University of Oklahoma Health Sciences Center

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Author/s:

Claeys, K. C., Trautner, B. W., Leekha, S., Coffey, K. C., Crnich, C. J., Diekema, D. J., Fakih, M. G., Goetz, M. B., Gupta, K., Jones, M. M., Leykum, L., Liang, S. Y., Pineles, L., Pleiss, A., Spivak, E. S., Suda, K. J., Taylor, J. M., Rhee, C., Morgan, D. J.

Date Added:

September 8, 2022

Journal/Publication:

Clinical Infectious Diseases

Publisher:

Infectious Diseases Society of America

Publication Date:

August 1, 2022

Issue:

Volume:

Pages:

382-389

URL:

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1093/cid/ciab987

PMID (1):

34849637

Keywords

Diagnostic Stewardship

Expert consensus

modified Delphi

urinary tract infections

urine cultures

MeSH

Anti-bacterial Agents / therapeutic use

Delphi Technique

anti-bacterial agents

urinalysis

Urinary Tract Infections* / diagnosis

RPR Commentary

A useful summary of practical recommendations for the appropriate ordering and interpretation of urine cultures. James W. Mold, MD, MPH

Abstract

Background: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.

Methods: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.

Results: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.

Conclusions: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Keywords: diagnostic stewardship; expert consensus; modified Delphi; urinary tract infection; urine cultures.

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