View source for Diagnostic stewardship of urine cultures

== Background ==

* [[Asymptomatic bacteriuria]] is common, but positive urine cultures are still often inappropriately treated
* The process of inappropriately treating asymptomatic bacteriuria can be interrupted at the culture collection stage

== Interventions ==

=== Urine Culture Ordering ===

* The following practices are recommended:
** Require documentation of signs or symptoms of UTI to obtain a urine culture, including dysuria or flank pain
*** Patients without urinary catheters
**** Appropriate signs and symptoms include dysuria, suprapubic pain, flank pain, CVA tenderness, or septic shock
**** Signs and symptoms of uncertain appropriateness include fever or leukocytosis with unknown cause
**** Inappropriate signs and symptoms include altered mental status or change in urine characteristics
*** Patients with urinary catheters are as above, except that delirium is of uncertain appropriateness
** Replace stand-alone urine culture orders with conditional reflex urine cultures
*** Direct urine culture may still need to be available to urology and obstetrics
*** Criteria for reflex culture is not standardized; elevated WBC count ≥10-50 is appropriate, but unclear whether leukocyte esterase or urine nitrate was appropriate
** Implement best practice alerts to discourage ordering urine cultures in the abscence of signs or symptoms of UTI
** Automatically cancel repeat urine cultures within 5 days of a positive culture (during the same hospital admisssion and 7 days for long-term care residents)
* As well, urine cultures should not be included in any standardized order sets except for septic shock
* Urine cultures should not be collected in response to a change in urine characteristics

=== Processing Urine Culture ===

* The following practices are recommended:
** Use elevated urine WBC as a criterion to reflex process a urine culture when the clinician orders a urine culture
*** See section above for further detail
** Require documentation of collection site and method (e.g. clean catch) prior to processing urine culture
* Reflex urine cultures should not be done on a urinalysis where the clinician did not specifically request culture

=== Urine Culture Reporting ===

* The following practices are recommended:
** Report that even high colony counts may not represent true infection in the absence of signs or symptoms
** Nudge clinicians to not treat asymptomatic bacteriuria or mixed flora
** Differentiate typical uropathogens from contaminants
** Without urine culture results when there are more than 2 unique bacterial strains in culture
** Report only recommended antibiotics if the organism is susceptible
** Withhold fluoroquinolone susceptibilities unless there is resistance to preferred oral antibiotics
* The reports should not nudge clinicians to not treat based on low colony counts, either
* Reports should not withhold information about organism identification or antibiotics susceptibilities unless the clinician calls the microbiology lab

== Further Reading ==

* Optimal Urine Culture Diagnostic Stewardship Practice—Results from an Expert Modified-Delphi Procedure. ''Clin Infect Dis''. 2022;75(3):382-9. doi: [https://doi.org/10.1093/cid/ciab987 10.1093/cid/ciab987]