Abstract
ObjectivePublished literature from resource‐limited settings is infrequent, although urinary tract infections (UTI) are a common cause of outpatient presentation and antibiotic use. Point‐of‐care test (POCT) interpretation relates to antibiotic use and antibiotic resistance. We aimed to assess the diagnostic accuracy of POCT and their role in UTI antibiotic stewardship.MethodsOne‐year retrospective analysis in three clinics on the Thailand–Myanmar border of non‐pregnant adults presenting with urinary symptoms. POCT (urine dipstick and microscopy) were compared to culture with significant growth classified as pure growth of a single organism >105 CFU/ml.ResultsIn 247 patients, 82.6% female, the most common symptoms were dysuria (81.2%), suprapubic pain (67.8%) and urinary frequency (53.7%). After excluding contaminated samples, UTI was diagnosed in 52.4% (97/185); 71.1% (69/97) had a significant growth on culture, and >80% of these were Escherichia coli (20.9% produced extended‐spectrum β‐lactamase (ESBL)). Positive urine dipstick (leucocyte esterase ≥1 and/or nitrate positive) compared against positive microscopy (white blood cell >10/HPF, bacteria ≥1/HPF, epithelial cells <5/HPF) had a higher sensitivity (99% vs. 57%) but a lower specificity (47% vs. 89%), respectively. Combined POCT resulted in the best sensitivity (98%) and specificity (81%). Nearly one in ten patients received an antimicrobial to which the organism was not fully sensitive.ConclusionOne rapid, cost‐effective POCT was too inaccurate to be used alone by healthcare workers, impeding antibiotic stewardship in a high ESBL setting. Appropriate prescribing is improved with concurrent use and concordant results of urine dipstick and microscopy.
Highlights
In view of increasing antibiotic resistance in low-income countries [1,2,3], efficient, economic and effective diagnostic and treatment strategies [4] are required for urinary tract infections (UTI), one of the most common reasons for adult outpatient attendance and antibiotic prescription [5]
The final working diagnoses given by healthcare workers were as follows: uncomplicated UTI 29.6% (73/247); pyelonephritis 27.5% (68/247); pyelolithiasis 4.0% (10/247); genito-urinary infection 2.8% (7/247); unknown febrile illness 14.6% (36/247); and unable to provide a definitive diagnosis in 21.5% (53/247)
Amongst the 47.6% (88/185) not diagnosed with UTI or pyelonephritis, there were 9.1% (8/88) who had a significant growth on culture and these were discharged without antibiotic treatment. This rural and remote population had many of the typical features reported previously on community-acquired UTI including a preponderance of female patients [5], a high proportion of infection due to E. coli [31] and discordance between point-of-care tests (POCT) and gold standard urine culture [14, 16, 32]
Summary
In view of increasing antibiotic resistance in low-income countries [1,2,3], efficient, economic and effective diagnostic and treatment strategies [4] are required for urinary tract infections (UTI), one of the most common reasons for adult outpatient attendance and antibiotic prescription [5]. The roll out of rapid diagnostic tests (RDT) and artemisinin combination therapy for malaria have revealed the millions of cases of fever misdiagnosed in tropical countries [10]. A Cochrane review emphasises point-of-care tests (POCT) to allow informed antibiotic prescribing [12]. Chalmers et al POCT in UTI antibiotic stewardship in remote area volume 00 no 00 commenced before urine culture results are available. Overdiagnosis from this approach is accepted as delaying antibiotics by more than 48 h, whilst waiting for the culture results, is much more likely to have poor symptom control, emphasising the importance of obtaining a rapid decision [13]
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