Urinalysis Orders Among Patients Admitted to the Inpatient General Medicine Service Cost Conscious Project Miriam Nojan PGY-2

Are urinlyses being ordered and acted on appropriately among inpatients admitted to the General Internal Medicine wards?

Asymptomatic Bacteriuria Asymptomatic Bacteriuria or asymptomatic urinary infection, is isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection

IDSA Guidelines Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (A-II) Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons: ◦ Premenopausal, nonpregnant women (A-I) ◦ Diabetic women (A-I) ◦ Older persons living in the community (A-II) ◦ Elderly, institutionalized subjects (A-I) ◦ Persons with spinal cord injury (A-II) ◦ Catheterized patients while the catheter remains in situ (A-I)

Evidence Pyuria is evidence of inflammation in the genitourinary tract and is common in subjects with asymptomatic bacteriuria. Pyuria is present with asymptomatic bacteriuria in: ◦ ∼ 32% of young women ◦ 30%–70% of pregnant women ◦ 70% of diabetic women ◦ 90% of elderly institutionalized patients ◦ 90% of hemodialysis patients ◦ 30%–75% of bacteriuric patients with short-term catheters in place ◦ 50%–100% of individuals with long-term indwelling catheters in place

Evidence Asymptomatic bacteriuria is not associated with long-term adverse outcomes, such as hypertension, chronic kidney disease, genitourinary cancer, or decreased duration of survival Treatment of asymptomatic bacteriuria neither decreases the frequency of symptomatic infection nor prevents further episodes of asymptomatic bacteriuria

Study Design Retrospective Cohort Study N = 12 Inclusion Criteria: ◦ Adult patients admitted to the inpatient Medicine Service who underwent UA during 04/12 – 04/22 upon admission Exclusion Criteria: ◦ ICU / OSH transfers Appropriate UA: ◦ AKI ◦ Dysuria or urinary complaints ◦ Fever / Sepsis of unknown origin ◦ AMS in elderly Inappropriate UA: ◦ Fever with obvious alternative source (eg. Pneumonia, cellulitis) ◦ Absence of urinary complaints

AgeChief ComplaintUTI SxUA Indicated (Y – x / N) Urine Microscopy / Culture (+ / -) Antimicrobial Therapy Initiated Antimicrobial Therapy Indicated 71BL LE CellulitiisNNNegativeNo 58Chronic LE Cellulitis / Hypotension / AKI NYNegativeNo 52Myasthenia w/Cough / Sepsis NYNegativeNo 45Pulmonary EmbolismNNNegativeNo 80Abdominal Pain / Dysuria YYPositiveYes 47Nasopharyngeal CA w/Bilateral Hand Numbess NNNegativeNo 55SVC Syndrome / Incidental leukocytosis NYNegativeNo 85Cough / HypoxiaNNNegativeNo 71BL LE CellulitisNNNegativeNo 35RCC w/Fevers / AKIYYNegativeNo 66Chest Pain (Hx CKD; Cr at baseline) NNNegativeNo 77Fever / AMS / Dysuria YYPositiveYes

Results Baseline Characteristics ◦ Mean Age: 61.8; Sex 6 Males / 6 Females UA Indicated in 6/12 (50%) patients UA Culture / Microscopy was positive for infection in 2/12 (17%) patients No instances of inappropriate treatment of asymptomatic bacteriuria

Analysis Healthcare Bluebook: ◦ UA: $10 ◦ Urine Culture : $21 ◦ Ceftriaxone (1g/day): $10 After controlling for other variables, those most likely to undergo UA without an appropriate clinical indication had multiple comorbidities. One possible explanation is that patients with complex medical problems are more likely to undergo a broader net of investigations.

Discussion Up to 50% of UA’s ordered in the inpatient setting during the study period analysis were done so without indication Treatment of asymptomatic bacteriuria may itself be associated with undesirable outcomes, including subsequent antimicrobial resistance, adverse drug effects, and cost. Positive UA results from these asymptomatic patients significantly increased their probability of receiving additional low-value care, including UC and antibiotics for asymptomatic pyuria or bacteriuria

Take Away These findings highlight the harms of UA overuse in this patient population because positive UA results can introduce cognitive biases in favor of a UTI diagnosis even when patients lack accepted guideline-based criteria Limiting indiscriminate UA ordering has the potential to improve resource utilization and antimicrobial prescribing practices among GM patients

References Lindsay E. Nicolle, Suzanne Bradley, Richard Colgan, et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am Sep;11(3): Penny Yin, MD; Alex Kiss, PhD; Jerome A. Leis, MD, MSc. Urinalysis Orders Among Patients Admitted to the General Medicine Service. JAMA Intern Med. 2015;175(10):