Dipstick Results Research Articles

Stop routine microscopic urinalysis in hospitalized patients with dipstick abnormalities?

Restricting the performance of microscopic urinalyses only to patients in whom it was specifically requested has been shown to reduce their number in laboratories servicing both inpatients and outpatients. To determine the effect of such restriction solely in in-patients in a 400-bed regional hospital. In 2017, we discontinued routine ('reflex') microscopic urinalysis for all positive dipstick results, and restricted such testing to in-patients in whom it was specifically requested by a doctor. We compared the numbers of patients in three internal medicine departments who had a urinalysis over 2-year periods before and after 2017, and reviewed doctors' complaints. Before 2017, more than 80% of all dipstick tested samples had one or more abnormalities that led to a microscopic examination. Discontinuation of reflex microscopy reduced microscopic urinalysis to less than 10% of all patients with dipsticks on admission. Requests for repeat urinalysis decreased from 4.3% to 2.5% and there were no complaints after the change in policy. Discontinuation of a 'reflex' microscopic urinalysis in patients with abnormal dipstick results did not increase repeat urine testing. Doctors apparently felt that the microscopic urinalysis does not have clinical utility in the vast majority of hospitalized adult patients.

56 ‘A Closed-Loop Audit on The Appropriateness of Urine Testing Carried Out on Surgical Patients in The Acute Surgical Unit in University Hospital Limerick as Compared with Hospital Guidelines’

Abstract Aim The acute surgical unit (ASU) in University Hospital Limerick (UHL) has a high turnover of patients of all surgical specialties, many of whom are sent home without the need for admission or follow-up. Urinalysis is very accessible, and is carried out on many patients, prior to them being seen by a doctor. Inappropriate urinalysis sets off a cascade of inappropriate urine culture, antimicrobial treatment and a waste of resources and time of nursing, medical and laboratory staff. We aim to identify and reduce inappropriate testing. Method The notes of all ASU patients during a one-week period were analysed using the ‘Therefore Navigator’ application, where all patient notes are scanned on leaving the ASU. Data relating to presenting complaint, presence or absence of urinary symptoms and abdominal pain, and urine dipstick and culture results (if performed) was collected for each patient. The results were compared with UHL guidelines on testing, an information sheet was designed and placed in ASU, and an education session for nursing staff was carried out. The second cycle was performed one month later. Results In the first cycle, 68% of the 99 ASU patients had urinalysis, and 48% had urine culture performed. Of cultures performed, only 23 of 47 (49%) were deemed indicated according to the guidelines. In the second cycle, 39% had urinalysis. 28% had urine cultured, 79% of these were deemed to have been indicated. Conclusions Inappropriate urine testing in the ASU decreased following teaching for nursing staff, together with an information leaflet being placed in the ASU.

Impact of a Mobile Health System on the Suppression of Schistosoma haematobium in Chad

ABSTRACT.This study determined the contribution of a mobile health (M-health) system to the treatment of Schistosoma haematobium in a region of Chad where S. haematobium is endemic. M-health involves the use of a mobile phone for health care. The study compared the prevalence of schistosomiasis in an area with an M-health system, newly installed in 2014, with an area without an adequate health infrastructure. Data were gathered after the M-health system had been running for 3 years. We took urine samples from children age 1 to 15 years, for a total of 200 children in a village in the M-health area and 200 in a village in a non-M-health area. Urine was checked for urinary schistosomiasis by using dipsticks for microhematuria and, in cases of positive dipstick results, microscopy was used to detect eggs. Comparison between the areas allowed us to assess the effectiveness of the installed M-health system after 3 years of operation. Based on dipstick outcomes, the non-M-health area had an infection rate of 51.5% compared with 29% in the M-health area. Microscopy results in non-M-health and M-health were 27.5% and 21%, respectively. The dipstick result difference between M-health and non-M-health areas was statistically significant. Dipsticks were more reliable than microscopy for the detection of schistosomiasis, especially in areas without qualified personnel. Based on these results, M-health proved its ability to reduce the infection rate of urogenital schistosomiasis, and the implementation of M-health shows great promise in areas where this disease is endemic and where no mass drug administration is provided.

Evaluating the Safety of Performing Flexible Cystoscopy When Urinalysis Suggests Presence of “Infection”: Results of a Prospective Clinical Study in 2350 patients

BackgroundThere is significant underutilisation of allocated health service resources when a scheduled flexible cystoscopy (FC) is cancelled because a pre-cystoscopy urinalysis (PCU) suggests “infection”, despite patients being asymptomatic for urinary tract infection (UTI). ObjectiveTo evaluate the risk of UTI or urinary sepsis when FC is performed in asymptomatic patients with a PCU positive for leucocyte esterase and/or nitrites. Design, setting, and participantsA prospective cohort study was conducted in a high-volume UK centre recruiting all patients undergoing outpatient FC. InterventionA protocol was developed to guide response to PCU performed prior to FC, which was performed regardless of the result, unless patients were symptomatic for UTI. All patients completed a questionnaire to identify risk factors and were followed up via a telephone survey and a review of electronic clinical records. Outcome measurements and statistical analysisPost-FC UTI was defined as hospital admission with UTI/urinary sepsis or if patients were symptomatic for UTI with receipt of antibiotics or with positive urine culture and sensitivity. An analysis of the association was performed. Results and limitationsAn initial pilot study confirmed the safety and feasibility of our protocol. Of 1996 patients, 136 (6.8%) developed a UTI by our definition, with 51 (2.6%) having a culture-proven infection. The risk was higher in patients with a positive PCU (odds ratio [OR] 1.61, 95% confidence interval [CI] = 1.07–2.40, p = 0.02), history of UTI (OR 1.72, 95% CI = 1.09–2.73, p = 0.02), or a bladder tumour on FC (OR 2.22, 95% CI = 1.27–3.90, p = 0.005). No patient with a positive PCU developed urinary sepsis. The main limitation of this study was the lack of pre-protocol control. ConclusionsWe observed a clinically low and acceptable risk of UTI, with no incidence of sepsis, when FC was performed in asymptomatic patients with a PCU suggesting “infection”. Routine cancellation of these patients is unnecessary and may worsen the burden on health service resources. Patient summaryWe evaluated the safety of performing flexible cystoscopy when the urine dipstick on the day suggested presence of an “infection” but the patient had no symptoms of urinary tract infection (UTI). Our study in over 2000 patients demonstrated a low incidence of UTI, and none of these patients developed sepsis. We therefore recommend that flexible cystoscopy should not be cancelled automatically on the basis of the dipstick result alone, as it might delay a time-sensitive crucial diagnosis.

Urinary Specific Gravity Decreases over Time in Adult Sickle Cell Patients

▪Introduction: Altered urinary concentration is one of the earliest and most common features of kidney disease in patients with sickle cell disease (SCD). This phenomenon is reversible in early age by transfusion but becomes fixed with time. Little data exist as to which additional clinical features are associated with impaired urinary concentration. Further, longitudinal changes in urinary concentration over time in adults have not been examined.Methods: We conducted a retrospective study of adult sickle cell patients seen between January, 2004 and December, 2013 at a single center. Clinical and laboratory variables were abstracted from medical records. Specific gravity was assessed from random dipstick urinalysis results. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Patients had confirmed SCD, were at least 18 years old, and were evaluated during routine clinic visits. Mixed effects models were fit to evaluate the change in specific gravity over time. Clinical and laboratory variables, including measures of kidney function or disease, hemolysis markers and associated comorbidities, were evaluated for their association with baseline specific gravity and on specific gravity over time in age- and sex-adjusted analyses. We also compared those with severe phenotypes (SS/Sβ0) to those with mild phenotypes (SC/Sβ+). A multivariable model was constructed utilizing covariates identified in univariate analyses with a final model produced via backward elimination with age and sex adjustment retained. We included interaction terms between covariates and to evaluate the longitudinal association of these variables on change in specific gravity. We also employed similar approaches in analyses stratified for those with SS and Sβ0 disease from those with milder SC and Sβ+disease.Results: Four hundred and forty-seven patients with SCD (SS = 280, SC = 102, Sβ0 = 22, Sβ+ = 33, SE = 2, SLepore = 2, SD = 2, SHPFH = 4) were followed over a median duration of 2.8 years (IQR: 0.99 - 6.3 years). Median age was 28.5 years (IQR: 20 - 40 years) and 238 were female (53%). Over time, specific gravity decreased (-0.00011 per year, SE 0.000030; p=0.0002). In stratified analysis, patients with SS/Sβ0 had a similar decrement (-0.00011, SE 0.000032; p=0.0005) while SC/Sb+ had a slightly lower decline (-0.00008, SE 0.000079; p=0.3) that was not statistically significant. Patients with SS/Sβ0 trended toward slightly higher baseline specific gravity (0.00079, SE 0.00035; p=0.03) compared to SC/Sb+ patients. At baseline, hemoglobin level (0.00017, SE 0.000079; p=0.03) and hemoglobinuria (0.00096, SE 0.00046; p=0.04) were associated with higher specific gravity. In multivariate modeling, only hemoglobinuria (0.0012; SE 0.00048; p=0.01) and SS/Sβ0 phenotypes (0.00096, SE 0. 00036; p=0.009) were associated with higher specific gravity. Over time, ferritin; (-0.00011, SE 0.000048; p=0.02) and priapism in men (-0.00029, SE 0.00010; p=0.006) were associated with annual decline in specific gravity. Use of angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB) (0.00018, SE 0.000076; p=0.02) was associated with a rise in specific gravity. In multivariate analyses, only ferritin (-0.00012, SE 0.000048; p=0.01) was associated with annual decline in specific gravity When evaluated separately, SS/Sβ0 demonstrated nearly identical findings in multivariate analysis for ferritin (-0.00013, SE 0.000057; p=0.02).Conclusion: Even in adult patients with SCD, specific gravity declines over time, and decline may be more prominent in those with SS/β0. Higher ferritin, a measure of iron overload, is associated with greater decline in specific gravity. Future prospective studies of kidney disease in SCD patients should include measures of specific gravity to better understand this phenomenon and its long-term consequences. DisclosuresAtaga:Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees; Reprixys Pharmaceuticals Corporation (formerly known as Selexys Pharmaceuticals Corporation, which is not affiliated with Selexis S.A.): Research Funding; Global Blood Therapeutics: Research Funding; Global Blood Therapeutics: Honoraria; Novartis: Honoraria; Novartis: Membership on an entity's Board of Directors or advisory committees.

Utility of remission criteria for the renal prognosis of IgA nephropathy

BackgroundNovel criteria for the remission of Immunoglobulin A nephropathy (IgAN) based on an opinion survey of Japanese nephrologists and literature review were proposed in 2013. This single-center, longitudinal retrospective cohort study was conducted to validate this criteria.MethodsPresent study included the IgAN patients diagnosed between 2001 and 2005 in the Juntendo University Hospital. Remission of hematuria was defined as three consecutive dipstick test results of ( −) to ( ±) or a red blood cell count < 5 in urinary sediment per high-power field during at least 6 months. Remission of proteinuria was defined as three consecutive dipstick results of ( −) to ( ±) during at least 6 months. We categorized four groups according to the remission status which was assessed 2 years after the renal biopsy. The primary outcome was a 50% increase in the serum creatinine over the baseline. We evaluated the slope of eGFR decline (mL/min/1.73 m2/year) and a decrease in the eGFR of 30% from baseline eGFR as the secondary outcome, respectively.ResultsA total of 74 patients (male: 47.3%, median age: 30 years) were included and were followed for a median of 86.5 months. During the period, forty-one patients achieved neither remission of proteinuria nor hematuria (NR). Twelve patients met the primary study outcome. A survival analysis revealed that the NR had the worst prognosis and the steepest slope of eGFR decline.ConclusionAlthough further validation in a large cohort is necessary, these novel remission criteria for IgAN patients appear to predict the renal prognosis.

Higher cardiovascular mortality in men with persistent dipstick hematuria.

We previously reported that dipstick hematuria (UH) was associated with higher all-cause mortality in men, but not in women. We extended the observation and examined the causes of death using repeated urinalysis in men. Subjects were those who participated the Tokutei-Kenshin between 2008 to 2015 in seven districts. Using National database of death certificate, we identified those who might have died and confirmed further with the collaborations of the regional National Health Insurance agency and public health nurses. Dipstick results of 1 + and higher were defined as hematuria. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Cox proportional hazard analysis. We adjusted for age, body mass index, eGFR, proteinuria, comorbid condition (diabetes mellitus, hypertension, and dyslipidemia), past history (stroke, heart disease, and kidney disease), and lifestyle (smoking, drinking, walking, and exercise). A total of 170,119 men were studied and 70,350 (41.4% of the total) were re-examined next year. The prevalence of UH (-/-), UH (-/+), UH (±), and UH (+ /+) was 77.2% (N = 54,298), 14.0% (N = 9,838), 1.4% (N = 1014) and 7.4% (N = 5,200), respectively. We identified 1,162 deaths (1.7% of the total of the re-examined). The adjusted HR (95% CI) was 1.49 (1.22-1.81) for all-cause mortality and 1.83 (1.23-2.71) for cardiovascular death compared to those with UH (-/-), respectively. However, that for cancer mortality risk was not significant: 1.23 (0.92-1.64). In men, persistent dipstick hematuria is a significantly risk factor of all-cause mortality, in particular cardiovascular death among general screening participants.

Basal glucose excretion in dogs: The impact of feeding, obesity, sex, and age.

BackgroundThe urine glucose (UG) measurements are an integral part of urinalyses, especially in dogs with polyuria and polydipsia. A positive dipstick result is considered pathologic for disease. This paradigm has been challenged by new ultrasensitive tests, where the manufacturers recommend tolerating slightly positive results. It implies that, as in other species, basal urine glucose losses can exceed the lower limits of detection using ultrasensitive glucose dipsticks in healthy dogs.ObjectivesWe aimed to determine whether glucose is routinely detectable using a sensitive quantitative wet chemistry method in the urine of nondiabetic, nonazotemic dogs, and investigate the impact of food intake, obesity, sex, castration status, and age.MethodsSerial UG measurements were performed in healthy clinic‐owned Beagle dogs that were randomly fasted or fed. Glucose was measured in morning urine samples from normal‐weight healthy and obese dogs, and the university's electronic database was searched for quantitative UG measurements (Gluco‐quant Enzyme Kit/Roche Diagnostics).ResultsSmall amounts of glucose were detected in 555 (99.1%) of 560 urine samples analyzed. All urine samples from the clinic‐owned Beagle dogs, as well as from privately owned obese and normal‐weight healthy dogs that tested positive for glucose. The median (range) UG concentration obtained from the university's electronic database was 0.39 (0‐1.55) mmol/L, and 2.2% of the samples tested negative. Feeding, obesity, gender, castration status, and age did not affect UG concentrations.ConclusionsStudies, including a larger number of healthy dogs, are warranted to define a cut‐off between physiologic and pathologic glucosuria.

Assessment of Interobserver Reliability of Nephrologist Examination of Urine Sediment

Urine sediment microscopy is commonly performed during the evaluation of kidney disease. Interobserver reliability of nephrologists' urine sediment examination has not been well studied. Assess interobserver reliability of the urine sediment examination. In this diagnostic test study, urine samples were prospectively collected from a convenience sample of adult patients from an academic hospital in the United States undergoing kidney biopsy from July 11, 2018, to March 20, 2019. Digital images and videos of urine sediment findings were captured using a bright-field microscope. These images and videos along with urine dipstick results were incorporated in online surveys and sent to expert nephrologists at 15 US teaching hospitals. They were asked to identify individual sediment findings and the most likely underlying disease process. Urine dipstick results and urine sediment images from patients undergoing native kidney biopsy. Interobserver reliability of urine sediment microscopy findings estimated by overall percent agreement and Fleiss κ coefficients. Secondary outcomes included concordance of diagnoses suspected by nephrologists with corresponding kidney biopsy results. In total, 10 surveys from 10 patients containing 76 study questions on individual features were sent to 21 nephrologists, 14 (67%) of whom completed them all. Their combined 1064 responses were analyzed. Overall percent agreement for casts was an estimated 59% (95% CI, 50%-69%), κ = 0.52 (95% CI, 0.42-0.62). For other sediment findings, overall percent agreement was an estimated 69% (95% CI, 61%-77%), κ = 0.65 (95% CI, 0.56-0.73). The κ estimates ranged from 0.13 (95% CI, 0.10-0.17) for mixed cellular casts to 0.90 (95% CI, 0.87-0.94) for squamous epithelial cells. In this study, substantial variability occurred in the interpretation of urine sediment findings, even among expert nephrologists. Educational or technological innovations may help improve the urine sediment as a diagnostic tool.

The utility of combined urine dipstick analysis and specific gravity measurement to determine feline proteinuria.

To assess the utility of urine dipstick strips for detection of feline proteinuria when used in combination with urine-specific gravity, compared with urine protein-to-creatinine ratio as the gold standard. Retrospective analysis of clinical records of comprehensive urine examination obtained from cats presented to a referral hospital. Diagnostic agreement and test accuracy were calculated for the dipstick test alone and in combination with the urine-specific gravity, using different cut-off values for proteinuria. Receiver-operating characteristic curves were also calculated. A total of 121 urine samples were included. The diagnostic agreement between dipstick and urine protein-creatinine ratio was poor. A dipstick result of equal or greater than "Trace" (0.1-0.3 g/L) had a sensitivity of 81% and a specificity of 31% to detect proteinuria. Grouping the samples by urine-specific gravity did not increase dipstick agreement with the urine protein-creatinine ratio and only resulted in a slight improvement in the accuracy of detecting proteinuria. The dipstick test was not accurate for detecting proteinuria when combined with urine-specific gravity in cats. Clinicians should not rely on this test and, regardless of the urine concentration, other appropriate quantitative methods such as urine protein-creatinine ratio should always be performed to detect proteinuria in cats.

How COVID-19 Has Changed the Management of Glomerular Diseases.

A 26-year-old woman contacted our office asking for an urgent call back. She had a history of steroid-dependent and frequently relapsing minimal change disease, and calls like this usually meant her home dipsticks had turned positive. Instead, she reported that she had just tested positive for the

Renal disorders in pregnancy

: Renal disorders in pregnancy are common. In high income countries, approximately 3% of pregnant women have chronic kidney disease (CKD) and often it is recognized for the first time during pregnancy. Approximately one fifth pregnant women developing preeclampsia before 30 weeks’ gestation have previously undiagnosed CKD, especially those with severe proteinuria. Defining and staging CKD in pregnancy is challenging: from one hand physiological hyperfiltration might significantly alter CKD staging. On the other hand, the application of equations for estimating glomerular filtration rate (GFR) is strongly discouraged during pregnancy. By analyzing data from the literature, it is reasonable to assume that serum creatinine and albuminuria should be considered the most appropriate tests both for diagnosing and monitoring pregnant women with CKD. Creatinine clearance is cumbersome and the collection of the 24-h urine sample is often inaccurate, while proteinuria is affected by several analytical pitfalls. Serum creatinine should be measured by traceable methods in order to make comparable results between different laboratories. Albuminuria can be screened by dipstick methods; however, any positive result must be confirmed by a quantitative measurement either on a 24-h urine sample or on a first morning urine sample, reporting results as albuminuria-to-creatininuria ratio. Nephelometric methods for albuminuria enable an accurate measurement even in a range of 5–15 mg/L. Any negative dipstick result must be carefully evaluated on the basis of history and clinical signs, tacking into account possible false negative results due to the presence of a protein mixture constituted either by a very low concentration of albumin or by globular proteins only. Cystatin C should be used in the first trimester to predict the risk of preeclampsia and that of gestational diabetes mellitus. Finally, pregnant women with proteinuria must be periodically checked for urinary tract infection (UTI) by urine cultures.

Liquid gold: the cost-effectiveness of urine sample collection methods for young precontinent children

BackgroundUrinary tract infection (UTI) is a common childhood infection. Many febrile children require a urine sample to diagnose or exclude UTI. Collecting urine from young children can be time-consuming, unsuccessful...

3 UTI Diagnosis and Management in the Over 65s According to Public Health England Guidelines

Abstract Introduction The diagnosis of urinary tract infections (UTI) becomes increasingly difficult with age. Dipsticks are unreliable and with the prevalence of asymptomatic bacteriuria increasing to 17% in females over 75 even urine culture results can be unreliable. Public Health England (PHE) released new guidelines in November 2018 with criteria for diagnosing UTIs in the over 65s. Methods Identify patients over 65 who are diagnosed with a UTI in Solihull acute medical unit. Collect data on presenting symptoms, dipstick and culture results and antibiotic use. Aim to improve guideline adherence and decrease dipstick use through education of medical and nursing staff via presentations and posters. Results Prior to the educational intervention guideline adherence when diagnosing UTIs in over 65s was 55%. This rose to 82% following the educational intervention. Dipstick usage decreased from 49% to 28% following the intervention. Dipsticks were shown to be unreliable as 21.6% of dipstick positive urine samples sent for culture had a normal (0-80) white cell count in the laboratory, whilst 43.8% of dipstick negative urine samples sent for culture had a raised white cell count in the laboratory. On retrospective analysis 16.1% of patients treated for a UTI appeared to have had an asymptomatic bacteriuria. Co-amoxiclav was initially used for 51% of patients however there was resistance to Co-amoxiclav in 31% of samples where an organism was cultured. Conclusions The educational intervention was able to increase PHE guideline adherence for diagnosing UTIs in the over 65s. There was also a decrease in the use of dipsticks which were shown to be unreliable in this age group. Prescribers remained reliant on broad-spectrum antibiotics with Co-Amoxiclav being most commonly used. This is likely to be ineffective in a significant number of patients given the common resistance seen in urine culture sensitivities.

Knowledge of nursing staff and healthcare assistants on the diagnosis of urinary tract infections in patients with urinary catheters

Background Asymptomatic bacteriuria is common in patients with urinary catheters. Current clinicalguidelines advise against dipstick testing or treating urine culture results in asymptomatic catheterised patients which can promote the development of antimicrobial resistance and present an unnecessary risk to patients. This study aimed to assess the knowledge of nurses and healthcare assistants (HCAs) on the diagnosis of urinary tract infections (UTIs) in patients with urinary catheters. Methods This study employed a cross sectional survey of opportunistically sampled nursing staff and healthcare assistants working at Northwick Park Hospital in May 2018. Results were analysed descriptively. Results 134 participants were included in the final analysis of whom 90% (N=120) were nurses and 10% (N=14) were HCAs. The majority of staff (38.6%, N=51) worked in a medical speciality and had over 15 years of work experience (45.3%, N=58). 79 participants (66%) believed that a positive dipstick result was diagnostic of a catheter associated urinary tract infection (CAUTI). A positive dipstick result was the most frequently selected indication (91% of respondents, N=108) for sending urine for culture in a catheterised patient, and was also the most frequently selected reason for sending urine for culture across staff of all years of experience and all specialities. Conclusion There is a need to improve the level of knowledge of nursing and HCA staff on the diagnosis of CAUTIs including misconceptions on the diagnostic value of dipstick testing in catheterised patients. The findings of this research will inform a quality improvement project to address these gaps in knowledge.

Diagnostic accuracy of urine dipstick for proteinuria category in Japanese workers.

Urine dipstick tests are often used to evaluate proteinuria during health checkups. We examined the dipstick's accuracy in assessing the proteinuria levels among Japanese workers. We assessed subjects aged ≥ 18years who had a health checkup at the University of Tokyo in 2016 or 2017 (n = 5383). Proteinuria was stratified by urine protein-to-creatinine ratio (PCR): A1, < 150mg/gCre; A2, 150-499mg/gCre; and A3, ≥ 500mg/gCre. The accuracy of a dipstick result of ± or higher to detect a PCR level of ≥ A2 was examined. We compared changes in dipstick results and PCR level in 136 subjects evaluated twice with a median interval of 119days. The subjects' mean age was 40years, and half were women. The dipstick results were - in 94.9%, ± in 4.1%, and ≥ 1 + in 1.0%. The PCR level was A1, A2, A3 in 98.6%, 1.2%, and 0.2% of the subjects, respectively. The sensitivity, specificity, and positive and negative predictive values of a ± or higher dipstick result to detect A2 or higher were 66.2%, 95.6%, 17.5%, and 99.5%, respectively. Among the 136 subjects examined twice, 134 (98.5%) had no change in PCR level (A1 in all cases) despite a decrease or increase in dipstick results. Urine dipstick results of ± or above had a high specificity but low sensitivity and positive predictive value to detect PCR proteinuria of A2 or higher. Confirmation by quantitative protein measurement should be recommended for individuals at high risk of chronic kidney disease.

The Effectiveness of Dipstick for the Detection of Urinary Tract Infection.

Background The balance between the choices of UTI diagnostic tools in most primary care settings has been settled for by the more rapid, less labour-intensive dipstick. This study aimed to evaluate the effectiveness of dipstick for diagnosing UTI. Method A total of 429 urine samples were collected from patients suspected of UTI; cultured on cysteine-lactose-electrolyte-deficient (CLED) agar, blood agar, and MacConkey agar; and incubated at 37°C overnight. Urine cultures with bacteria count ≥105 cfu/ml were classified as “positive” for UTI. A dipstick was used to screen for the production of nitrite (NIT) and leucocyte esterase (LE), following the manufacturer's instructions. Biochemical reactions of nitrite and leucocyte esterase > “trace” were classified as “positive.” A quantitative urine culture was used as the gold standard. Results The highest sensitivity value and negative predictive value were recorded for the combined “NIT+ or LE+” dipstick results. The highest specificity value, positive predictive value, positive likelihood ratio, and negative likelihood ratio were recorded for “nitrite-positive and leucocyte esterase-positive” results. Combined “nitrite-positive or leucocyte-positive” result was relatively the best indicator for accurate dipstick diagnosis, with AUC = 0.7242. Cohen's kappa values between dipstick diagnosis and quantitative culture were <0.6. Conclusion Combined performance of nitrite and leucocyte esterase results appeared better than the solo performance of nitrite and leucocyte esterase. However, little confidence should be placed on dipstick diagnosis; hence, request for quantity culture should be encouraged in the primary healthcare settings.

Current practice on the management of pre-operative urine dipstick results in women undergoing gynaecological surgery in Wales

A survey was circulated to consultant gynaecologists across Wales, to evaluate the management of pre-operative urine dipstick results. Questions were based on NICE guideline 171, regarding the management of urinary incontinence in women. Six respondents never checked their patient's urine dipstick results. Of the remaining 37 respondents, 70% always check and 30% sometimes check. Overall, 37.1% cancelled surgery when a urine dipstick was positive for either nitrite or leukocyte-esterase (LE). A significantly larger proportion cancelled surgery when symptomatic for urinary tract infection (p< 0.001), and when nitrite and LE positive compared to only LE positive (p< 0.05).This survey provides evidence that gynaecological operations are potentially being cancelled unnecessarily based on a screening test with limited sensitivity and specificity. Further research is needed into the outcomes of gynaecological surgery in women symptomatic of urinary tract infection to provide guidance on the use of pre-operative urinalysis and the management of test results.Impact statementWhat is already known on this subject? The strongest risk factor for postoperative urinary tract infections (UTIs) is a pre-operative recurrent UTI (Nygaard et al. 2011). This is the reason behind the urine dipstick being part of the pre-operative checklist for gynaecological surgery. Traditionally, a suspected UTI would mean postphoning surgery whilst treating the UTI. It is known that the sensitivity of the nitrite test and leukocyte-esterase test when used alone is low and cannot rule out UTI in most patients (Mambatta et al. 2015). Urine culture is therefore suggested for all patients with a suspected UTI (John et al. 2006). To our knowledge, there are no data available on whether we should be postphoning gynaecological surgery based on a urine dipstick result.What the results of this study add? Overall, 37.1% of respondents cancelled surgery when a pre-operative urine dipstick was positive for either nitrite or leukocyte-esterase. This provides evidence of variation in the practice of using the urine dipstick in women undergoing gynaecological surgery in Wales. These cancellations are potentially unnecessarily. Furthermore, 14% of respondents did not use a urine dipstick and the majority did not act on an abnormal results, implying clinicians have a low confidence in the test as a screening tool.What the implications are of these findings for clinical practice and/or further research? We propose removing the urine dipstick as a pre-operative screening test. Asymptomatic bacteriuria is common in women and routine screening for UTI pre-operatively will therefore inevitably lead to unnecessary intervention (i.e. cancellation). Further research is needed into the outcomes of gynaecological surgery in women symptomatic of UTI to be able to provide guidance on the use of pre-operative urinalysis and management of the test results.

An audit on the use and utility of midstream specimen of urine cultures in general practice

BackgroundA midstream specimen of urine (MSU) culture is a diagnostic test commonly used to guide the management of suspected lower urinary tract infections (LUTI). Inappropriate use of MSUs leads to unnecessary treatment of asymptomatic bacteriuria, delayed antibiotic prescriptions, and increased costs.AimThis audit investigates the use of MSUs in a primary care practice in Birmingham before and after an educational intervention designed to increase adherence to guidelines.MethodAll MSUs sent during June and July 2017 for non-pregnant adults were audited. Patient demographics, request details, indications, dipstick results, and relevant prescriptions were extracted from the electronic record. Clinical management was compared with the National Institute for Health and Care Excellence (NICE) quality standard QS90. Results were presented to practice staff; training based on QS90 was given and supported by new management algorithms. Re-audit was then undertaken over another 2-month period.ResultsThe audit included 157 samples, with a further 138 samples in the re-audit. The proportion of MSU samples that were clinically indicated increased from 66% to 77% following the educational intervention. Suspected LUTI was the most common indication in both audit cycles: 68% and 64% respectively. Adherence to QS90 increased from 68% to 84% and improvements were seen among both doctors (71% to 78%) and practice nurses (36% to 55%).ConclusionEducational intervention and the introduction of management algorithms improved adherence to NICE QS90. There is scope for enhancement with further education and uptake of management algorithms. The cohort is small and limited to one practice, but could easily be repeated on other sites.

Reliability of Symptoms and Dipstick for Postoperative Catheter-Associated Urinary Tract Infections.

The aim of the study was to determine the diagnostic reliability of patient symptoms and urine dipstick results, including blood, leukocyte esterase, and nitrite, in diagnosing postoperative catheter-associated urinary tract infections (CAUTIs) after gynecologic surgery. A prospective cohort study of patients undergoing gynecologic surgeries who required short-term (>24 hours) postoperative catheterization was conducted. Patients completed a questionnaire regarding symptoms. Urine dipstick analysis was completed on catheterized urine samples and urine was sent for culture for all patients. Positive likelihood ratios (LRs) were used to examine diagnostic reliability of patient symptoms and urine dipstick results in diagnosing postoperative CAUTIs. Fifty-seven patients with postoperative short-term indwelling catheterization were recruited, 25 (44%) of whom had CAUTIs diagnosed by urine culture at recruitment and 32 (56%) of whom did not have CAUTIs. Urine dipstick parameters were found to successfully diagnose CAUTIs, with positive LRs of 1.44 (95% confidence interval [CI], 1.04-1.99), 6.77 (95% CI, 2.23-20.52), and 9.47 (95% CI, 1.23-72.69) for blood, leukocyte esterase, and nitrite, respectively. The combination of leukocyte esterase and nitrite yielded a positive LR of 9.48 (95% CI, 2.62-34.25). Individual symptoms, alone or in combination, did not successfully diagnose positive urine culture (positive LRs <1.8). Urine dipstick parameters are reliable diagnostic tests for diagnosing postoperative CAUTIs after gynecologic surgery, particularly when in combination. Patient symptoms have little diagnostic value for positive urine cultures in catheterized patients after gynecologic surgery.