, and predictive values at one or more test cutoff
points. If this were true, it might be possible to substitute
the dipstick test for the urinalysis.
5 0 6
The objective of this study was to compare the test
characteristics of urine dipstick and urinalysis at various
test cutoff points in women presenting to EDs and an
intermediate care center with symptoms of urinary tract
infection.
M AT E R I A L S A N D M E T H O D S
This was a prospective, observational study of women
older than 18 years of age presenting to the Borgess Medi-
cal Center ED, Bronson Methodist Hospital ED, or Wood-
bridge Intermediate Care Center with symptoms sugges-
tive of a urinary tract infection. The study was approved
by the institutional review boards of both hospitals.
Inclusion criteria were dysuria, urgency, urinary fre-
quency, urinary incontinence, hematuria, gross pyuria,
suprapubic pain or pressure, or flank pain. Patients who
were unable to provide a reliable history, had taken anti-
biotics in the past 72 hours, or had indwelling Foley
catheters, symptomatic vaginal discharge, diabetes melli-
tus, or immunodeficiency disorders were excluded.
Patient history was recorded on a data form by an
emergency physician or nurse, and physical findings
were recorded by a physician. If patients had vaginal
bleeding or were physically unable to provide a clean-
catch urinalysis, urine was collected by urethral catheter-
ization using a Davol Female Cath Kit (C. R. Bard, Inc.,
Covington, GA). Urine was collected from all other
patients by the midstream clean-catch technique after
they had received standardized verbal and written
instructions.
An ED nurse divided each urine sample into 2 aliquots.
The nurse tested the first aliquot immediately using
Multistix 9 SG reagent strip (Bayer Corporation, Elkhart,
IN) for urinalysis from a sealed, air-tight container that
had been opened within the past 30 days. Dipstick find-
ings were recorded as follows:
Leukocyte esterase: negative, trace, 1+ (small), 2+
(moderate), or 3+ (large)
Nitrite: negative or positive
Blood: negative; or nonhemolyzed—trace or moderate;
or hemolyzed—trace, 1+ (small), 2+ (moderate),
3+ (large)
The urine specimen was sealed and sent within 1 hour
of collection to the hospital laboratory, where it was
divided into 2 aliquots, 1 for urinalysis and 1 for urine
culture. Laboratory urinalysis included automated dip-
stick reading by a Clinitek 200 Reflectance Spectrophoto-
ANNALS OF EMERGENCY MEDICINE 38:5 NOVEMBER 2001
URINE DIPSTICK VERSUS URINALYSIS
Lammers et al
meter or a Yellow Iris Reflectance Spectrophotometer
(Boehringer Mannheim Corporation, Chatsworth, CA),
plus a manual or semiautomated microscopic analysis of
urine sediment. A 10-mL aliquot of urine was centrifuged
at 1,500 rpm for 5 minutes. The supernatant was removed
and the sediment was resuspended into solution with 1 mL
of supernatant. One drop (0.4 mL) of the resuspended
sediment was placed onto a microscope slide, covered,
and examined under ×100 and ×400 magnifications. The
laboratory technician interpreted the results as the num-
ber of WBCs and RBCs per high-power field (hpf) (×400
magnification).
Specimens for urine culture were taken with a 1-µL
calibrated disposable loop. One microliter was placed
onto a TSA II 5% sheep’s blood agar plate (Baltimore Bio-
logical Laboratories, Cockeysville, MD) and 1 µL was
placed onto a McConkey’s plate (Baltimore Biological
Laboratories). Turbid urine was documented as such by
the microbiology technician, and an additional 1 µL was
cultured on a Columbia CNA SB plate (Baltimore Bio-
logical Laboratories). All plates were incubated at 35°C
(95°F) and read for growth after 48 hours. Isolated organ-
isms were reported as the number of colonies per milli-
liter of urine.
A culture-proven urinary tract infection was defined as
100,000 or more colonies of 1 or 2 species per mL of urine.
A negative urine culture was defined as either a sterile cul-
ture or a culture that grew less than 100,000 colonies per
mL of 1 or 2 species. If the laboratory reported 3 or more
distinct species of bacteria that were not considered uro-
pathogens, the culture was considered contaminated and
classified as negative. Urine cultures reported as “gross
contamination,” with or without “normal urethral flora”
or with “mixed flora,” were classified as negative. Urine
cultures reported as “gross contamination; pathogens
suspected” were analyzed on the basis of total colony
count. Urine specimens containing squamous epithelial
cells were not excluded from analysis because other in-
vestigators have found that the presence of squamous
cells does not affect the diagnostic accuracy of the test.12
Interpretation of dipstick test results and choice of
therapy were left to the treating physician. As patients
were entered into the study, urine samples and data forms
were coded. Study urinalyses and urine culture results
were not used by the treating physicians.
All nurses were skilled in the dipstick procedure; inter-
rater reliability was not measured. Sensitivity, specificity,
and predictive values were calculated at various cutoff
points for combinations of leukocyte esterase, nitrite, and
blood on dipstick and for RBCs and WBCs on urinalyses.
NOVEMBER 2001 38:5 ANNALS OF EMERGENCY MEDICINE
Dipstick and urinalysis results were compared with urine
culture results, which were used as the reference standard
to determine presence or absence of urinary tract infec-
tion. The probability of an erroneous decision to with-
hold treatment on the basis of a negative test result (and a
positive culture) was defined as “undertreatment,” or 1
minus the negative predictive value. “Overtreatment” was
defined as 1 minus the positive predictive value. Data
were reanalyzed using 10,000 colonies or more per mL as
the definition of a positive urine culture.
Areas below the receiver operating characteristic (ROC)
curves were computed for matched pairs of rates. With
classic ROC curves, different cutoff points are compared
within a single rating model. We used different binary
models for both dipstick and urinalysis data. Models var-
ied both by cutoff points for dipstick and urinalysis vari-
ables (ie, leukocyte esterase, nitrites, blood on dipstick;
RBCs and WBCs on urinalysis) and by the number of vari-
ables used. Therefore, binary ROC curves13 were com-
puted. Models with similar overtreatment and under-
treatment rates were compared using binary ROC curves
and their Wilcoxon approximation of a standard error.14
P values were calculated using a 2-tailed hypothesis with
a Bonferroni adjustment. Statistical analysis was per-
formed with the SAS (version 6.12, SAS, Cary, NC) soft-
ware package.
R E S U LT S
Three hundred forty-three patients were enrolled. Twelve
cases were withdrawn because of missing urinalysis or
culture results. The average patient age was 33 years (range,
18 to 84 years). Patients had the following clinical findings:
84% (278/331) had urgency; 84% (278/331), frequency;
79% (261/331), dysuria; 39% (129/331), suprapubic ten-
derness; 18% (60/331), costovertebral angle tenderness.
Four percent (13/331) reported pregnancy. Two percent
(7/331) had been catheterized within 2 weeks before pre-
sentation.
Forty-six percent (152/331) of patients had urine cul-
tures with 100,000 colonies/mL or greater; 66% (218/331)
had 10,000 colonies/mL or greater. Using the 100,000
colonies/mL definition of a positive culture, 77% (116/151)
of the 151 positive urine cultures grew Escherichia coli.
Other organisms included: Proteus mirabilis, 5% (7/151);
Klebsiella pneumoniae, 4% (6/151); streptococcal species,
4% (6/151); Enterobacter, 2% (3/151); and other single
species cultures, 9% (14/151). Few cultures grew mixed
uropathogens. When a positive culture was defined as
10,000 colonies/mL, 10 cultures reported as “gross con-
5 0 7
URINE DIPSTICK VERSUS URINALYSIS
Lammers et al

tamination; pathogens suspected” by the laboratory were
classified as positive. Eight urine specimens were ob-
tained by catheterization. Fifty percent (4/8) of cultures
from catheterization specimens were positive.
Tables 1 and 2 list the test characteristics for several
cutoff points for the urine dipstick and urinalysis using
the 100,000 colonies/mL count definition of a positive
culture. The Figure shows similar overtreatment and
undertreatment rates for both tests. For example, if the
urine dipstick results performed in the ED was defined as
“positive” when leukocyte esterase or nitrite was positive
or blood was more than trace, the overtreatment rate with
this test was 47%, and the undertreatment rate was 13%
(model B). A similar set of test characteristics can be
found for urinalysis. For example, the urinalysis results
were defined as “positive” when WBCs were more than
3/hpf or RBCs were more than 5/hpf, the overtreatment
rate was 44%, and the undertreatment rate was 11%
(model W).
There were no statistically significant differences be-
tween any of the matched pairs shown (Table 3). Test cut-
off points that maximize sensitivity for both tests still
result in undertreatment rates that were greater than 6%
to 7% (Figure).
The analysis was repeated using a different definition
of a positive culture. Defining a positive culture as more
than 10,000 colonies/mL lowered the overtreatment rate
and raised the undertreatment rate at each test cutoff
point (Tables 4 and 5). Dipstick and urinalysis had similar
test characteristics for matched cutoff points.

Table 1.
Test characteristics for dipstick performance when a positive culture is defined as 100,000 cfu/mL.

Models Leukocyte Sensitivity Specificity Overtreatment Undertreatment

Paired Esterase Nitrites Blood (%) (%) PPV (%) NPV (%) Rate (%) Rate (%)

A >0 or + or >0 99 19 51 94 49 6
B >0 or + or trace 96 27 53 87 47 13
C >0 or + 92 39 56 83 44 17
>0 NA 91 41 56 82 44 18
D >trace or + 85 53 60 78 40 22
E >1 or + 77 66 66 74 34 26
>2 or + 53 83 72 64 28 36
>0 and + 30 91 74 57 26 43
>trace and + 27 93 77 56 23 44
>1 and + 21 96 82 55 18 45
>2 and + 9 99 88 52 13 48
PPV, Positive predictive value; NPV, negative predictive value; NA, not applicable.

Table 2.
Test characteristics for urinalysis performance when a positive culture is defined as 100,000 cfu/mL.

Models Sensitivity Specificity Overtreatment Undertreatment

Paired RBC WBC (%) (%) PPV (%) NPV (%) Rate (%) Rate (%)

V >0 or >0 99 17 50 93 50 7
W >5 or >3 95 36 56 89 44 11
>5 or >5 92 43 58 85 42 15
X >10 or >5 91 44 58 83 42 17
>5 90 47 59 83 41 17
Y >5 or >10 85 54 61 79 39 21
>50 or >10 80 60 63 75 37 25
Z >10 78 63 64 74 36 26
PPV, Positive predictive value; NPV, negative predictive value.

5 0 8 ANNALS OF EMERGENCY MEDICINE 38:5 NOVEMBER 2001

URINE DIPSTICK VERSUS URINALYSIS
Lammers et al

DISCUSSION demonstrates that bedside urine dipsticks can be substi-

tuted for urinalysis to diagnose uncomplicated urinary
Urinary tract infection is a problem that is commonly tract infections. Use of dipsticks instead of urinalysis will
treated in EDs and urgent care centers. This study decrease patient time in the ED and the cost of testing.
However, basing treatment decisions on either urine dip-
sticks or urinalysis alone results in substantial under-
treatment and overtreatment rates at most test cutoff
Figure. points.
Test characteristics: dipstick versus urinalysis. Refer to Tables 1 Almost every test has false-positive and false-negative
and 2 for performance values for models. Shaded square,
Dipstick performance; empty circle, urinalysis performance. rates. False-negative tests may result in undertreatment,
and untreated urinary tract infections could cause renal
damage or sepsis. False-positive tests that result in misdi-
Overtreatment rate (%) agnosis of urinary tract infections may lead to the wrong
50 diagnosis, increase costs, and expose patients to the risks
of unnecessary antibiotics, including allergic reactions
and side effects. Overtreatment and undertreatment rates
were compared in this study because they provide a more
40
intuitive sense of the clinical consequences of an incorrect
test result. Physicians must select test positivity criteria
AV that balance the consequences of overtreatment with those
BW
30 of undertreatment.
CX The reference standard for the diagnosis of urinary
DY tract infections has long been the isolation and quantifi-
cation of bacteria by urine culture. More than 100,000
20 EZ colony-forming units per mL (cfu/mL) has been set as the
threshold for “significant bacteriuria.”15 However, even
the urine culture has limitations. Stamm,16 Stamm et al,17
10 Stamm,18 Stamm et al,19 and Kunin et al20 have suggested
that lower colony counts represent infection in women
with symptoms of urinary tract infection. Consequently,
0
the “acute urethral syndrome” has been used to describe
0 10 20 30 40 50 acute dysuria, frequency, urgency, and pyuria, with a
Undertreatment rate (%) good clinical response to antibiotics in women despite
cultures that grow 100 to 10,000 cfu/mL.16,19,21

Table 3.
Comparison of various models of dipstick and urinalysis cutoffs.

Dipstick Urinalysis Statistical Results

Overtreatment Undertreatment Overtreatment Undertreatment ROC SE of
Model No. Rate (%) Rate (%) ROC Rate (%) Rate (%) ROC Difference Difference P Value

1 49 6 0.59 50 7 0.580 0.01 0.044 .88

2 47 13 0.615 44 11 0.655 0.04 0.043 .36
3 44 17 0.655 42 17 0.675 0.02 0.042 .64
4 40 22 0.69 39 21 0.695 0.01 0.041 .90
5 34 26 0.715 36 26 0.705 0.01 0.040 .81
A positive culture is defined as 100,000 cfu/mL.

NOVEMBER 2001 38:5 ANNALS OF EMERGENCY MEDICINE 5 0 9

URINE DIPSTICK VERSUS URINALYSIS
Lammers et al

A lower threshold for positive urine cultures increases
the false-positive error rate and introduces technical prob-
lems. At these lower levels of colonization, differentiating
contaminants from infecting pathogens may be difficult.
Accurately quantifying colony-forming units in the range
of 100 to 1,000 per mL requires alterations in normal labo-
ratory procedure, including the use of larger inoculation
loops, which can increase the contamination rate.22,23 The
best definition of a positive urine culture remains unclear.
The diagnostic accuracy of microscopic urinalysis and
urine dipstick for suspected urinary tract infections has
been studied extensively, but results of these investiga-
tions have varied depending on patient population, test
cutoffs, and laboratory techniques.1-3,6,8,10,11,23,25 Other
studies have also suggested that the diagnostic accuracy
of these 2 tests are similar.1,5-7 For example, Blum and
Wright1 studied ambulatory women with symptoms sug-
gestive of urinary tract infection, using a reference stan-
dard of more than 10,000 cfu/mL on urine cultures. Posi-
tive urine dipstick results were defined as any detectable
leukocyte esterase or nitrites. For urinalyses, cutoff for a
positive result was more than 10 WBCs/hpf and more
than 2+ bacteria, or more than 5 RBCs/hpf and more than
2+ bacteria. They reported a positive predictive value of
78% for urine dipsticks and 79% for urinalysis. The nega-
tive predictive values were 82% for urine dipsticks and
96% for urinalysis.1 Using similar cutoffs for dipstick and
urinalysis and the same cutoff for urine culture, our data
showed a positive predictive value of 77% for dipstick
and 80% for urinalyses. Negative predictive values were
79% and 73% for dipstick and urinalysis, respectively.
The differences in predictive values between these 2 stud-
ies are partially a function of the prevalence of urinary
tract infections (41% in the Blum and Wright study; 66%,
at a more than 10,000 cfu/mL definition, in this study).
Increasing the cutoff for a positive culture to more than
100,000 cfu/mL in our study lowered the positive predic-
tive value and raised the negative predictive value for
both tests.
Some investigators have studied the utility of urine
dipsticks in populations with even lower incidences of
urinary tract infection and found higher negative predic-
tive values (84% to 93%) than in our study.23-25 Neverthe-
less, they concluded that negative results for the urine
dipstick alone resulted in an unacceptable undertreatment
rate if used as the sole criterion for excluding urinary tract
infection. Several investigators have concluded that the
urine dipstick is nonspecific in diagnosing urinary tract
infection.1,2,8,10,11,25 Some of these have suggested that
negative dipstick results are sufficiently accurate to pre-
clude further testing or treatment.2,3,6,8,10,11 Fowlis et al10
evaluated the urine of urologic clinic and renal transplant
patients. They reported a negative predictive value of
98% to 99% for urine dipstick. However, their test cutoffs
were set high. Samples with less than 5 WBCs/hpf were
considered uninfected and not cultured. A positive cul-
ture threshold was defined as more than 100,000 cfu/mL.
Wiggelinkhuizen et al8 reported a negative predictive
value of nearly 99%, with the same reference standard in a
sample population with an incidence of infection of 13.5%.
As demonstrated in our data, if the urine culture reference
standard is set higher, the negative predictive value will
increase, but a greater number of infections will be missed.
There are no established guidelines for acceptable
undertreatment and overtreatment rates for ED patients
with presumed urinary tract infections. If stringent cutoff
points for urine dipstick are used (ie, leukocyte esterase
>2 and nitrite positive), the overtreatment rate ranges

Table 4.
Test characteristics for dipstick performance when a positive cul-
ture is defined as 10,000 cfu/mL.
Table 5.
Test characteristics for urinalysis performance when a positive
Leukocyte Sensitivity Specificity PPV NPV culture is defined as 10,000 cfu/mL.
Esterase Nitrites Blood (%) (%) (%) (%)

>0 or + or >0 96 25 71 86 Sensitivity Specificity PPV NPV

>0 or + 87 48 77 79 RBC WBC (%) (%) (%) (%)
>1 or + 68 75 84 70
>2 or NA 45 90 90 62 >0 or >0 97 23 71 88
>trace and + 26 95 90 56 >5 or >5 87 54 79 80
>1 and + 16 3 84 92 >5 or >10 77 62 80 73
>2 and + 7 100 100 52 >10 70 71 83 70
PPV, Positive predictive value; NPV, negative predictive value. PPV, Positive predictive value; NPV, negative predictive value.

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URINE DIPSTICK VERSUS URINALYSIS
Lammers et al
from 13% (positive culture, 100,000 cfu/mL) to 0% (pos-
itive culture, 10,000 cfu/mL), whereas the corresponding
undertreatment rates increase to unacceptable levels
(48% for both). The true overtreatment rate actually may
be lower for any cutoff point if the acute urethral syn-
drome is considered. Both dipstick and urinalysis would
be expected to perform less favorably in populations with
lower infection rates.
A number of management strategies for urinary tract
infections are possible. Undertreatment rates may be re-
duced by following negative urine dipstick results with a
confirmatory urine culture. However, confirmatory urine
cultures would add to the cost and would delay treatment
for patients with urinary tract infections. Another strategy
for dealing with the inaccuracy of urine testing is empiric
treatment of patients with symptoms of urinary tract in-
fections.26-28 Using a cost-utility analysis, Barry et al26
demonstrated the value of this approach in uncomplicated
patients with dysuria. A published clinical guideline for
urinary tract infection also advocates the empiric therapy
option.28 In our patient population, empiric treatment for
all patients with any of the 8 inclusion criteria would elimi-
nate undertreatment but result in overtreatment rates of
34% (10,000 cfu/mL) to 54% (100,000 cfu/mL). Clini-
cians generally base diagnoses on a complex combination
of history, physical examination, and laboratory results.
Another approach to improving the accuracy of urinary
tract infection diagnosis is the combination of a quantita-
tive clinical scoring system with urine dipstick results.29
This strategy merits additional study in ED patient popu-
lations. Many questions must be answered before a clear,
decisionmaking strategy for urinary tract infection diag-
nosis is established. Whatever strategy is followed, this
study demonstrated that the test characteristics of urine
dipsticks are similar to urinalysis; therefore, confirming
negative urine dipstick results with a urinalysis provides
minimal additional information.
This study has several limitations. First, most urine
specimens were collected by the clean-catch method
rather than by catheterization. Clean-catch specimens
can result in contaminated cultures, which are more diffi-
cult to interpret. Although defined as negative, some con-
taminated cultures could have contained uropathogens.
However, the majority of urine specimens are obtained by
this method in the outpatient setting. Second, not all
patients presenting to these 3 facilities were included
during the study period. This limitation is inherent to any
clinical study that relies on busy medical and nursing per-
sonnel to fill out data forms. Although a sampling error is
possible, it is unlikely to have been systematic. Third,
NOVEMBER 2001 38:5 ANNALS OF EMERGENCY MEDICINE
overtreatment and undertreatment rates were derived
from predictive values; therefore, they are affected by
prior probability of disease. Populations with different
infection rates will have different overtreatment and
undertreatment rates. However, it is unlikely that the
relationship between the 2 tests would change through-
out the spectrum of infection rates. Fourth, the range of
cutoff points for urine dipstick is greater than that for uri-
nalysis. The comparisons between dipstick and urinalysis
are limited to the ranges for which there are comparable
data.
In summary, test cutoffs for urine dipsticks can be set at
points to provide overtreatment and undertreatment rates
that are equivalent to those for urinalysis. Urine dipsticks
can be substituted for urinalysis for adult women with
symptoms suggestive of urinary tract infection. Cutoff
points that maximize sensitivity for both tests still result
in undertreatment rates greater than 6% to 7% when posi-
tive cultures are defined as more than 100,000 cfu/mL.
The limitations in the diagnostic accuracy of urine dip-
stick and urinalysis should be incorporated into medical
decisionmaking.
Author contributions: RLL designed the study and obtained research funding. RLL, SG, DK,
WS, and GS participated in recruitment of participating centers, data collection, and qual-
ity control activities. RLL analyzed the data and wrote the manuscript; SG and DK con-
tributed to manuscript revisions. All authors gave final approval of the version to be pub-
lished. RLL takes responsibility for the paper as a whole.
We gratefully acknowledge Diana Cucos for her assistance with the statistical analysis
and the nurses and physicians of Bronson Methodist Hospital, Borgess Medical Center,
and Woodbridge Intermediate Care Center for their assistance with data collection.
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