American Journal of Infection Control 44 (2016) 1750-1

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American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Brief Report

Impact of eliminating reflex urine cultures on performed urine

cultures and antibiotic use
Jessica Dietz PharmD, BCPS a,b,*, Tze Shien Lo MD c, Kimberly Hammer PhD a,d,
Milagros Zegarra MD e
a
Fargo Veteran Affairs Healthcare System, Fargo, ND
b
Pharmacy Service, Fargo Veteran Affairs Healthcare System, Fargo ND
c Department of Infectious Disease, Fargo Veteran Affairs Healthcare System, Fargo, ND
d
Research Service, Fargo Veteran Affairs Healthcare System, Fargo ND
e
Department of Nephrology, Fargo Veteran Affairs Healthcare System, Fargo, ND

Key Words: Inappropriate treatment of asymptomatic bacteriuria is often the result of unnecessary urinalyses and
Urinary tract infection urine cultures. This study aimed to determine the impact of stopping the practice of reflex urine cul-
urine culture tures. Our study demonstrated that stopping urine reflex cultures decreased the number of urine cultures
asymptomatic bacteriuria
performed and there was a trend toward a decrease in antibiotic use.
Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and
Epidemiology, Inc.

Urinalyses are often ordered as part of a general workup re-
gardless of symptomatology. A recent study reviewed 195 patients
who underwent urinalysis: 62% of the patients had this test com-
pleted without specific symptoms of urinary tract infection (UTI).1
Another study showed that positive results from a urinalysis are non-
specific and occur in as many at 90% of asymptomatic elderly
patients.2 Inappropriate use of urinalysis and urine cultures in as-
ymptomatic patients often leads to overuse of antibiotics.2
At the Fargo Veterans Affairs Healthcare System, urinalysis is
commonly used as part of a general workup in the emergency de-
partment and clinics. Starting in April 2006, the facility automatically
started sending urinalyses with positive nitrite or white blood cell
counts ≥8 per high-power field for culture. The antimicrobial stew-
ardship team felt that this practice was leading to incidental findings
of bacteriuria in asymptomatic patients who were subsequently
treated with antibiotics. In an effort to decrease treatment of as-
ymptomatic bacteriuria the laboratory policy was changed in
September 2014 to remove the reflex urine cultures and instead
require providers to order a culture separately from the urinalysis
if deemed appropriate based on urinalysis results and patient symp-
* Address correspondence to Jessica Dietz, PharmD, BCPS, Fargo Veteran Affairs
Healthcare System, 2101 N Elm St, Fargo, ND 58102.
E-mail address: jessica.dietz@va.gov (J. Dietz).
Conflicts of Interest: None to report.
Disclaimer: The contents of this manuscript do not represent the views of the
Department of Veterans Affairs or the U.S. Government.
toms. The patient’s urine sample is held in the laboratory for 3 days
to allow for urine culture to be added if the provider feels this is
warranted. The following message was also added to the labora-
tory results for all urinalysis and urine cultures: Patients with
asymptomatic bacteriuria, funguria, or pyuria without UTI symp-
toms usually do not require treatment with an antimicrobial agent.
The purpose of this study was to determine if the change in the Fargo
Veterans Affairs Healthcare System policy regarding reflex urine cul-
tures was effective in decreasing the number of inappropriate urine
cultures and decreasing overall use of antibiotics commonly used
to treat urinary tract infections.
MATERIALS AND METHODS
The primary end points for the study were the change in the
number of urine cultures performed and the change in antibiotic
prescribing. Rates of urinalysis and urine culture performed in both
the inpatient and outpatient settings were collected retrospec-
tively for the preintervention period (November 2013-August 2014)
and the postintervention period (October 2014-July 2015). All in-
patient and outpatient antibiotic use was collected for the pre- and
postintervention periods for antibiotics commonly used to treat UTIs,
including ciprofloxacin, levofloxacin, sulfamethoxazole-trimethoprim,
and nitrofurantoin. No antibiotic prescriptions were excluded. An-
tibiotic use data were collected in different units for outpatients and
inpatients because of the way the data are collected at the facility.
Inpatient antibiotic use data were collected through the Centers for

0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
http://dx.doi.org/10.1016/j.ajic.2016.04.232
 J. Dietz et al. / American Journal of Infection Control 44 (2016) 1750-1 1751

Table 1
All antibiotic use pre- and postintervention

Antibiotic Preintervention Postintervention P value

Outpatient antibiotic use (percentage of encounters)
Ciprofloxacin 0.13 0.12 .65
Levofloxacin 0.04 0.08 .0009
Sulfamethoxazole-trimethoprim 0.07 0.09 .08
Nitrofurantoin 0.01 0.01 .42
Inpatient antibiotic use (rate of antimicrobial days/total patient days)
Ciprofloxacin 24.03 18.02 .27
Levofloxacin 9.89 31.72 .001
Sulfamethoxazole-trimethoprim 11.88 4.00 .01
Nitrofurantoin 0.56 0.38 .34

Disease Control and Prevention’s Antimicrobial Use Option. Out- Table 2

patient antibiotic prescription data were collected from the Fargo All positive blood cultures for uropathogens

Veterans Affairs VISTA outpatient prescription database. In order to
determine the safety of this laboratory change, the rates of posi-
tive blood cultures for common uropathogens were compared to
determine if the removal of reflex urine cultures impacted the rates
of severe infections. Laboratory data were collected from the Fargo
Veterans Affairs health records laboratory package. Patients were
at least 18 years of age, and all patients seen at the Fargo Veterans
Affairs Healthcare System from November 2013-July 2015 were in-
cluded. Pre- versus postintervention analyses were performed using
unpaired Student t tests. The study was approved by the facility’s
institutional review board and research and development commit-
tee prior to data collection.
RESULTS
In the preintervention period (November 2013-August 2014)
there were a total of 1,085 urine cultures completed (901 outpa-
tient, 184 inpatient). The total number of urine cultures decreased
in the postintervention period (October 2014-July 2015) to 761 (613
outpatient, 148 inpatient). There was no significant change in the
number of urinalyses completed during the pre- and postintervention
periods (preintervention: 837 ± 181; postintervention: 806 ± 178;
P = .90). Overall, rates of urine cultures per month were statistical-
ly decreased in the postintervention period (preintervention:
108.5 ± 8.36; postintervention: 76.1 ± 5.78; P = .0004). When divided
based on patient location, the difference in rates of urine cultures
was not statistically significant in the inpatient setting (18.4 ± 1.84
pre, 14.8 ± 1.53 post, P = .15), but the decrease in urine cultures
after the intervention was statistically significant in the outpa-
tient setting (preintervention: 90.1 ± 2.49; postintervention:
61.3 ± 4.33; P < .0001).
Antibiotic use in the outpatient and inpatient settings were
also compared (Table 1). There was no statistically significant
change in outpatient antibiotic use except for levofloxacin use,
which increased (P = .0009). In the inpatient setting, antimicrobial
use also increased for levofloxacin (P = .0011); however, use of
sulfamethoxazole-trimethoprim significantly decreased (P = .01).
Ciprofloxacin and nitrofurantoin use decreased but did not reach
statistical significance.
All blood culture results performed at the facility showing gram-
negative organisms and enterococcus were compared, and there was
no difference noted (Table 2).
Uropathogen Preintervention Postintervention
Gram-negatives 16 15
Enterococcus 3 4
Total 19 19
DISCUSSION
Overall, the number of urine cultures after the intervention de-
creased. There appeared to be some decrease in the use of antibiotics,
but this was only statistically significant for sulfamethoxazole-
trimethoprim in the inpatient setting. A major limitation to the study
was that the antibiotic use was collected as a whole for the speci-
fied antibiotics, and this may have created measurement bias because
the antibiotics could have been used for indications other than sus-
pected UTI. The increase in levofloxacin use in both the outpatient
and inpatient settings is likely partially because of the facility shift
in formulary preference from moxifloxacin to levofloxacin for treat-
ment of respiratory infections. Moxifloxacin use decreased after the
shift in formulary preference (outpatient: pre- and postintervention:
0.06% and 0.03%, respectively; P = .006; inpatient: pre- and
postintervention: 13.7 and 6.7, respectively; P = .047). Rates of bac-
teremia related to common urine tract pathogens stayed consistent
after removal of the reflex urine culture practice, suggesting the in-
tervention did not increase rates of serious infections as a result of
uropathogens.
Based on the cost of urine culture tests, the facility would save
approximately $6,000 per year (this savings does not include the
technician time or other supplies required to complete the test; the
cost of 1 test is $9.23). Despite cost savings there was no signifi-
cant decrease in the use of antibiotics as hoped with the removal
of reflex cultures. Further interventions are necessary to decrease
antibiotic treatment of asymptomatic patients. Future research
should focus on the impact of removing urine cultures specifically
on the antibiotic treatment of asymptomatic patients.
References
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