{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,4,3]],"date-time":"2025-04-03T15:24:23Z","timestamp":1743693863514},"reference-count":23,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2023,7,26]],"date-time":"2023-07-26T00:00:00Z","timestamp":1690329600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,9,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>It is not well known how reliably clinicians order reflex urinalysis to microscopy and culture (rUA-cx) for outpatient urinary tract infection (UTI) workup. Antibiotic appropriateness cannot be fully appreciated until the prevalence of UTIs and asymptomatic bacteriuria (ASB) are realized.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Objective<\/jats:title>\n                  <jats:p>This quality improvement study has two major aims, first to determine UTI symptom accuracy for rUA-cx ordering and second, to confirm UTI and ASB cases by integrating rUA-cx and cascaded urinalysis results. Antibiotic utilization and diagnostic coding were secondarily linked to UTIs and ASB.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>An electronic best-practice alert informed the ordering of two rUA-cx options: symptomatic- rUA-cx specifically for dysuria, frequency, urgency, costovertebral pain, suprapubic pain or fever versus non-specific-rUA-cx for vague complaints. UTI symptoms were verified by chart review. Confirmed UTI was defined as a significant culture with UTI symptoms and ASB as a significant culture without UTI symptoms.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>rUA-cx (2065) were prospectively collected over 6 months from female patients at risk for uncomplicated UTIs. Symptomatic-rUA-cx and non-specific-rUA-cx were associated with UTI symptoms for 53% (809\/1527) and 20% (107\/538), respectively. Overall, 44% (916\/2065) of all rUA-cx had UTI symptoms. rUA-cx were overordered by a factor of 9 (2065\/225) for every confirmed UTI. The UTI-to-ASB relative ratio was 2.6 (225\/86). Regarding UTI-relevant antibiotics, 39% (214\/553) were appropriately associated with UTI whereas only 22% (74\/339) of inappropriate antibiotics were captured by the ASB definition, underestimating the problem 4-fold.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>UTI and ASB remain challenging to categorize despite a meticulous method that applied acceptable criteria.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/jac\/dkad233","type":"journal-article","created":{"date-parts":[[2023,7,26]],"date-time":"2023-07-26T09:16:04Z","timestamp":1690362964000},"page":"2283-2290","source":"Crossref","is-referenced-by-count":1,"title":["Diagnostic and antibiotic stewardship lessons: an outpatient assessment of symptomatic reflex urinalysis ordering accuracy using an electronic best-practice alert"],"prefix":"10.1093","volume":"78","author":[{"given":"Hien M","family":"Nguyen","sequence":"first","affiliation":[{"name":"Department of Infectious Diseases, Northwest Permanente , Portland, Oregon , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shaun","family":"Flerchinger","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Insight Northwest , Portland, Oregon , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeffrey R","family":"Smith","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northwest Region Laboratories , Portland, Oregon , USA"},{"name":"The Permanente Federation, Convergent Medical Terminology , Oakland, California , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrew H","family":"Felcher","sequence":"additional","affiliation":[{"name":"Department of Hospital Medicine, Northwest Permanente , Portland, Oregon , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marianne","family":"Turley","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Insight Northwest , Portland, Oregon , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Mcnamara","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics, Northwest Permanente , Portland, Oregon , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2023,7,26]]},"reference":[{"key":"2023090502535527000_dkad233-B1","doi-asserted-by":"crossref","first-page":"e00003-20","DOI":"10.1128\/CMR.00003-20","article-title":"The five Ds of outpatient antibiotic stewardship for urinary tract infections","volume":"34","author":"Goebel","year":"2021","journal-title":"Clin Microbiol Rev"},{"key":"2023090502535527000_dkad233-B2","doi-asserted-by":"crossref","first-page":"ofx207","DOI":"10.1093\/ofid\/ofx207","article-title":"Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis","volume":"4","author":"Flokas","year":"2017","journal-title":"Open Forum Infect Dis"},{"key":"2023090502535527000_dkad233-B3","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1093\/cid\/cis534","article-title":"The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat?","volume":"55","author":"Cai","year":"2012","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B4","doi-asserted-by":"crossref","first-page":"574","DOI":"10.1086\/675829","article-title":"Urine cultures among hospitalized veterans: casting too broad a net?","volume":"35","author":"Drekonja","year":"2014","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2023090502535527000_dkad233-B5","doi-asserted-by":"crossref","first-page":"1533","DOI":"10.1001\/jamainternmed.2021.4075","article-title":"Prevalence, costs, and consequences of low-value preprocedural urinalyses in the US","volume":"18","author":"Shenoy","year":"2021","journal-title":"JAMA Intern Med"},{"key":"2023090502535527000_dkad233-B6","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1093\/cid\/ciab987","article-title":"Optimal urine culture diagnostic stewardship practice\u2014results from an expert modified-Delphi procedure","volume":"5","author":"Claeys","year":"2022","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B7","doi-asserted-by":"crossref","first-page":"e000834","DOI":"10.1136\/fmch-2020-000834","article-title":"Case-based audit, and feedback around a decision aid improved antibiotic choice and duration for uncomplicated cystitis in primary care clinics","volume":"9","author":"Grigoryan","year":"2021","journal-title":"Fam Med Commun Health"},{"key":"2023090502535527000_dkad233-B8","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1016\/S1553-7250(10)36060-0","article-title":"A comparison of methods to detect urinary tract infections using electronic data","volume":"36","author":"Landers","year":"2010","journal-title":"Joint Commis J Qual Patient Safety"},{"key":"2023090502535527000_dkad233-B9","doi-asserted-by":"crossref","first-page":"501","DOI":"10.3928\/00220124-20151020-02","article-title":"SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process","volume":"46","author":"Ogrinc","year":"2015","journal-title":"J Control Educ Nursing"},{"key":"2023090502535527000_dkad233-B10","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1017\/ice.2014.73","article-title":"Overtreatment of asymptomatic bacteriuria: identifying targets for improvement","volume":"36","author":"Hartley","year":"2015","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2023090502535527000_dkad233-B11","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1016\/j.clinmicnews.2014.05.003","article-title":"Laboratory diagnosis of urinary tract infections: guidelines, challenges, and innovations","volume":"36","author":"Pezzlo","year":"2014","journal-title":"Clin Microbiol Newsletter"},{"key":"2023090502535527000_dkad233-B12","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1093\/ajcp\/81.5.634","article-title":"Urine screening strategy employing dipstick analysis and selective culture: an evaluation","volume":"81","author":"Loo","year":"1984","journal-title":"Am J Clin Pathol"},{"key":"2023090502535527000_dkad233-B13","doi-asserted-by":"crossref","first-page":"1136","DOI":"10.1016\/j.ajic.2014.06.020","article-title":"Lessons from audit and feedback of hospitalized patients with bacteriuria","volume":"42","author":"Leis","year":"2014","journal-title":"Amer J Infect Control"},{"key":"2023090502535527000_dkad233-B14","doi-asserted-by":"crossref","first-page":"84","DOI":"10.3390\/antibiotics8020084","article-title":"Qualitative analysis of primary care provider prescribing 322 decisions for urinary tract infections","volume":"8","author":"Grigoryan","year":"2019","journal-title":"Antibiotics"},{"key":"2023090502535527000_dkad233-B15","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1017\/ice.2020.37","article-title":"Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: a multicenter experience","volume":"41","author":"Watson","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2023090502535527000_dkad233-B16","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1017\/ice.2020.5","article-title":"Sustained decrease in urine culture utilization after implementing a reflex urine culture intervention: a multicenter quasi-experimental study","volume":"41","author":"Howard-Anderson","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2023090502535527000_dkad233-B17","doi-asserted-by":"crossref","first-page":"e883","DOI":"10.1093\/cid\/ciaa1512","article-title":"Reducing catheter-associated urinary tract infections via cost-saving diagnostic stewardship","volume":"72","author":"Luu","year":"2021","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B18","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1017\/ice.2020.400","article-title":"Conditional reflex to urine culture: evaluation of a diagnostic stewardship intervention within the Veterans\u2019 Affairs and Centers for Disease Control and Prevention Practice-Based Research Network","volume":"42","author":"Claeys","year":"2021","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2023090502535527000_dkad233-B19","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1093\/cid\/ciy381","article-title":"A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)","volume":"67","author":"Baron","year":"2018","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B20","doi-asserted-by":"crossref","first-page":"1284","DOI":"10.1093\/cid\/ciab749","article-title":"Envisioning future UTI diagnostics","volume":"74","author":"Patel","year":"2022","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B21","doi-asserted-by":"crossref","first-page":"1332","DOI":"10.1093\/cid\/ciaa274","article-title":"Asymptomatic bacteriuria and pyuria in premenopausal women","volume":"72","author":"Hooton","year":"2021","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B22","doi-asserted-by":"crossref","first-page":"1339","DOI":"10.1093\/cid\/ciaa280","article-title":"Urinary tract infections as a continuum: implications for diagnostic and antibiotic stewardship","volume":"72","author":"Trautner","year":"2021","journal-title":"Clin Infect Dis"},{"key":"2023090502535527000_dkad233-B23","doi-asserted-by":"crossref","first-page":"536","DOI":"10.3390\/antibiotics9090536","article-title":"Validating use of electronic health data to identify patients with urinary tract infections in outpatient settings","volume":"9","author":"Germanos","year":"2020","journal-title":"Antibiotics"}],"container-title":["Journal of Antimicrobial Chemotherapy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jac\/article-pdf\/78\/9\/2283\/51310701\/dkad233.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jac\/article-pdf\/78\/9\/2283\/51310701\/dkad233.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,9,5]],"date-time":"2023-09-05T02:54:08Z","timestamp":1693882448000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jac\/article\/78\/9\/2283\/7231177"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,7,26]]},"references-count":23,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2023,7,26]]},"published-print":{"date-parts":[[2023,9,5]]}},"URL":"https:\/\/doi.org\/10.1093\/jac\/dkad233","relation":{},"ISSN":["0305-7453","1460-2091"],"issn-type":[{"value":"0305-7453","type":"print"},{"value":"1460-2091","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2023,9]]},"published":{"date-parts":[[2023,7,26]]}}}